Part I: Discharge Workflow Challenges and Successes 

This is Part I of our three-part Multidisciplinary Discharge Series.



Kerri: Greg and Pat, welcome and thank you for taking the time to speak with me today. Our 5.66 Discharge interview will kick off our MEDITECH.com article series on popular EHR topics. To start, can you comment on your current release, Meaningful Use status, and 5.66 Discharge roll-out status?


Pat: Kalispell is Client/Server 5.66 Priority Pack 8 in LIVE, and began attesting for Meaningful Use Stage 2 in July 2014. We’ve been LIVE with the Multidisciplinary Discharge routine since Nov. 2013. 


Greg: Avera is also Client/Server 5.66 Priority Pack 8 in LIVE. We’ve been LIVE with the Discharge routine at all of our facilities since April 12, 2014 and began our attestation period for Stage 2 in July 2014.


Kerri: We all know the importance of the Finalize function in the Discharge routine. If the patient is not appropriately finalized, necessary patient packet information will not be sent to the EMR, eChart, or even the Patient Portal. Who is responsible for finalizing the Discharge routine at your facilities? Nurses, physicians, or both?


Greg: Currently at all of our Avera Health facilities, nurses are finalizing 100 percent of the time. This made the most sense for our organization because nurses are the discharge gatekeepers and last person patients see before they are sent home. We did not give access to physicians or pharmacists at any of our facilities.


Kerri: What about compliance? How is your organization ensuring nurses are doing the right thing and finalizing every patient appropriately? 


Greg: We ask our Nursing leaders at all of our facilities to run the MEDITECH Unfinalized reports (MG RW # 01900, CS RW # 01899) on a weekly basis. This definitely helps us locate and fix any errors in a timely manner and helps avoid any hold ups or issues downstream, especially if the patient returns to the hospital.  


Kerri: How is Avera doing with these MEDITECH unfinalized patient reports? Are you seeing a lot of reports that you have to go back and fix — for example, finalize or undo any old draft actions?  


Greg: Our unfinalized numbers are actually very low right now. The patients that are hitting the report are the ones we would expect to see, such as patients that transferred, passed away, or left against medical advice (AMA).


Kerri: We received requests to remove expired patients from our audit reports. In response to these requests, we recently added a new Disposition filter to our MEDITECH Unfinalized audit reports (MG RW # 01900, CS RW # 01899). This change will allow organizations to exclude patients by ADM disposition — for example, expired.  


Greg: I know Avera Health was definitely one of the organizations requesting this report enhancement. This is great to hear. Filtering out expired patients will definitely help streamline this auditing process for us.  


Kerri: Excellent. Pat, over to you. Who is finalizing at your facility?  


Pat: Mostly the nurses. The physicians have access to finalize, but most of them don’t. Just like Greg said, the nurses end up finalizing because they are the discharge gatekeepers. Interesting you mention this unfinalized report, we’ve never run a report like this because our nurses live and die by the discharge packet, and you can’t print the packet unless the patient is finalized. So I wouldn’t think we have any issues with this, but I would definitely be interested in running this report for peace of mind. 


Kerri: In a previous conversation, you mentioned Durable Medical Equipment (DME) was a challenging workflow for your organization. Could you share those challenges and how you were able to overcome them?  


Pat: We had a real challenge with DME because of all the changes in regulatory requirements. The most challenging part was figuring out what information was needed in the system and the timing of workflow. We also had issues with requiring a diagnosis for every DME order because it wasn’t visible up front in the system which was frustrating for physicians, so we ended up using Reason for Use instead of Diagnosis. We also had some DME script output issues with headers and trailers not printing on every page that we were able to resolve with a MEDITECH custom output report. See Pat’s workflow diagram here. 


Kerri: Regarding the issue mentioned with required fields not being visible enough to the providers, a DTS was recently submitted (CS RXM 6255). Once coded, the DTS will ensure the provider is notified that required detail is missing prior to clicking select or save.  


Greg, you mentioned you wish your organization had the discharge transfer process fully vetted out before you went LIVE. We understand this is a challenging workflow process, which is why we recently completed a Medication Reconciliation Focus Group. While MEDITECH works through the future solutions for this, can you share with everyone what your organization’s workflow looks like now for patient transfers?  


Greg: Yes, this is actually one the most challenging issues that we have faced because we have many different hospitals within our health system, so we run into this frequently. The best solution we came up with is to have the provider access the Discharge routine and continue all the patients’ home medications, then convert any inpatient medication the patient will go home with. The one thing they are not converting would be some of the PRN-type medications, for example, if a patient needed a PRN stool softener and was transferring to Rehab, they wouldn’t convert that; they would just order the stool softener on the next account.  


The nurse would then go ahead and finalize in Discharge, and a second account will be generated through Admissions. Once the patient transferred, on the next account, the provider then would do the Continue from Ambulatory (CFA) routine. So really, what we’ve done here is create an active medication list instead of a home medication list so the provider can do CFA and then go into POM and add any new additional orders for the visit (PRNs, IV antibiotics, and things like that).


Lastly, the nurse restores the home medication list in Med Rec. This is an extra step but the reason we wanted the nurses to restore the home medication list was to ensure the provider could easily use the convert functionality and create new prescriptions for the patient in the Discharge routine once the final account was ready to be discharged.


Kerri: How is this process working out for your organization?  


Greg: It’s a tough process for us because its so time-demanding. We’ve done some re-education for the nurses as far as how to restore the home medication list. One thing we did do to help was give them access to view discontinued home medication in Med Rec. From there, if it was just a reported med, they could go in and re-activate it without having to re-enter the home medication again. It affects our Critical Access Hospitals more, just because they get that with their swing beds. It’s getting easier but takes time.


Kerri: Thanks Greg. Pat, how is Kalispell handling transfers in Discharge? 


Pat: We mostly use the same approach as Avera, except for our Rehab transfers. We use the POM Restorable Orders functionality instead of the CFA routine to activate inpatient orders and meds that were active prior to the patient being discharged from inpatient unit. We also created a transfer to Another Facility Discharge Form that captures all the information that the other facility might need, especially like our long term care, such as resuscitation status. The Provider Documentation template captures all the necessary information the provider needs to document for the next facility. We then print it out and send it with the patient.  


Kerri: How is this discharge transfer process working out for Kalispell?  


Pat: Again, we really needed to get the nurses up to speed first so they could help the physicians...This way, when the provider stops and says, ‘What do I do?,’ the nurse is there to help him through it. 



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