Impact of Using the Electronic Health Record to Improve the Rate of Discharge Counseling in a Quaternary Academic Medical Center



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Purpose. The impact of an electronic health record consult order used to increase the pharmacist-provided discharge counseling capture rate in a large, teaching institution are described.

Methods. A quasi-experimental quality improvement study was conducted in a large, academic medical center and included adult patients discharged from a nursing unit primarily treating heart failure. Patients were divided into two groups: control group (January 3 to April 2, 2016) – pre-implementation of consult order and intervention group (January 1 to April 1, 2017) – post implementation of consult order. During the intervention period, the nursing staff would enter a consult order notifying the pharmacist at least 24 hours prior to the patient's anticipated discharge date. The pharmacist prioritizes provision of discharge counseling to patients based on timing of discharge, if the patient is high risk for early readmission based on the LACE index score and if the patient continues or initiates anticoagulants or antibiotics. The number of discharge counseling sessions, consult orders entered and addressed, readmission rates and additional clinical interventions discovered during discharge counseling were evaluated to assess the impact of the consult order on the pharmacist-provided discharge counseling capture rate.

Results. The study included 816 patients with 404 in the control group and 412 in the intervention group. The rate of pharmacists performing discharge counseling significantly increased between the control and intervention groups, 4.7% to 39.8% respectively (p < 0.0001). Within the intervention group, the nursing staff entered a consult order for 146 patients and pharmacists addressed 74% of the consults. Sixty-one additional clinical interventions were discovered through discharge counseling including anticoagulation adjustments and therapy duplications. The consult order did not significantly reduce the 30-day readmission rate between the two groups (p = 0.825).

Conclusion. An electronic health record consult order to alert pharmacists of patients’ anticipated discharge was associated with a significant improvement in the pharmacists-provided discharge counseling rate, including patients at high-risk for 30-day readmission.



Discharge counseling, Pharmacy, Transitions of care, Electronic health record, Readmission rate