Blog | Friday, November 30, 2018

The abysmal discharge paperwork we give to our patients

The discharge process has now been recognized as one of the most crucial points at which the actions of doctors and hospitals can have a huge impact on immediate health outcomes for our patients. At a time when 30-day readmission rates are still touching almost 20% for Medicare patients (higher for certain patients, with up to a third of these occurring in the first 7 days!), there is an increasingly urgent need to focus on this transition of care point. Discharging a patient is, by its very nature, a risky process. Patients are typically still not at their baseline, and their recovery hangs in the balance. As the main attending physician, the role of hospital doctors is pivotal in making discharges as flawless as possible.

Let's go through how the typical hospital discharge works in the world of medicine. The doctor will see the patient and make the decision that they are well enough to leave the hospital. These discharge plans will often only be made clear at the last moment. The nurse may be taken by surprise as the doctor pops their head through another patient room to inform her of the great news: “Mr. Adams can go home, I'm discharging him”. After a brisk discharge summary and the completion of the paperwork, the patient and their family will get a piece of paper given to them by their nurse. If it's not written in ineligible writing (using medical jargon that most doctors' own parents wouldn't even understand) on a thin sheet of paper, they will get a printed piece of paper where the doctor has entered the information on a computer.

In either case, the whole piece of paper will be less than appealing in appearance. It will contain the patient's discharge diagnosis, medications (frequently with changes from the admission medications), and follow-up instructions. This is one aspect of the discharge that I've always wondered about, and has pretty much been overlooked in every hospital I've ever worked in: The design of the discharge paperwork. What am I talking about? Well let's suppose you are asked to follow through on some very important instructions, would you be more likely to follow them if they were presented to you on a tatty piece of paper or well-presented in a more beautiful and eye-catching way?

There is simply no way that most patients can understand what's given to them. It's strange that we don't pay more attention to this. When we hand patients, especially the elderly, papers with a dull and dreary design and small unattractive fonts—they are considerably less likely to be able to read the information. In fact, the current printed paperwork most hospitals give to patients often looks like it comes from the typewriter age!

More importantly, what message does it give about the hospital and our profession? As a further sign of how little thought we put into the paperwork, it's fairly common everywhere for doctors to use abbreviations such as “CHF with low EF” (congestive heart failure with low ejection fraction) or “COPD with PNA” (chronic obstructive pulmonary disease with pneumonia). I mean, who is the paperwork really for? It's no wonder that the discharge process can be haphazard and risky when the piece of paper we hand our patients is so difficult to understand.

This is a classic example of where we get one simple but vital aspect in a communication chain wrong. Although nearly all hospitals now have printed instructions, thanks in part to fulfilling “Meaningful Use requirements” (an understandably important goal for hospitals)—things still need to be taken to the next level. Remember, the idea of certain parts of Meaningful Use is to better communicate medication changes to patients. When the printout is suboptimal, we are therefore missing a final link in the communication chain. It might contain the most valuable insights imaginable, but without people wanting to read it, it's quite worthless.

What do we need? Hospitals should design beautiful, colorful, easy-to-read discharge instructions. These should be printed on high quality paper. Short and simple. No complicated medical terminology or abbreviations. Whatever patients do with it afterwards; read it, put it on their fridge, or even throw it away—is up to them, but at least we have given them something that they are more likely to read in the first place. Hospitals need to get patient and staff feedback on their current paper format and then utilize their design department to improve on what they have. Other marketing advice might also be needed. A small investment really for the enormous potential benefits.

There are of course many other facets of the discharge process that are problematic, and affect readmissions, including the ability to follow-up in a timely manner with a primary care doctor, or get adequate care in the community. But the discharge paperwork is something that we have total control over and is a common sense area to improve. Something that we must place higher value upon, it's arguably one of the most crucial things we give our patients during their healthcare interaction.

Note: This piece originally appeared on my blog almost 5 years ago, and having worked in even more hospitals since then, we've made almost zero progress (perhaps only that less hand-written info is given to patients). Very frustrating, and that's why I wanted to raise this issue again!

Suneel Dhand is an internal medicine physician, author and speaker. He is the founder of DocSpeak Communications and co-founder at DocsDox. He blogs at his self-titled site, where this post first appeared.