NURS 6051 Week 4 Clinical System Review Example

Review of an Electronic Discharge Module on a Medical-Surgical Unit: Workflow Effects and the Point Where Interoperability Stops

Student Name

College of Nursing, Walden University

NURS 6051: Transforming Nursing and Healthcare Through Technology

Instructor Name

Month Day, Year

Review of an Electronic Discharge Module on a Medical-Surgical Unit: Workflow Effects and the Point Where Interoperability Stops

System Description

The system reviewed is the discharge module of the electronic health record on a composite 32-bed medical-surgical unit. It contains a discharge order screen for providers; a medication reconciliation screen shared by providers, pharmacists, and nurses; a patient education screen where nurses select and print teaching materials; a discharge instructions document generated from those entries; and a discharge summary that the provider signs and the system sends to other organizations. Providers, pharmacists, registered nurses, case managers, and unit clerks all touch the module at different points. The review follows one typical discharge, a patient returning home with home health services after treatment for heart failure, and asks where the module helps, where it hinders, and where it makes no difference.

Workflow, Step by Step

1. The provider signs the discharge order. Verdict: helped. The order populates the unit's discharge list immediately, so nurses, case management, and transport see the discharge at the same time rather than hearing about it by phone.

2. Medication reconciliation. Verdict: helped, with a caveat. The shared screen shows home medications, inpatient medications, and discharge prescriptions side by side, which makes discrepancies visible. The caveat is that home medications entered incompletely at admission carry forward into the discharge list.

3. Pharmacist review. Verdict: unchanged. The pharmacist reviews the list in the same screen as before the module, and turnaround depends on staffing, not software.

4. Nurse selects patient education. Verdict: hindered. The education library is organized by diagnosis code, so finding heart failure teaching on low-sodium diet and daily weights takes several clicks, and the printed materials are long and written above the reading level of many patients.

5. Discharge instructions generated. Verdict: helped. The instructions document assembles medications, appointments, and activity orders automatically, reducing transcription errors compared with handwritten instructions.

6. Nurse reviews instructions with the patient and documents teaching. Verdict: hindered. The teaching documentation requires separate entries for each topic and each learner, which lengthens charting during a busy period.

7. Case manager arranges home health. Verdict: unchanged. Referrals still depend on phone calls to agencies to confirm acceptance.

8. Patient leaves and the discharge summary is sent. Verdict: partly helped. The summary reaches the primary care practice through the regional health information exchange, but not the home health agency, as described below.

Where the Summary Stops

Following the discharge summary outward shows the limit of the module's interoperability. The summary is created as a structured document that other systems using compatible standards can receive, and the primary care practice, which uses the same health information exchange, gets it within hours. The home health agency that will visit the patient the next day cannot accept it electronically; its system does not connect to the exchange. So the discharging nurse prints the summary, the medication list, and the instructions and faxes them to the agency, then calls to confirm they arrived. On a busy afternoon this adds ten to fifteen minutes to the discharge, and if the fax goes to a wrong or unattended machine, nobody knows until the home health nurse calls asking for records. The patient's information travels electronically to the office that will see him in two weeks and by fax to the nurse who will see him tomorrow.

This is not unusual. National surveys have found that while most hospitals can send patient information electronically, fewer can receive, find, and integrate information from outside organizations, and post-acute providers such as home health agencies have lagged in adoption because they were not included in the federal incentive programs that drove hospital EHR adoption (Holmgren et al., 2017). The practical result on this unit is duplicated work, a paper step that can fail, and a delay in the information home health nurses need for the first visit.

Effects Weighed in Both Directions

The module's positive effects are real. Shared medication reconciliation and automatically assembled instructions reduce transcription and make discrepancies visible, which matters because communication failures at discharge are common: a systematic review reported that primary care physicians often had no discharge summary in hand when they first saw the patient after discharge, and that summaries commonly omitted pending tests and medication details (Kripalani et al., 2007). Electronic transmission to primary care addresses part of that problem.

The negative effects fall mainly on nursing time and on usability. Education materials that are hard to find and poorly matched to health literacy, and teaching documentation that requires many separate entries, lengthen the discharge at the point where nurses are most pressed. Research on EHR usability has found that poor design contributes to both inefficiency and safety risks, including errors from confusing screens and excessive clicks (Ratwani et al., 2018). And the fax step to home health reintroduces the very risk of lost or delayed information that the module was meant to remove. On balance, the module improves the accuracy of what is sent and the speed of internal coordination, while shifting burden onto nurses at teaching and at the handoff to home health (McGonigle & Mastrian, 2022).

Two Changes the Unit Controls

First, the unit's education champion will build a heart failure discharge teaching bundle as a favorites set in the education screen, containing a one-page low-sodium diet sheet, a daily weight log, and a symptom action plan written at a sixth-grade reading level, with a single documentation entry for the bundle. This is within the unit's authority because favorites and order sets are configured locally with the informatics team's help.

Second, the unit will create a standard work checklist for home health handoffs: fax the three documents, call to confirm receipt, and document the name of the person who confirmed. This does not fix interoperability, which requires decisions beyond the unit, but it makes the paper step reliable and visible. The unit council will also send the review to the hospital's informatics committee, which can pursue a connection with the major home health agencies in the area, and the council will repeat this step-by-step review six months after both changes take effect.

References

Holmgren, A. J., Patel, V., & Adler-Milstein, J. (2017). Progress in interoperability: Measuring US hospitals' engagement in sharing patient data. Health Affairs, 36(10), 1820-1827. https://doi.org/10.1377/hlthaff.2017.0546

Kripalani, S., LeFevre, F., Phillips, C. O., Williams, M. V., Basaviah, P., & Baker, D. W. (2007). Deficits in communication and information transfer between hospital-based and primary care physicians: Implications for patient safety and continuity of care. JAMA, 297(8), 831-841. https://doi.org/10.1001/jama.297.8.831

McGonigle, D., & Mastrian, K. G. (2022). Nursing informatics and the foundation of knowledge (5th ed.). Jones & Bartlett Learning.

Ratwani, R. M., Savage, E., Will, A., Arnold, R., Khairat, S., Miller, K., Fairbanks, R. J., Hodgkins, M., & Hettinger, A. Z. (2018). A usability and safety analysis of electronic health records: A multi-center study. Journal of the American Medical Informatics Association, 25(9), 1197-1201. https://doi.org/10.1093/jamia/ocy088