athenahealth

Hospital Discharge Reimagined

Background

As a Lead Designer on athenahealth's inpatient clinical EHR product I worked to identify key areas of impact for both the business and our users. After working with the Hospital Documentation team it became clear that one of the greatest areas of the product we could impact was Hospital Discharge. 

In this case study I will outline the process I took to build top-down buy-in and the work that went into better understanding and re-designing the inpatient discharge process.

Providing Value to Users while

Simultaneously Building Value for the Business

Often times it takes more than just qualitative data to build a case for why certain projects should be prioritized and resourced over others. This project was no different. 

 

We had numerous complaints around our discharge workflows and yet the discharge process remained relatively untouched and under-resourced since the original flows and features were built years prior.

As a company athenahealth was a very data driven organization. Impacting users was important, but being able to measure that impact was essential. For this project I focused on key metrics to show the importance and potential ROI of re-designing the discharge process.

User Impact

100% of patients admitted to the hospital are discharged via the inpatient discharge workflow.

Financial Impact

Contributes to over $10mm in Discharge Not Final Billed (DNFB) due to outstanding discharge tasks.

Compliance (Legal)

The discharge workflow is disjointed, clunky, and noncompliant - to the point of formal grievances.

The Team & Process Overview

As the Lead Designer I worked closely with the Hospital Documentation team (later known as the Hospital Discharge team) as well as two other strategic designers/researchers.

 

We used a rapid, iterative prototyping-feedback loop to identify must-have components and to define the overall framework for how those components would ultimately fit together. We prioritized modules that created external value in the short term and enabled us to learn how to increase that value over time.

Understanding Hospital Discharge & Building Empathy

Leading up to the official kick-off of this project I had completed a large amount of research, but wanted to continue to speak with users and bring other stakeholders, who had not previously been involved, along for the journey. We held a number of research calls with customers focusing primarily on two user groups, nurses and doctors. We followed our calls up with multiple site visits around the country to experience first hand the pain points of our current discharge process.

*Map of locations used for site research.

"A patient could have a great experience at the hospital, and the last thing they remember is the delays in discharge.”

     

- Shift Nurse

"We just hope nobody gets discharged over the weekend, because Shirley doesn’t work on weekends.”     

- Head Nurse

*User research being conducted at a Detroit area surgical and rehabilitation hospital.

The initial research I had conducted also helped me generate artifacts that could be shared with other stakeholders to help better facilitate some of the inherent complexities within our current workflow as well as a proposal for future improvements that could be made.

Synthesizing Our Findings

After conducting a number of rounds of research calls and site visits we took time to synthesize our findings. It's amazing how quickly a few gator boards, sharpies and a couple hundred sticky notes can bring together weeks of research! Through our synthesis we were able to pull out a number of key insights:

Finding the info I need is like searching for a needle in a haystack.

It’s unclear what happens to my data.

Discharge documents aren’t meaningful or useful to recipients.

I’m not sure what I need to do next.

Complexity isn’t the problem, coordination is!

Features don’t match the clinical mental model or complexity of needs.

*The "War Room" where all of our research synthesis and design concepts were created.
 

These key insights were then broken down further into themes that we would then use to help formulate a guiding design principle and set the corner stone for our concepts and eventual design direction.

1

Facilitate clear and efficient communication of care provided.

2

Improve date-of discharge efficiency by surfacing what needs to be finished.

3

Enable collaboration to ensure appropriate care continues beyond the stay.

Guiding Principle

"Create a place where the entire care team can coordinate & complete discharge work efficiently, starting when the patient is admitted and continuing until their care continues beyond the hospital."

Concept Generation & Validation

After synthesizing our research down to key themes and formulating our guiding principle we were ready to start generating concepts to validate with our users. For this project we decided to conduct two phases of concept testing. Each concept would look to answer specific questions that could help guide us closer to our final design.

Phase One consisted of 3 different concepts with 5 different users.

Concept A: "Guided"

  • What is the value of a more step-by-step workflow?

  • What is the value of a dedicated space to do discharge work?

Concept B: "Workspaces"

  • What is the value of a more collaborative workflow?

  • What is the value of a dedicated space to do discharge work?

Concept C: "Consolidated"

  • What is the value of an “all-in-one” screen/workspace?

  • What is the value of embedding discharge work in existing areas of the product?

  • What is the value of making a literal connection between input (documentation) and output (documents)

We used the first three concepts to determine the most intuitive mental model for organizing discharge work, validate required pieces and functionality, and identify what added the most perceived value to our users. These insights then helped inform the second round of concepts we tested.

 

Phase Two consisted of 2 different concepts with 5 different users.

Concept A: "Impactful"

  • What works or doesn’t for inpatient?

  • What features are “must-have” vs “nice-to-have”?

  • What works or doesn’t for ED/surgery?

Concept B: "Visionary"

  • What is the value of evolving each of the features?

  • How might it make sense to incorporate care planning in the future?

The second round of concepts enabled us to gain valuable insights into the features and flows that would become the new discharge experience and position athenahealth's discharge process for future expansion into other areas of the hospital outside of the inpatient care setting.

The Final Design

In the end I was able to delivery the Hospital Documentation team with an initial set of designs for the entire discharge workflow. These designs were also the first project to utilize athenahealth's in-progress design system, Forge, and gave me the ability to provide product specific input that impacted the global design system being built.

 

This re-imagined experience consisted of a new navigational paradigm that created a hierarchy which emphasized the key parts of inpatient discharge, providing easy access to everything our users needed without resulting in a prescribed workflow. This enabled us to build a scalable framework that ensured compliance and optimized patient care while still allowing for variation in mental model of our diverse user base.

The addition of a dedicated planning section was a brand new concept in our discharge process and the first piece of the project we prioritized on our road map. This new workflow piece directly impacted one the themes we had identified as part of our research, facilitate clear and efficient communication of care provided.

A clear checklist of items that needed to be completed in order to discharge patients helped ensure our users were staying compliant and not forgetting any important aspect of the patient discharge process. These features helped us improve date-of discharge efficiency by surfacing what needed to be finished.

Improved documentation provided users with a simplified process for generating important discharge documents prepared at the end of the patients stay. These documents helped lower hospital readmission rates and enabled collaboration to ensure appropriate care continued beyond the stay.

Measuring Success

In the end the design work done around athenahealth's discharge experience had an impressive impact on our users. We were able to drive adoption, save time, and impact the bottom line of every single hospital on athenahealth's network all while at the same time improving inpatient care and post discharge outcomes for tens of thousands of patients.

77%

Provide Patients with Discharge Education

Increase of 14.0%

(pre-GA 63.2%)

84%

Utilize Discharge Planning

Workflow

Increase of 44.4%

(pre-GA 39.6%)

1hr

Reduction in Time to Discharge

Out performing 

OKRs by +20%

In addition to the quantitative data that supported the impact this project had, our users loved it too!

"Amazing, Awesome, Super, Great! Love how easy it is to get to them and don’t have to add a new document every time! ”

     

- Shift Nurse

"Everyone is thrilled about it. All in one area, everyone can see what everyone is doing."

     

- IT Support Specialist

“Way easier to use than any EHR I’ve used before”

     

- Shift Nurse

© 2020 Daniel Reineberg.

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