Abstract 136: Complexity and Collaboration in Discharge Planning for Inpatient Cardiology

Background: Multidisciplinary, collaborative care improves outcomes and reduces costs but may unintentionally increase the operational overhead to manage the complexity of increasingly sophisticated teamwork. Objective: To quantify complexity of a standardized discharge planning process by closely examining team continuity, composition, and experience for both explicitly defined, deliberately organized teams and implicitly defined, organically assembled teams. Methods: We examined discharge planning team membership for inpatient cardiology encounters with a length of stay (LOS) greater than 48 hours for a three-year period from 2012-2014 in a large academic medical center. By constructing a co-affiliation graph from transactional EHR data, we determined the frequency of team occurrence and size. We then calculated the shared experience of teammates using a pairwise similarity metric and identified modularity, groups of healthcare personnel with dense connections, within the graph by applying a community detection algorithm. Results: We identified 52,254 transactions for 3,213 encounters with an average LOS of 8.7 days for the time period. The standard discharge planning team accounted for 41,101 (79%) transactions, consisted of 7 team member types, and comprised 709 individual providers performing 36 activities. We identified 569 additional discharge planning team members, consisting of 22 additional provider types. When constrained to only explicitly defined teams, 404 unique teams with an average size of 5.9 members occurred with a mean of 8 (min=1, max=118) shared encounters. When unconstrained, organically assembled teams with no explicit definition occurred 3,209 times (mean=1; min=1, max=3) with an average size of 7.3 members. Single-encounters accounted for 21,107 (62%) of all provider pairs. However, over 50% of all discharges had at least 1 pair sharing over 99 encounters (median=4 pairs). Community detection found 9 modules (range: 12-275 members) among pairs with more than 5 shared encounters. Conclusions: We have shown by deconstructing digital interactions via the EHR, a core group of providers, defined by role and activity, anchor most discharge planning teams. However, the EHR can also identify identify the 20% of teams with constantly recombining membership due to situational care; this can impose overhead when targeting team-wide process improvements, communication strategies, or educational initiatives.