Physicians Are Guardians of the Patient Transition

Oversight is vital to reducing readmissions


By Steven Schwartz, MD


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In the relay race to get hospital information on discharged patients to the next point of care, getting it right can be the exception vs. the rule. So many things can go awry. I see at least nine or ten specific weak links in the chain that can lead to improper medication or other treatment plan errors occurring over a patient’s transition.

Before joining Cleveland Clinic in 2013, I practiced in skilled nursing facilities (SNFs) across the Eastern and Midwestern United States, so I know the scope and consequences of this all too well. I’ve seen patients come into an SNF with medication lists that include the very combinations that put them in the hospital to begin with. I’ve found patients with diabetic ketoacidosis (DKA) transitioning to an SNF with no glucose monitoring or even insulin ordered for 24 hours after arrival. I’ve also seen patients who on an IV antibiotic at the hospital who arrive at the SNF with no antibiotic order at all because it didn’t transfer to the hospital discharge med list.

Several key culprits conspire against transition process integrity, including:

  • The sheer number of people providing care and entering data into both the hospital and SNF EMRs
  • Cut-and-paste options in electronic medical record (EMR) systems, which boost efficiency but also open the door for more error
  • Discrepancies between the foreseen and actual discharge day, resulting in discontinued meds and therapies remaining on the treatment plan, or new ones omitted due to a premature reconciliation
  • Multiple discharge med lists (with unexplained discrepancies among them)
  • Medication reconciliations performed by newer staff not intimately familiar with the case vs. the attending physician
  • Preadmission med lists that were not kept current

At the Center for Connected Care, the integrity of the handoff is one of many issues we tackle as part of our mission to coordinate care touch points for patients within the Cleveland Clinic health system. Effectively minding the baton prevents acute consequences of medication and other mix-ups, and impacts readmission rates. This is not just a dollars and cents issue because readmission for patients, especially elderly ones, is correlated with higher rates of delirium and overall health deterioration.


In this information age, does the solution lie with a universal EMR system? Only in part, and we are far away from the day we have that. What we can and must do now involves the human element — checking all the links in the chain to ensure that the final plan is correct and appropriate.

For me and my team, this means visiting SNF patients earlier and more often. I usually do a comprehensive visit with a transitioned patient, within one to two days of discharge to the SNF, and very carefully review the medical, hospitalization, and medications history, double-check the meds entered into the EMR at the SNF, and communicate with the patient and family. These steps help make sure each patient’s treatment plan and meds are correct before problems can arise from a confusing or incorrect record.

Cleveland Clinic leaders are prioritizing accurate reconciliations, with Nirav Vakharia, MD, Associate Chief Quality Officer, leading a team with this mission, and we are seeing improved accuracy rates. Efforts include:

  • For patients returning home, a pilot program where community paramedics make three visits within the first 30 days of discharge to review treatment plans and check for proper medications
  • A risk stratification tool that flags high-risk patients for pharmacists to review the records prior to discharge
  • Alerts in the computer system to ensure that reconciliation has been performed
  • A 30-day supply of medication for patients returning home, to ensure they are covered over the transition period

Efforts like these across the country have begun to produce results. The average 30-day readmission rate from SNFs has dropped from about a quarter to a fifth of all cases. For the years 2016 and 2017, our average Connected Care readmission rate at Cleveland Clinic has been between 16 and 17 percent and continues to improve each year.


In full recognition of the many opportunities for error, healthcare professionals have to remain vigilant and take nothing for granted. The human element remains exceedingly important. As long as systems have kinks and multiple people are inputting and manipulating data, comprehensive oversight is key. That is why we have physicians in our department dedicated to reviewing EMR records, a practice I highly recommend for all large healthcare practices.

Steven Schwartz, MD, is a geriatrician with Cleveland Clinic Center for Connected Care.

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