Study shines light on poor transfer communications
Focus on discharge summaries can reduce problems
Quality improvement professionals have long known of the difficulties involved in discharge communications between hospital-based physicians and primary care physicians, but in the words of one observer, "This is the first time the problem has been quantified."
"This" is a new article in the Journal of the American Medical Association (JAMA), entitled "Deficits in Communication and Information Transfer Between Hospital-Based and Primary Care Physicians."1
Extracting data from observational studies, the researchers found that:
- Direct communication between hospital physicians and primary care physicians occurred infrequently (3%-20%);
- The availability of a discharge summary and the first post-discharge visit was low (12%-34%) and remained poor at four weeks, affecting the quality of care in approximately 25% of follow-up visits and contributing to primary care physician dissatisfaction;
- Discharge summaries often lacked important information such as diagnosis test results (missing from 33%-63%), treatment or hospital course (7%-22%), discharge medications (2%-40%), tests results pending at discharge (65%), patient or family counseling (90%-92%), and follow-up plans (2%-43%).
"As a hospitalist, I and my colleagues have had a lot of anecdotal experience about the communications around hospital discharge being poor," notes Sunil Kripalani, MD, MSc, assistant professor in the department of medicine, Emory University School of Medicine and assistant director of the hospitalist program at Grady Memorial Hospital, both in Atlanta, and lead author of the paper. "I am also trained in primary care, and, as such, I know these doctors feel they often don't have enough information about the patient. But [this problem] has never been emphasized formally, so we decided to flesh out the specifics of the problem and see what can be done about it."
Kripalani and his colleagues did just that; they not only put the problem squarely into focus, but they also laid out a template for a new discharge form they think will help eliminate many of the quality issues they detailed in the paper.
"We know that this is a huge issue, and it occurs with specialists as well as with hospitalists," adds Bev Cunningham, MS, RN, associate administrator, clinical performance improvement, Medical City Dallas Hospital.
"For example, if your pulmonologist gets a referral, especially if you are a referral center, your docs should take a very good look at making sure their communications with the primary physician are handled well."
Discharge communications, she continues, raise a number of important issues. "One is safety; the patient can definitely get 'lost,'" she asserts. "Second is The Joint Commission standard of handoff, which does include the physician. The third is results: If you want people to refer patients back to you, you want to have the right processes in place, because it can affect volume."
A matter of time?
While The Joint Commission does have standards pertaining to this issue, Kripalani says quality professionals should look beyond those standards to achieve optimal performance.
"I think one of our main findings was the 'disconnect' between the information that needs to be communicated promptly at hospital discharge and what the current Joint Commission requirements say," he asserts. "The majority of times the primary care physician does not have detailed information from the hospital when he begins follow-up care.
"One of the reasons is that the current performance standards hold discharge summaries under the umbrella of all other hospital records, so there is a 30-day time period for completing discharge summary, and the physician is not considered delinquent until a certain percentage of their records has been incomplete for 30 days. In other words, the physician may have several chart summaries not completed within one month before he is really considered an outlier."
That is just not sufficient for patient follow-up, Kripalani continues. "Patients often receive follow-up care within a week of discharge; I saw one study where the median was six days," he observes.
"This is so true," echoes Cunningham. "If someone comes here for a severe infection, or to see a big-time oncologist, what happens two days later when they are 100 miles away and their primary care doctor does not have a clue [about what happened]? It goes back to patient safety, which is why it is part of The Joint Commission standards and National Patient Safety Goals."
It's also why, she continues, a conscientious facility would not be satisfied with a 30-day wait, regardless of The Joint Commission's standards. "If you have a patient, regardless of the standard, why would we wait 30 days for that?" she poses.
But the first communication need not be written, she adds. "It could be a 'howdy' call, in which you give them a summary, and then document it," she offers. "It's like the immediate post-op note that you have to write in the record and then have to dictate."
At her facility, she says, "My hospitalist group is not employed [by the hospital], but the president of the group is entrepreneurial; he knows if his communication is good, his referrals will match. And I want him to have referrals, because I want full beds."
Cunningham provides her hospitalists with a nurse practitioner, who makes the "howdy calls," and then documents the calls. "In a smaller facility, it could be some sort of advanced practice nurse, or even a physician's assistant," she suggests.
Other ways to speed the process, Cunningham notes, include faxing the discharge form. "The other consideration here is with the EMR [electronic medical record]; as more and more hospitals move to this technology, it becomes easier to transition information from the patient's record to the physician electronically," she notes.
In any event, says Kripalani, time is of the essence. "There's a patient safety argument that can easily be made that information flow has to be prompt and complete — occurring within a week of discharge," he asserts. "Another line of thought is that perhaps the performance standard should be revisited."
Thus, to Kripalani's thinking, speed is not the only important element in discharge communication; the information that is received quickly should also be complete — ergo, the recommendations for a more detailed discharge form.
Elements of discharge summary
The researchers recommend, for example, that discharge summaries should include the following elements:
- primary and secondary diagnoses;
- pertinent medical history and physical findings;
- dates of hospitalization, treatment provided, and brief hospital course;
- results of procedures and abnormal laboratory test results;
- recommendations of any subspecialty consultants;
- information given to patient and family;
- the patient's condition or functional status at discharge;
- reconciled discharge medication regimen, with reasons for any changes and indications for newly prescribed medications;
- details of follow-up arrangements made;
- specific follow-up needs, including appointments or procedures to be scheduled, and tests pending at discharge;
- name and contact information of the responsible hospital physician.
"One important consideration from the process standpoint would be to systematize prompt completion of discharge summaries the day the patient is discharged," says Kripalani.
"Like most performance improvement initiatives, it should involve a multidiscipline approach; for example, in a hospital that relies on care managers to oversee the discharge process, you may make it their responsibility to ensure the form is completed. Other facilities may be configured around billing software, which could prompt the physician to enter the form when the charge is billed. There are a variety of ways completion could be anchored to something already in place in the individual hospital."
He adds that quality managers could play an important role by completing part of the form themselves, as well as by monitoring how consistently the new form is being used.
In tracking results, Kripalani thinks the successful use of the forms is worth measuring, but it's not everything. "Simply completing forms in a timely manner would be an improvement, but it wouldn't be optimal," he argues. "An optimal process would also include ensuring the primary care provider has received the form in a timely manner. The reason I mention that is, today, patients are sometimes admitted without having a designated primary care provider. In that context, it's expected that 15%-20% of the PCPs following these patients still may not receive the hospital information, perhaps because they were not the PCP at the time the patient left the hospital or they were but their contact information was not available." In the study, he notes, 15% of primary care physicians reported never receiving a discharge form.
A simple way to track performance, Kripalani continues, would be on a subset of the discharge documents. "Include a postcard for the PCP to return upon receipt of the information," he suggests. "That's a simple way of auditing; you could even have a date on it." A more hi-tech counterpart, he notes, would be e-mail.
Another way to measure performance/results, says Cunningham, would be a survey, which could be part of your documentation. As for anticipated results, she says. "I would hope it would impact readmissions, satisfaction of PCPs, and I would hope it would also impact patient satisfaction.
"We do our [patient satisfaction] work with Gallup; we're currently fixing it so that we can drill down to the physician level."
As more and more national organizations look at pay for performance and at physician and nurse satisfaction, she says, "There might be a question such as, 'If you are the patient of a hospitalist, did you feel your primary care provider had the necessary communications to take care of you?' Or, 'Did you have the information you needed to take care of yourself when you went home?'
"Another might be, 'Did you feel your hospitalist and primary care provider worked as a team after your discharge?'"
- Kripalani S, LeFevre F, Phillips CO, Williams MV, Basaviah P, and Baker DW. Deficits in Communication and Information Transfer Between Hospital-Based and Primary Care Physicians: Implications for Patient Safety and Continuity of Care. JAMA Feb. 28, 2007; 297, 8: 831-841.
[For more information contact:
Bev Cunningham, MS, RN, Associate Administrator, Clinical Performance Improvement, Medical City Dallas Hospital. Phone: (972) 566-6824. Fax: (972) 566-7533.
Sunil Kripalani, MD, MSc, Assistant Professor, Department of Medicine, Emory University School of Medicine, Atlanta, GA. Phone: (404) 449-1242.]