Published in the January 2010 issue of Today’s Hospitalist
EVERYBODY KNOWS that discharge summaries need improvement, but a recent study confirms how “grossly inadequate” inpatient doctors are when it comes to using these documents to record tests with pending results.
Only 16% of tests with results pending at discharge make their way into discharge summaries, according to a study at two large academic hospitals in Indiana published in the September 2009 issue of the Journal of General Internal Medicine. The study found that while all patients in the study were waiting for test results at the time they left the hospital, only a quarter of discharge summaries mentioned any pending tests, and a scant 13% documented what those pending tests were.
The study’s lead author, hospitalist Martin C. Were, MD, MS, anticipated finding a problem, but he was shocked at the magnitude of information that goes missing. “We already know that outpatient providers aren’t very good at following up on pending tests documented in the discharge summary,” Dr. Were says. “Imagine how much worse the follow-up is when pending tests aren’t even documented.”
And while information technology might help manage pending test results, Dr. Were says that’s only half the battle. There are no accepted standards for who should receive those results and who is responsible for following up on them.
No better with experience
Previous research has shown that in about 10% of patients, an error will occur, Dr. Were says, “because somebody failed to look at an actionable test result.”
Dr. Were, an assistant professor of medicine at Indiana University School of Medicine in Indianapolis and a research scientist at Regenstrief Institute, says his study found that the rates of missing test results were the same regardless of whether the doctor preparing the discharge summary was an experienced attending, a rookie resident or a nurse practitioner. Researchers also found no real differences related to how long it took for test results to come back or to a patient’s length of stay.
“I expected discharge summaries to be inadequate, but I didn’t expect them to be that inadequate,” Dr. Were explains. “This is a universal problem.”
And it’s a problem, he adds, that’s being exacerbated by the growth of hospital medicine for two reasons: More and more patients are seen by separate inpatient and outpatient physicians, and sicker patients are being discharged sooner from hospitals.
Barriers to more complete information
Dr. Were is quick to point out, however, that fixing the gap and improving the handoff of pending test information is beyond the ability of individual hospitalists. Instead, he explains, solving the problem requires both technological improvement and administrative commitment.
Better systems “preferably electronic “are a start, Dr. Were explains, because it’s difficult for even the best-intentioned hospitalists to compile a list of all pending tests when they prepare a discharge summary. With tests ordered by multiple providers at various stages of a hospital stay, hospitalists would need to look at the admission, discharge and transfer systems, the order entry system, and the lab result system to comprehensively compile a list.
“In most places, these systems don’t communicate with each other,” Dr. Were says. “In the middle of preparing a discharge summary, you are just not going to be able to easily pull information from these separate systems.”
But the lack of superior technology is only one barrier. Even if hospitalists could create a comprehensive list of pending tests, they may not know who’s responsible for reviewing and following up on those results. “You talk to inpatient providers,” Dr. Were points out, “and some feel that once a patient is discharged, the results should be followed up by the outpatient provider.” Outpatient doctors, on the other hand, think that studies done in the inpatient setting “should be followed up by the inpatient providers.”
Whose job is it?
An example, Dr. Were says, would be an HIV test that comes back positive the day after the patient is discharged. “Who should tell the patient about this result?” he asks. Should it be the patient’s primary care doctor “presuming the patient even has one “or the hospitalist who ordered it, “because he or she knows why the test was ordered in the first place?” Crafting institutional policies that spell out who’s responsible when might help resolve that conflict.
Another issue is how hospitalists can identify tests that are essential and should be documented for outpatient follow-up. Because it’s impossible to tell in advance which results will be actionable, Dr. Were says, it’s not reasonable to include all pending tests in the summary because outpatient providers might follow up unnecessarily. Primary care physicians don’t need to know about every pending kidney function test or complete blood count ordered, especially if results have been normal throughout the hospitalization.
While Dr. Were is working on follow-up research to determine which physician should be responsible for pending tests, he says that for now, at least, the responsibility of reviewing results falls on hospitalists’ shoulders.
“Every result for a test that is ordered needs to be viewed by at least one provider,” he points out. If hospitalists fail to tell an outpatient doctor about tests, they should be held responsible for reviewing results “and acting on them if necessary.
As for solutions, “One institution might say, ‘We are going to have a dedicated nurse who works with the hospitalist group to triage test results,’ ” Dr. Were explains, “while another might have residents take responsibility for following up on the tests of hospitalists’ patients.” Closed health systems that employ both inpatient and outpatient physicians might take another route, asking their outpatient offices to follow up on pending test results because these physicians have easy access to results.
Given the increasing adoption of electronic medical records, Dr. Were strongly advises hospitalists to demand that these systems be able to easily identify tests with pending results at any point in a hospitalization. “You’d be surprised how many of the very expensive systems out there cannot tell which tests have pending results at any given time,” he says. “Providers need to get more involved as these systems come on board.”
Dr. Were’s research revolves around integrating admissions, ordering and lab computer systems so discharging physicians can easily call up a list of tests with pending results. Discharging physicians, he says, should be able to identify which pending tests should be included in a discharge summary, as well as which results should be sent to the outpatient physician. “The presumption will be that if a test is not documented in the summary,” he explains, “it is the hospitalist’s responsibility to follow up.”
Obviously, Dr. Were adds, “these interventions complement but don’t replace direct communication between physicians. We need to find a way to foster a discussion so outpatient providers don’t feel blindsided by our discharge documents.”
Deborah Gesensway is a freelance writer based in Toronto who reports on U.S. health care.