Published in the April 2007 issue of Today’s Hospitalist
For years, hospitalists and primary care physicians alike have bemoaned the state of discharge communications. Now a new study not only sheds light on what’s wrong with that process, but gives hospitalists concrete steps they can take to improve the flow of information at discharge.
In examining more than 35 years of research on the topic, researchers found a situation that can be safely described as dire. In fact, the study, which appeared in the Feb. 28, 2007, Journal of the American Medical Association, reads like a catalog of what’s wrong with the discharge process.
The review of 73 studies found that discharge summaries often don’t make it to primary care physicians in time for follow-up visits. Patients see or talk to their primary care doctor before a detailed discharge summary arrives between 66% and 88% of the time. And in about 25% of cases, outpatient physicians never receive any discharge summary at all.
Even more disturbing, when discharge summaries do make it into the hands of primary care physicians, the reports often don’t provide all the relevant details. The review found that key information is frequently missing, including the main diagnosis (missing close to 18% of the time) and discharge medications (missing 21% of the time).
While no one can say precisely how missing information affects patient care, the article notes that one study found a trend toward higher re-admission rates when follow-up took place before a discharge summary arrived. According to another study, primary care physicians estimate that their follow-up management is hurt by the lack of information about 24% of the time.
The need for standardization
To anyone who has followed the literature on discharge snafus, the problems pointed out in this roundup will sound familiar. But lead author Sunil Kripalani, MD, MSc, found some surprises.
"I was struck by the fact that a lot of hospitals, at least those represented in the literature review, did not follow a structured process for their discharge communications," says Dr. Kripalani, assistant professor of medicine at Emory University School of Medicine in Atlanta and assistant director of the hospitalist program at Grady Memorial Hospital.
That lack of standardization is a problem, he explains, because research has found that without structure, discharge summaries suffer. "When a template is not followed," says Dr. Kripalani, "important information can be left out inadvertently."
What primary care physicians want
When the review looked at what primary care physicians say they want from discharge communication, researchers found that structured discharge summaries are high on the list.
That’s because these summaries probably come across physicians’ desk as part of a stack of many other papers that must be reviewed, Dr. Kripalani says. Having the ability to quickly glean information from a structured template probably increases doctors’ satisfaction.
While primary care physicians may prefer a structured discharge summary, less structured communications such as discharge letters actually reach them more often and more quickly. Studies found that a week after discharge, primary care physicians receive discharge letters 53% of the time, but they receive discharge summaries only 14.5% of the time.
According to Dr. Kripalani, discharge letters are likely sent more quickly because they’re often a carbon copy of patient instructions or a letter handwritten by the hospital physician on the day of discharge. While primary care physicians may prefer a more structured summary that contains all relevant details, the more loosely constructed letter appears to be the winner in terms of timeliness.
One problem with discharge summaries, Dr. Kripalani explains, is that they are usually prepared as a transcribed dictation, and there may not be a sense of urgency to complete them.
Physicians may wait until several discharges accumulate, which immediately creates delays. They then gather medical records, dictate the summary, wait for a transcript, correct that transcript and mail it to the primary care physician. This process may take too long for discharge summaries that need to be received by a primary care physician before the patient follows up, which may be only a few days after discharge.
Discharge letters, on the other hand, "are on the mind of the inpatient physician if they’re prepared immediately as part of the discharge process," Dr. Kripalani says. Discharge letters are often handed to the patient for delivery to the outpatient physician, "so they are more available when the patient follows up."
A hybrid approach
In an ideal world, Dr. Kripalani says, hospitalists would take a hybrid approach, incorporating the timeliness of discharge letters with the structured nature of discharge summaries.
"The ideal would be to complete a structured discharge summary on the day of discharge and deliver it immediately to the primary care physician," he explains. "If that is not feasible, hospitalists should complete a short handwritten summary on the day of discharge that includes the diagnoses, discharge medications, results of important procedures, specific things that require follow-up and any pending tests."
The review offers a box that distills recommendations from a number of studies. Dr. Kripalani says that some recommendations may be news to hospitalists because they come from studies that asked primary care physicians what they look for in discharge communications.
"Something that’s often absent from discharge summaries that primary care physicians want to know is what education has been provided to the patient and family," he explains. "Hospitals that already have a discharge summary template should make sure that this is included."
Dr. Kripalani also urges hospitalists to work with their information technology departments to develop a discharge summary template that could be populated automatically with information already in the patient’s record. Research has found that such an approach improves summary content and the timeliness of delivery.
The idea, Dr. Kripalani says, is simple. Take elements of the discharge summary already in the record “patient medications and allergies, name and age, date of admission and discharge, and consultations ” and have them entered automatically in the discharge summary, without the physician having to type a word. The hospitalist could then review and correct that data, and add specific information about the patient’s follow-up needs.
"Under this approach, the discharge summary is already half completed, and it can be finished more quickly," says Dr. Kripalani. "There are opportunities for hospitalists to become more engaged with their hospitals to develop a discharge document that works with their system."
Needed: a joint effort
Dr. Kripalani says his research also points out that a similar spirit of cooperation is needed between general internists and hospitalists if the discharge process is going to improve. He notes that the research was done by a joint task force of members from the Society of Hospital Medicine and the Society of General Internal Medicine.
A major problem with discharge communications, he says, is that hospitalists and primary care physicians alike picture a one-way pipeline. That notion, Dr. Kripalani explains, "has not promoted a two-way dialogue between the inpatient and outpatient setting."
Not only do hospitalists need to do a better job of communicating, he says, but outpatient physicians have to get more involved too. Primary care physicians, for example, could call the local hospitalist to review the case when a patient is headed to the hospital. They could even visit the hospital or call the hospitalist from time to time to touch base. That would make it that much easier, Dr. Kripalani points out, to have another conversation around the time of discharge to plan the patient’s follow-up care.
Edward Doyle is Editor of Today’s Hospitalist.