Published in the October 2012 issue of Today’s Hospitalist
HOSPITALISTS TAKE A LOT OF HEAT “sometimes justifiably so ” for not getting enough information fast enough to outpatient physicians after discharge. Studies have shown that discharge summaries can languish, and test results can go unreported.
But what about the information that hospitalists need from outpatient doctors to safely care for patients? A study that was first presented at the annual meeting of the Society of Hospital Medicine (SHM) this spring and is being published this month in the Journal of Clinical Outcomes Management decided to take a look. Results indicate that at least some primary care physicians could be a lot more accountable themselves.
A researcher from Penn State Hershey Medical Center in Hershey, Pa., faxed forms to the primary care physicians of 77 inpatients within 24 hours of admission. Those forms asked for key patient information, including medications and allergies. But only half (53%) of those doctors provided any response, and many of them didn’t return all the information that was asked for.
“If we’re going to have a discharge bundle, there should be an admission bundle too.”
Those results illustrate how often hospitalists have to fly blind in terms of knowing patient’s medications and diagnoses, according to researcher Eileen Hennrikus, MD. But findings also highlight how often communication around admissions is ignored, even as all the talk about transitional care becomes more amplified.
According to Dr. Hennrikus, her academic center has worked with SHM’s Project BOOST to enhance the discharge process. And she and her fellow hospitalists have made a strong push to improve handoffs in the hospital.
“But why did everybody forget about admission?” Dr. Hennrikus asks. “If we don’t get things right on admission, then everything is wrong all the way through. Every other transition has been addressed, but if we’re going to have a discharge bundle, there should be an admission bundle too.”
Complications from information technology
In asking primary care physicians for information, Dr. Hennrikus took her cue from Joint Commission national patient safety goals and from recommendations made by several specialty societies after a 2007 transitional care conference. The faxed forms asked for six categories of information: patient medications, problems, allergies, vaccinations, code status and date of last visit.
Dr. Hennrikus excluded inpatients for whom getting information was urgent. In such cases, she says, Penn Hershey staff got on the phone to retrieve the information needed. (Each of those calls, she notes, can easily eat up between 20 and 30 minutes of a doctor’s time.)
Also excluded were primary care physicians affiliated with Penn State Hershey who all share the same electronic medical record. For those patients, Dr. Hennrikus and her colleagues can see all outpatient notes, while outpatient doctors can read all inpatient entries.
But Dr. Hennrikus estimates that between 30% and 40% of the patients treated at the regional center aren’t covered by affiliated primary care physicians. Some of those unaffiliated doctors are only a mile away, while others are situated throughout rural eastern Pennsylvania. Then there are the providers she tries to reach in New York and Maryland whose patients visit Hershey Park, but then have an acute medical problem.
For all those patients, she says, information technology just seems to be throwing up more walls, not removing them.
“Each primary care office is getting its own software that doesn’t necessarily communicate with the hospital,” Dr. Hennrikus notes. “The information is out there, but it stays out there and doesn’t come to us.”
The loss of standardization
Then there’s the problem of what information does come back when outpatient offices respond. According to Dr. Hennrikus, that can be all over the map.
Many physicians in the study, for example, didn’t bother to check what information was requested. Some would have their staff fax back notes from only the patient’s last visit. Others would fax 25 (completely extraneous) pages from an outpatient chart.
A practicing physician for 30 years, Dr. Hennrikus points out that she was a primary care physician herself until 2000. “I was shocked when I began working as a hospitalist because I always kept an updated front sheet, all encompassing, for patients when I did outpatient work,” she says. “But when I became a hospitalist, I realized not everybody does that. There’s nothing standardized right now, and the things I got returned weren’t standardized at all.”
The lack of such a front sheet, she adds, points to changes that she thinks are due to the rise of hospital medicine. As an outpatient physician who used to follow her patients into the hospital, she needed just such a sheet. Now that outpatient physicians aren’t being called to the hospital in the middle of the night, their need to access immediate, accurate information about patients has decreased.
No more code-status discussions
Dr. Hennrikus also notes a major shift in the kind of information that primary care physicians maintain.
Among doctors who did respond to her faxed requests, 91% provided a list of patients’ medications. But only 88% responded with patient problems, 76% noted the patient’s last visit, 71% reported allergies, 65% sent back a record of vaccinations “and only 21% provided code status.
“I see that discussion just dropping,” she says about talks on end-of-life options. As a primary care physician who followed patients to the hospital, she made sure to have that time-consuming conversation about code status long before she was called to the hospital at 3 a.m.
“But I feel that’s getting pushed off the burner, and a lot of folks don’t talk about that,” says Dr. Hennrikus. “When someone comes in in extremis, it’s so hard to rapidly gain the trust of the family if they’ve never met you before. It puts us, the hospitalists, sometimes in a compromised situation.”
Finding the right format
Having quantified just how often informational requests from hospitalists go unanswered, Dr. Hennrikus says she’s trying to figure out what to do about it. She plans, for instance, to work with her center’s chief quality officer, who’s done a great job with Project BOOST.
She hopes that he and his team will be interested in “working on the other end,” she says. And looming changes in organizations and reimbursement “such as accountable care organizations and bundled payments ” could bring the need for better transitional communication into even sharper relief.
In the meantime, says Dr. Hennrikus, hospitals need “a standardized format of pertinent medical information that needs to be transferred” that can serve as an admission bundle. That format would probably look very much like the form she faxed out during her study.
“What we may do here is have the admitting department send that out, call each outpatient office and say, ‘Here is our admitting bundle, this is the information we need, please send it within the next 24 hours,’ ” Dr. Hennrikus says. “We need to make that a standard process like we’re doing for discharge. That might be a start.”
Phyllis Maguire is Executive Editor of Today’s Hospitalist.