One of the persistent problems in our healthcare system is the communication gap between inpatient and outpatient care.
One of the persistent problems in our healthcare system is the communication gap between inpatient and outpatient care. The increasing use of electronic health records hasn’t really resolved this problem, because, unless ambulatory-care physicians are using the same EHR that their hospital is, comprehensive information about a patient’s inpatient care is still hard to obtain in a timely manner. Discharge summaries are supposed to contain this data, but they often arrive too late to be helpful; and even if a primary-care doctor receives this document soon after a patient’s discharge, it may be missing key information.
A recent study in the Journal of General Internal Medicine found that tests pending at discharge were mentioned in only a quarter of discharge summaries and that only 13 percent of the summaries stated what those tests were. “We already know that outpatient providers aren’t very good at following up on pending tests documented in the discharge summary,” commented Dr. Martin Were of the Regenstrief Institute, the study’s author, in an article about the study’s findings. “Imagine how much worse the follow-up is when pending tests aren’t even documented.” Were added that the growing use of hospitalists and the tendency to discharge sick patients faster make the situation even more alarming.
The discontinuity of care between hospitalists and outpatient physicians has been mentioned in a number of studies. Internist Robert Wachter of the University of California San Francisco, one of the hospital movement’s leaders, told me a few years ago that good hospitalists believe it is essential to contact referring doctors when one of their patients is discharged. “They ‘get’ that sending the patient back to the primary-care physician without the right information and without a phone call is a bad thing to do, both for the patient and in terms of the program’s credibility,” he said. But he admitted that some hospitalists in some programs are not very good about calling outpatient physicians; they might have a nurse or house doctor do it.
Even if the hospitalist does call the primary care doctor, he or she might not mention a pending test. The hospitalist might think it’s more important to focus on the most relevant issues in a brief call. There are also reasons why pending tests might not be documented in a discharge summary, Were points out. For example, multiple consultants order tests at different stages during a hospitalization. To find out which were pending, the hospitalist might have to pull information from several different hospital systems. Of course, that would not be the case in a hospital with a computerized physician order entry system-but only about 15 percent of hospitals have CPOE.
Even if hospitalists are aware of all pending tests, Were notes, they must distinguish between which are important enough to include in a discharge summary. Outpatient physicians will be annoyed if they are prompted to follow up unnecessarily on tests such as kidney function or CBC tests if the results had been normal throughout a patient’s hospitalization.
Another major issue is confusion over who has responsibility for following up on pending tests in the hospital, Were notes. Even if a primary-care physician knows about a pending test, he or she may feel that the inpatient physician should follow up. Hospitalists, on the other hand, may believe that, after a patient is discharged, the outpatient physician is responsible for all aspects of that patient’s care. But if a pending test is not documented, Were believes, it should be the responsibility of the hospitalist to follow up on it.
Blogger Kevin Pho observes, “Some hospitals have post-discharge clinics where hospitalists do the follow-up themselves, but that’s not commonplace. We clearly have a ways to go in bridging the communication gap between hospitalist and outpatient physician.”
This is an area that deserves much more attention, especially given the shockingly high readmission rate of Medicare patients. Part of the solution is to give hospitalists better tools and incentives for communicating all key inpatient data to primary care physicians, whether on the phone or in the discharge summary. In addition, as we build electronic health record systems in hospitals and physician offices, national health IT policy should prioritize the creation of electronic connectivity between inpatient and outpatient care settings.