Transitions of Care Between Hospitalists and Office Internists

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Transitions of Care Between
Hospitalists and Office Internists
How to Better the “Handoff”
August 4th 2006
Eric E. Howell, MD
Assistant Professor, Johns Hopkins University School of Medicine
Johns Hopkins Bayview Medical Center
Hospital Medicine is Change
Hospital Medicine is Change
1893
1991
Hospital Medicine is Change
1893
1991
Change usually brings challenges
A Difficult Challenge for Hospital
Medicine is the Transition of Care
of Patients
Objectives: Bettering the “Handoff”
1) Review the data the discharge process
2) Identify components of the patient transfer that
are “high risk”
3) Evaluate three potential options for
improvement:
a) Communications between hospitalists and office
internists
b) IT solutions
c) Interdisciplinary teams aiding in the discharge
process
Discharge Scenario: Incidentaloma
• 65 year old man with chest pain
– CAD work up is negative
– Lung nodule on CXR: “compare to
previous CXR, or evaluate with CT”
– Prior to D/C:
• A PCP follow-up visit was arranged
• Medications prescriptions given
• Patient educated about nodule
– Discharged on day hospital day 2
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Clinical Scenario (cont)
• A discharge summary is sent to PCP with
CXR finding and recommendations
• Patient misses the follow up appointment
• Nine months later the patient visits PCP
• Work up of CXR finding begins
The Handoff: What’s the Big Deal?
• Hospitalists = Care Discontinuity =
Potential miscommunications
– Loss of information: “voltage drop”
– Confusion over responsibilities
– Potential patient dissatisfaction
• Communication important to physicians
and patients
• There is increased risk, medically &
legally, with poor communication
The Handoff & Patient Perceptions
• Vast majority satisfied with hospitalist – PCP
communications (90%)
• Majority thought PCP had important info to give
to the hospitalist
– Medical information (88%)
– Personal and family information (64%)
– Patient treatment and decision making preferences
(55 & 64% respectively)
• Majority thought the hospitalist had important
medical information for PCP (82%)
Hruby, how do patients view the role of the primary care physician in inpatient care? (Dis
Mon. 2002 Apr;48(4):230-8.)
The Handoff & Physician Perception
• Most PCPs desire handoff communication (78%)
• 63% of PCPs “always or usually” received D/C
summaries
• 56% of PCPs thought handoff satisfactory
• Mode of communication preferred varies:
–
–
–
–
Telephone
Face-to-face
Fax
Discharge summary
Pantilat, primary care physician attitudes regarding communication with hospitalists (Dis Mon. 2002
Apr;48(4):218-29.)
The Reality
• Hospitalist-PCP communication
documented 8% of time*
• Phone notification of D/C 31% of time 
• PCPs receive D/C summary by f/u
appointment only 8-33% of time  €
*Hruby, how do patients view the role of the primary care physician in inpatient care?
Pantilat, primary care physician attitudes regarding communication with hospitalists
€ Van Walraven, dissemination of discharge summaries. Not reaching follow-up physicians (Can Fam
Physician. 2002 Apr;48:737-42.)
Transfer Information at “High-Risk”
• On Admission
– Meds
– Code Status
– Other patient preferences
• On Discharge
– Meds
– Testing (completed, pending and planned)
– New diagnosis
Pantilat, primary care physician attitudes regarding communication with hospitalists
Handoff and the Patient
• Fumbled Handoffs Effect:
– Patient understanding
• Hospitalized patients had decreased
“communication problems” if PCP involved*
– Readmission:
• Post discharge follow-up by in-patient physician
decreased readmission
*Simon, communication problems for patients hospitalized with chest pain (J Gen Intern Med. 1998
Dec;13(12):836-8.)
van Walraven, continuity of care and patient outcomes after hospital discharge (J Gen Intern Med. 2004
Jun;19(6):624-31.)
Handoff and the Patient
• Fumbled Handoffs Effect:
– In-to-out patient communications:
• In-patient physician unaware of posthospitalization test results*
– Patient morbidity and mortality:
• Case report of patient death due to poor interphysician communications
*Roy, patient safety concerns arising from test results that return after hospital discharge (Ann
Intern Med. 2005 Jul 19;143(2):121-8.)
Capen, findings of negligence followed communication lapses in BC aneurysm case (CMAJ.
1997 Jan 1;156(1):49-51.)
Patient Transitions & The Law
• No hospitalist specific case law
• Legal precedent from care transitions before
hospitalists:
– Emergency Departments
– Radiologists
– Surgeons
– Between covering outpatient physicians
Can we apply lessons learned to Hospital Medicine?
Alpers, key legal principles for hospitalists (Dis Mon. 2002 Apr;48(4):197-206.)
The Law: Using Lessons Learned
• The hospitalist has a “duty” to the patient upon
discharge to assure care until the handoff is
complete
– Pending or “changed tests”
– Incidental findings
– Medical treatments started in-hospital
• PCP has a duty to the patient to
– Obtain hospital records if not received
– Ensure proper follow up once the handoff is complete
• The PCP and hospitalist share the risk
Alpers, key legal principles for hospitalists (Dis Mon. 2002 Apr;48(4):197-206.)
“The Rub”
•
•
•
•
Patients think we do well
Physicians think we do so-so
The data shows we do not do well
Evidence that highest risk when:
–
–
–
–
Incidental findings
Missed follow up
Changed test results
Medication changes
• There is case law indicating it is our duty
= Area ripe for improvement
Discharge Scenario: New Medication
• A 43 year old diabetic woman
is hospitalized with pneumonia
– ACE inhibitor started for HTN
– A discharge summary is done
– The patient is sent home
• The D/C summary is not available
during the follow-up visit, patient
does not bring information
• PCP does not check renal function
• Two months later the patient is hospitalized with
hyperkalemia and ARF
Bettering the Handoff
• Physician directed improvements
• Systems improvement
• Discharge facilitators/Multidisciplinary
teams
Physician Directed Improvements:
Benefits
• Important to physicians
• Good communication can:
– Decrease legal risk* 
– Decrease medical risk €
Applies to written, telephone or person-to-person
* Nelson, the importance of post-discharge telephone follow-up for hospitalists: a view from the trenches (Dis
Mon. 2002 Apr;48(4):273-5.)
Lester, listening and talking to patients: a remedy for malpractice suites? (West J Med. 1993
Mar;158(3):268-72.)
€ van Walraven, effect of discharge summary availability during post-discharge visits on hospital readmission
(J Gen Intern Med. 2002 Mar;17(3):186-92.)
Physician Directed Improvements:
Barriers
• Limited time
– PCP & hospitalist
• Varied communications preferences
– Phone
– Fax
– E-mail
• Little pressure to improve (to date)
How Physicians Communicate
• Telephone
• Paper documents & Fax
– Chart
– Discharge summary
• Electronic documents
– EMR
– E-mail
• In person
PCP Communication Preferences
• Telephone:
– Most prefer telephone contact (77%)
– Contact on admission and discharge
important (73%, 78%)
– Although less than half thought interruption
needed for important tests (48%)
– Few thought daily notification important (6%)
Pantilat, primary care physician attitudes regarding communication with hospitalists
Telephone Communication
• Shown to improve clinical outcomes in
other settings
– ER follow-up (Jones, a randomized trial to improve compliance in
urinary tract infection patients in the emergency department)
– Cancer patients (Kelly, ovarian cancer treatment: the benefit of
patient telephone follow-up post-chemotherapy)
– CAD after MI (Debusk, A case-management system for coronary risk
factor modification after acute MI)
– Follow-up of depression (Tutty, telephone counseling as an
adjunct to antidepressant treatment in the primary care setting)
Hospitalist-PCP Communication
via FAX
• Can be automatic (discharge summaries)
• Often received (63%) & often received too
late (69%)*
• May decrease readmission rates
*Pantilat, primary care physician attitudes regarding communication with hospitalists
van Walraven, effect of discharge summary availability during post-discharge visits on hospital readmission
Hospitalist-PCP Communication
via FAX
• No way to confirm it was received without
more communication
• No way to alert PCP when it arrives
• “One way”, no dialogue
Discharge Summaries
• PCP preferences
– Most (84%) indicate D/C summaries too detailed!
– Useful:
•
•
•
•
Meds
Diagnosis
Hospital procedure & test results
PCP follow-up date
– Not useful:
• Physical
• Code status
Pantilat, primary care physician attitudes regarding communication with hospitalists
Hospitalist-PCP Communication
• E-mail
– Few preferred e-mail (8%), although general
use was overall low (35%)
– Can be reviewed at one’s own pace
– Can allow confirmation of receipt
– Allows dialogue
Pantilat, primary care physician attitudes regarding communication with hospitalists
Hospitalist-PCP Communication
• E-mail
– Most systems not considered secure
– No data on effect on handoff
– Some data suggests it is less reliable for

clinical communications in general *
*Goldman, culture results via the internet: a novel way for communication after an emergency department
visit (J Pediatr. 2005 Aug;147(2):221-6.)
Ezenkwele, a randomized study of electronic mail versus telephone follow-up after emergency
department visit (J Emerg Med. 2003 Feb;24(2):125-30.)
Systems Improvements
• IT solutions
– No documented studies demonstrating
reduced risk, medically or legally
– Little data on effective systems as a whole
– Even in-hospital IT improvements in infancy
IT Solutions: National Database
Department of Health and Human Services:
“National electronic health records are 10 years
away”
Although interest in development is renewed
Scotland anyone?*
• e-communications used by minority
• Reliability and accessibility an issue
Pagliari, adoption of electronic clinical communications in Scotland (Inform Prim Care.
2005;13(2):97-104.)
IT Solutions
• Web based services
– Providing secure communication tools
between physicians
– Documents communications between
physicians
– Allows dialogue between PCP and Hospitalist
– May “auto search” for PCPs outside of
network
Discharge Planner: Effect
• Some studies show a decrease in
readmission rates*
• Other studies showed no decrease in readmission rate
• One study showed a potential decrease in
mortality
,€
§
*Naylor, the effects of a discharge planning and home follow-up intervention on elders hospitalized with
common medical and surgical conditions (J Cardiovasc Nurs. 1999 Oct;14(1):44-54.)
*Naylor, comprehensive discharge planning for the hospitalized elderly (Res Nurs Health. 1990
Oct;13(5):327-47.)

Cowan, the effect of a multidisciplinary hospitalist/physician model and advanced practice nurse
collaboration on hospital costs (J Nurs Adm. 2006 Feb;36(2):79-85.)
€
Einstadter, effect of a nurse case manager on postdischarge follow-up (J Gen Intern Med. 1996
Nov;11(11):684-8.)
§
Palmer, the effect of a hospitalist service with nurse discharge planner on patient care in an academic
teaching hospital (Am J Med. 2001 Dec 1;111(8):627-32.)
Discharge Planner: Effect
• Some models demonstrate cost
effectiveness in context of global care
• They do improve PCP follow up rate and
cost per case
• Most studies demonstrate decreased
LOS

,€,§
,§

Cowan, the effect of a multidisciplinary hospitalist/physician model and advanced practice nurse
collaboration on hospital costs
€
§
Einstadter, effect of a nurse case manager on postdischarge follow-up
Palmer, the effect of a hospitalist service with nurse discharge planner on patient care in an academic
teaching hospital
Discharge Scenario: Amended Result
• A 62 year old man is admitted with
abdominal pain
• A CT done and reviewed with attending
radiologist and hospitalist together
• A diagnosis of constipation is made:
patient is treated and discharged
• Two months later irate patient contacts
hospitalist demanding to know why he
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was not told of diagnosis of renal cell cancer
• CT was revised after initial read to include probable renal
cell carcinoma in report, with no communication to
hospitalist
Summary
• Hospitalist to PCP discharge process has risks
medically and legally, with the highest risk:
–
–
–
–
Incidental findings
Pending and/or revised hospital tests
Required testing as an outpatient
Medication changes
• PCPs and hospitalists share the risk burden
– Hospitalists have a duty to “provide care” after
discharge
– PCPs have a duty to obtain hospital data
Summary
• Any type of hospitalist-PCP communication
reduces that risk
• Verbal hospitalist to PCP communication should
be strongly considered for any discharge with
the highest risk (in addition to usual method)
–
–
–
–
Incidental findings
Pending and/or revised hospital tests
Required testing as an outpatient
Medication changes
Summary
• The data demonstrates poor performance on
hospitalist-PCP communication
– Written, verbal or faxed
• In general PCPs prefer telephone contact, but
contact method will need to be individualized
• No IT systems solutions developed, although
future promising
• Data on discharge facilitator demonstrates
– Improved PCP follow-up
– Decreased LOS
– Mixed data on improved clinical outcomes
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