Wednesday, July 23, 2014

This Is An Obvious But Important Finding! Discharge Summaries Need To Arrive Promptly.

This appeared last week:

Late discharge letters frustrate GPs

16 July, 2014 Michael Woodhead
The frustration GPs feel over late-arriving hospital discharge letters is justified, according to a new study that shows tardy communication impairs patient management.
Researchers in WA have measured the additional burden created by delayed discharge letters, finding that GPs are unable to adequately manage a discharged patient's problems until they receive the all-important discharge information.
The study showed that a timely but brief discharge letter was preferable to a longer letter that arrived after a discharged patient had attended their GP.
And delayed discharge letters often meant that patients had to revisit their GP.
More here:
Here is the abstract:

BMJ Open 2014;4:e005475 doi:10.1136/bmjopen-2014-005475

A randomised trial deploying a simulation to investigate the impact of hospital discharge letters on patient care in general practice

  1. Moyez Jiwa1,
  2. Xingqiong Meng2,
  3. Carolyn O'Shea3,
  4. Parker Magin4,
  5. Ann Dadich5,
  6. Vinita Pillai1


Objective To determine how the timing and length of hospital discharge letters impact on the number of ongoing patient problems identified by general practitioners (GPs).
Trial design GPs were randomised into four groups. Each viewed a video monologue of an actor-patient as he might present to his GP following a hospital admission with 10 problems. GPs were provided with a medical record as well as a long or short discharge letter, which was available when the video was viewed or 1 week later. GPs indicated if they would prescribe, refer or order tests for the patient's problems.
Results Numbers randomised 59 GPs. Recruitment GPs were recruited from a network of 102 GPs across Australia. Numbers analysed 59 GPs. Outcome GPs who received the long letter immediately were more satisfied with this information... see link below for details
Conclusions Receiving information during patient consultation, as well as GP characteristics, influences the number of patient problems addressed.
Here is the link:
If ever there was a clear justification for using electronic messaging to get discharge summaries into the hands of GPs this is it. They need to be done on discharge and then transmitted directly. If the patient has a PCEHR they can go there as well - but the vital step is to use the secure message transmission to the GP that is already in place for results etc. in many, many practices. We know it works so it is hard to understand why it is not happening everywhere - other than the distraction that has afflicted us with the PCEHR Program.
It is interesting to note that simple and quick is seen as better than long but slower!


Terry Hannan said...

David, this reference to e-discharge summaries is not new. I also believe that the studies listed below provide strong arguments against the current PCEHR model(s) which is built upon the uploading of existing document structures. Terry
Communication of health care is maintained using a summary patient format in the
ambulatory setting
Fries. J. Alternatives in medical record formats. Medical care. 1984;12:871-881

Summary patient record - information accessible four times faster - contains up to four
times more information -Tabulated results allow physicians to better - predict future trends
in results.
Whiting-O’Keefe QW,Simborg DW,Epstein WV,Medical Care 1980;18:842-852

The use of existing low-cost technologies to enhance the medical record documentation
using a Summary Patient Record. S. Bart, T. Hannan. Proceedings MEDINFO2007, Brisbane
August 2007

Patients participating in our focus groups felt that providing printed summary information to patients at the end of a clinic visit improves their understanding of their care, enhances their relationships with providers, improves their satisfaction with care, and motivates them to adhere to treatment plans. Further empirical studies are necessary to test their perceptions.Informing Patients:A Guide for Providing Patient Health Information. J Am Med Inform Assoc. 1998;5:563–570.PAUL C. TANG, MD, CAROL NEWCOMB, MHSA

Interventions, including computer-generated discharge summaries and using patients as couriers, shortened the delivery time of discharge communications. Use of standardized formats to highlight the most pertinent information improved the perceived quality of documents.
Kripalani, Sunil MD, MSc; LeFevre, Frank MD; Phillips, Christopher O. MD, MPH; Williams, Mark V. MD; Basaviah, Preetha MD; Baker, David W. MD, MPH. Deficits in Communication and Information Transfer Between Hospital-Based and Primary Care Physicians Implications for Patient Safety and Continuity of CareJAMA. 2007;297:831-841
Physicians who more intensively interact with EHRs through their documentation style may pay greater attention to coded fields and clinical decision support and thus may deliver higher quality care. [CAD/Diabetes]
Dictation 9% QOC poorer on 3 measures - a/platelets, tobacco use, eye examination
• No measures better than Structured or Free Text
Structured documentation 29% QOC better on 3 measures-BP, BMI, diabetic foot examination
Free Text 62% QOC better on 1 measure- influenza vaccination
EHR-assessed quality is necessarily documentation-dependent, but physicians who dictated their notes appeared to have worse quality of care than physicians who used structured EHR documentation.
Method of electronic health record documentation and quality of primary care. Linder JA, Schnipper JL, Middleton B. Journal of the American Medical Informatics Association : JAMIA. 2012 May 19;
> 50% of AEs are related to poor communication
Diagnosis delays
Missed Rx
Redundant test ordering
Patient harm
Malpractice litigation
41% discharged before all tests reported
9.4% potentially actionable
38% physicians aware of TPAD [despite access to an integrated EMR]
Improved awareness rate TPAD 76% vs 38%, p<0.001
Attending Physicians 85% / PCP 63%
[Dalal AK, Roy CL, Poon EG, Williams DH, Nolido N, Yoon C, et al. Impact of an automated email notification system for results of tests pending at discharge: a cluster-randomized controlled trial. J Am Med Inform Assoc. 2014;21(3):473-80. Epub 2013/10/25.

Bernard Robertyson-Dunn said...

"Conclusions: Receiving information during patient consultation, as well as GP characteristics, influences the number of patient problems addressed."

Now there's a thing. Value associated with the nature, processing and use of information.

It's good to see at least some people putting value on the information, not the technology.