BACKGROUND: Communication between hospital providers and primary care physicians at the time of hospital discharge is necessary for optimal patient care and safety. Content of the inpatient discharge summary (DS) is not uniformly addressed by residency programs.
OBJECTIVE: To improve DSs quality through a brief educational intervention.
METHODS: We prospectively enrolled interns (first-year pediatric residents [PL1s]) in an educational intervention that consisted of a group session in which components of a high-quality DS were taught and a subsequent brief small-group session in which key components with distribution of a reminder card were reiterated. Six key components were identified: diagnosis; timely completion; pending laboratory work/studies; medications; length ≤3 pages; and discharge weight. DSs prepared by PL1s before and after the small-group session were objectively scored by blinded reviewers on the basis of how many DS components they contained (maximum score: 6). Scores were compared with historical controls of PL1s from the previous year. Audit scores were analyzed by using a mixed-effects linear regression model.
RESULTS: Sixty-four PL1s were enrolled in the study; 477 DSs were scored. Mean score before the small-group reminder session was 3.6 in both groups. In mixed-effects models, scores in the intervention group increased by 0.56 points (P = .002) and DSs incorporating at least 5 of 6 components increased from 22% to 41% (P < .001) after the small-group session, whereas the control group's scores were unchanged.
CONCLUSION: A brief, low-intensity educational intervention can improve quality of discharge communication and be incorporated into residency training. Electronic templates should incorporate prompts for key components of a DS.
- discharge summary
- hospital discharge summary
- discharge planning
- residency training
- copy and paste
- resident education
- electronic medical record
- educational intervention
WHAT'S KNOWN ON THIS SUBJECT:
Good discharge communication is essential for high-quality care, but it is not uniformly addressed in residency training programs.
WHAT THIS STUDY ADDS:
The results of this study indicate that a brief, low-intensity educational intervention can significantly improve quality of discharge communication and can be incorporated into residency training.
The complexity and subspecialization of modern medicine has resulted in the evolution of a health care system in which many hospitalized patients are no longer cared for by their primary care physicians (PCPs) but, rather, by hospitalists and/or inpatient subspecialists. This new model of care has created an urgent need for strong communication between inpatient and outpatient physicians during transitions of care. Study results have indicated that direct communication between hospital PCPs during the discharge process occurs infrequently.1 The majority of PCPs believe that overall communication with hospital-based physicians regarding the discharge process is inadequate.1,–,4 PCPs typically rely on patients and families and on the hospital discharge summary (DS) to encapsulate what occurred during their patient's hospitalization, which places a strong emphasis on the need for accurate, timely, and effective DS. Good communication between inpatient and outpatient health care teams has been shown to decrease hospital readmission, the risk of medical errors, and adverse clinical outcomes.5,6
Elements of a high-quality DS elucidated in the literature include timeliness, conciseness, and inclusion of information critical to the PCP. The DS should be available to the PCP at the time of the patient's initial hospital follow-up visit and provide a brief summary of the hospital course, including presenting symptoms, significant examination, laboratory, or radiology findings, treatment rendered, and consultant recommendations. Additional information that is critical for preventing miscommunication includes that conveyed to the family about the illness, an updated medication list, and specific plans for care after patient discharge, including tests requiring follow-up.4,7,8
The importance of good communication is recognized as a core competency by the Accreditation Council for Graduate Medical Education (ACGME). The ACGME requires that resident physicians “demonstrate communication skills that result in effective exchange of information…with families and health care professionals…and maintain comprehensive and timely medical records.”9 Despite this mandate, most medical schools and residencies lack formal instruction on how to construct an effective DS. In addition, medical education remains focused on episodes of hospital care and neglects preparation for the transition of care to the PCP.10
Complicating the discharge communication discussion are unanticipated difficulties associated with electronic medical records (EMRs). EMR systems were developed initially to enhance information accessibility and improve clinical efficiency. However, along with newly transcribed information, many EMR systems allow information to easily be carried forward or cloned by using copy-and-paste and/or auto-population functions. These functions can lead to lengthy and difficult-to-read notes of uncertain accuracy. This form of clinical plagiarism11 has potentially deleterious consequences for the patient, particularly because it hinders clear and accurate communication of the medical encounter, and may put the provider at risk for overreimbursement and fraud.12 Furthermore, many practitioners lack familiarity with these potential drawbacks given the relatively short history of EMR use in the medical industry.
To address concerns about whether residents are adequately trained to develop a high-quality DS, and do so in the context of an EMR system, we developed a brief educational intervention for first-year pediatric residents (PL1s). We hypothesized that PL1s could be taught the critical components of a high-quality, electronically generated DS, resulting in increased inclusion of 6 key components of the DS: final diagnosis; timely completion; pending laboratory work/studies; medication list; length of ≤3 pages; and discharge weight.
The study was conducted by using a cohort of 28 pediatric and combined medicine-pediatric PL1s at a 136-bed tertiary care children's hospital within a publicly funded academic medical center. Thirty-six PL1s from the previous 12 months at the same institution served as historical controls. PL1s rotate for a 4-week block on the general pediatrics hospital service. This team discharges ∼10 to 15 patients per week; the average length of stay was 3.6 days from July 2007 to June 2008 and 3.0 days from July 2008 to June 2009.
The medical center at which this study was conducted uses an internally developed, fully integrated EMR that includes reports from inpatient and outpatient general and subspecialty encounters, ancillary service provider encounters, and laboratory, radiology, and pathology results. Inpatient DSs are generated by using a standard template into which results of laboratory, radiologic, and procedural data can be selected for auto-population. Additional information can be typed manually or copied and pasted from previously created patient records. DSs signed by a PL1 are forwarded electronically to the supervising physician, who then signs and routes an acceptable DS to an external provider via an integrated faxing system. The supervising physician may also edit the DS summary before it is sent to the PCP.
Study approval and waiver of consent was obtained through the University of North Carolina at Chapel Hill Biomedical Institutional Review Board.
Intervention and Design
Existing literature, as described above, confirmed by local consensus opinion, was used to define 6 key elements of a high-quality and timely DS. These 6 independent components were selected for the focus of the educational intervention and subsequent chart audit (Table 1). Each component was objectively defined, and written definitions were shared among the study investigators. Timeliness was defined as completion of the DS within 48 hours after discharge from the hospital.
The educational intervention consisted of 2 parts. The first part of the intervention was conducted during PL1 orientation and consisted of a 1-hour, interactive, large-group teaching session led by 1 of the study investigators who focused on the appropriate content and organization of a written DS. In addition, the investigator discussed the appropriate use of carried-forward information, otherwise known as the “cut-and-paste” function, through the EMR system. At this session, PL1s were given examples of poorly constructed DSs and asked to revise them as a group.
The second part of the intervention consisted of an individual reminder session with each of the PL1s during the second week of their 1-month inpatient general pediatrics hospital service rotation. These brief (5- to 10-minute) interactive sessions were led by 1 of 3 study investigators and allowed for focused questions from each PL1. Each PL1 was given both verbal instructions regarding inclusion of the 6 components and a reference pocket card with the 6 key elements of a DS. PL1s were informed that their DS would subsequently be audited.
DSs were audited for every patient discharged during the first and third weeks of each rotation, which represented the weeks before and after the individual reminder sessions. We used the PL1s serving on the inpatient general pediatrics rotation during the 12-month period before the start of the intervention (July 2007 to June 2008) as a historical control group. During this period, PL1s received no formal instruction or feedback regarding DSs. The same group of supervising physicians was in place during the entire 24-month period.
An administrative database generated a list of all patient discharges from the inpatient general pediatric team between July 2007 and June 2009. During that time period, the DSs eligible for audit included all DSs corresponding to discharges during weeks 1 and 3 of each 4-week block.
Each DS was printed, deidentified, and assigned a unique number by using a random-number generator.13 Audits were performed by 1 of 4 investigators blinded to the identity of the PL1, supervising physician, date, and intervention status. Possible scores for each DS ranged from 0 to 6 on the basis of inclusion of the 6 components listed in Table 1. One point was given for each fully completed component, and no partial points were given. In addition, ∼10% of the charts were audited by second reviewers for interrater reliability; a κ statistic of 0.75 indicated good agreement.
With bivariate analyses we compared total scores and the percentage of DSs with each component to examine differences between the control and intervention groups, as well as changes across time (before and after the individual reminder sessions). Audit scores were analyzed with a mixed linear regression model. We expected some improvement in scores throughout the first 12 months of residency (“residency experience”), so control and intervention subjects were matched on the basis of their month of internship. Fixed effects included intervention status (before intervention, July 2007 to June 2008, or after intervention, July 2008 to June 2009), timing within block (first or third week), and month of internship (0–11), as well as all interactions among the 3 variables. PL1s functioned as a random effect.
All analyses were performed by using Stata 10.0 (Stata Corp, College Station, TX).
A total of 64 PL1s were included in the study (28 in the intervention group and 36 who served as historical controls). There were 477 discharges from the inpatient general pediatric team during the weeks of interest for which DSs were written by a PL1. Of the DSs audited by investigators, there were 250 in the control group (106 in week 1, 144 in week 3) and 227 in the intervention group (94 in week 1, 133 in week 3). The number of DSs audited per PL1 ranged from 1 to 20.
In the first week, after having received only the large-group session, PL1s in the intervention group had similar total scores to those of the control PL1s (Table 2) but were more likely to have the DS sent to the PCP within 2 days and less likely to have a medication list in the DS. In week 3, however, after reinforcement, those in the intervention group had significantly higher total scores (4.11 vs 3.38; P < .001) and the DSs were significantly more likely to include the patient's discharge weight (60.9% vs 27.1%; P < .001) and pending laboratory work (41.4% vs 25.0%; P = .004) and to have been sent to the PCP in a timely manner (57.9% vs 20.1%; P < .001) (Fig 1). Between weeks 1 and 3, there were no significant changes in the control group in total score or the likelihood of including any specific component.
The total percentage of DSs with ≥5 of the 6 components was greater in the intervention group compared with the control group, both at week 1 and week 3. In week 3, 12% of the control group's DSs and 41% of the intervention group's DSs contained at least 5 of 6 items (P < .001). Also in week 3, after reinforcement, the intervention group was more likely to have ≥5 items than at week 1 (P = .003).
Multivariate models that controlled for the effect of residency experience yielded similar results of the effects of the intervention. The intervention effect was an increase of 0.88 points (P = .002) on final scores. Across time (from week 1 to week 3), the scores of the control group decreased in a nonsignificant manner by 0.13 points (P = .553); however, the scores of the intervention group improved significantly by 0.56 points (P = .002). As expected, residency experience had a positive effect on final scores (0.11 points per month, P = .001), but this effect was attenuated by the intervention, which resulted in a nonsignificant effect of residency experience among those in the intervention group.
The DS is an important component of the transition of care between the hospital physician and the PCP. As the care of patients in the inpatient and outpatient settings continues to fragment, this method of communication is and will continue to be extremely important. A high-quality DS is timely, concise, and inclusive of information critical to the PCP for follow-up care of the patient. We have shown that a low-intensity educational intervention addressing the components of a DS can significantly improve the quality and timeliness of DSs created by PL1s. This finding builds on a study performed by Myers et al,14 who conducted a similar but notably more time-consuming educational intervention with internal medicine residents using dictated DSs. Our study results build on existing data and show that DSs can be improved by an even less time-consuming educational intervention, that this improvement can be seen across specialties, and that this improvement is also applicable to electronic DSs.
EMR templates can standardize the content of documentation. However, in our study, even with the existence of a DS template, incorporation of important data or timely delivery of those data to PCPs did not consistently occur. The results of our intervention indicate that targeted education improves discharge communication by producing a more informative and available document and, thus, improves the transfer of information between inpatient and outpatient physicians.
An interesting observation was that the large-group session alone did not significantly alter mean total scores, although at week 1 the intervention group was more likely to have the DS sent to the PCP in a timely manner and more likely to have ≥5 components of the DS. This lack of effect may reflect the tendency of learned material to be better assimilated when the application is immediately evident and active learning is used. However, given that adult learners retain information more readily with repeated exposure, it is possible that the reminder sessions would not have been as successful without the initial group session.
Our data suggest that system-level changes in templates used for discharge communication have the potential to augment physician training and sustain improvement. This is supported by the fact that 2 of the 3 prompted criteria within our EMR, discharge diagnoses and medications, had high compliance levels at baseline. Discharge weight, which was not electronically prompted, was included twice as often when prompted by the educational intervention. Use of an electronic prompt for discharge weight could improve and sustain compliance with its inclusion.
Inclusion of the third prompted criteria, pending studies, was low at baseline and increased significantly after the educational intervention. We suspect that this low baseline inclusion was multifactorial. The “pending studies” field often requires searching for data that are not readily available, which increases the time needed for DS completion. Finally, PL1s may lack awareness of the importance of this information to the outpatient provider and especially to those providers who lack access to the inpatient facility's EMR.
The remaining 2 components, length of DS note and timeliness, were not prompted in the existing EMR. We were surprised that the average length of the DSs was ≤3 pages at baseline, because the perception was that they were typically longer; this component was unchanged after intervention. Timeliness improved significantly after PL1 DS education, indicating that the DSs were completed and signed by PL1s more rapidly and sent to the supervising physician, which is required before the automated fax system routes the DS to the PCP.
Our study had several limitations. First, 3 investigators were involved in the delivery of the intervention, which may have introduced stylistic differences between the individual reminder sessions despite our efforts to standardize content delivery by using written materials. Second, inherent differences between the control and intervention groups may have existed, because these groups comprised 2 different classes of PL1s. However, these differences were minimized by the relatively short time period and unchanged acceptance criteria for pediatric residency positions at our institution. Also, because PL1s in the intervention period were told that their DSs would be audited, some differences in the groups may have been seen as a result of the Hawthorne effect, a form of reactivity whereby subjects improve an aspect of their behavior while being experimentally measured simply in response to the fact that they are being studied. Third, there were small changes to the EMR during the study period, including a change from dictation to direct entry in October 2007, 4 months into the historical control year. These changes may have facilitated or hindered inclusion of some components of the DS.
A timely, accurate, and complete DS is an important component of medical communication. This communication is essential to the continuity of care between the inpatient and outpatient settings and is becoming more important as health systems become more complex and subspecialized. We have demonstrated that a brief educational intervention can significantly improve the quality of DSs created by PL1s. We recommend that medical training programs formalize instruction on the creation of timely and well-constructed electronic DSs. In addition, electronic templates should incorporate prompts for the key components of a DS to increase their inclusion in the medical record, and if possible, electronic templates should auto-populate with information from patient records within the EMR to improve efficiency and accuracy of discharge documentation. When required data are neither prompted nor straightforward, inclusion of these data are most affected by resident education. Thus, as payers and the federal government urge broad EMR implementation, system processes must be complimented with education and training of all users to ensure good-quality documentation.
- Accepted June 23, 2010.
- Address correspondence to Matthew C. Lewis, MD, Division of General Pediatrics and Adolescent Medicine, CB 7225, 333 S Columbia St, 231 MacNider Building, Chapel Hill, NC 27599-7225. E-mail:
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
- PCP =
- primary care physician •
- DS =
- discharge summary •
- EMR =
- electronic medical record •
- PL1 =
- first-year pediatric resident
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Noted by WVR, MD
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