MedicalResearch.com Interview with:
Leora Horwitz, MD, MHS
Director, Center for Healthcare Innovation and Delivery Science
New York University Langone Medical Center
Director, Division of Healthcare Delivery Science
Department of Population Health, NYU School of Medicine
New York, NY 10016
Medical Research: What is the background for this study? What are the main findings?
Dr. Horwitz: We reviewed over 1500 discharge summaries from 46 hospitals around the nation that had been collected as part of a large randomized controlled trial (Telemonitoring to Improve Heart Failure Outcomes). All summaries were of patients who were admitted with heart failure and survived to discharge. We found that not one of them met all three criteria of being timely, transmitted to the right physician and fully comprehensive in content. We also found that hospitals varied very widely in their average quality. For instance, in some hospitals, 98% of summaries were completed on the day of discharge; in others, none were. In the accompanying Data Report, we show that summaries transmitted to outside clinicians and including more key content elements are associated with lower risk of rehospitalization within 30 days of discharge. This is the first study to demonstrate an association of discharge summary quality with readmission.
Medical Research: What should clinicians and patients take away from your report?
Dr. Horwitz: For clinicians, it is important to recognize the importance of discharge summaries as an essential part of transitions in care. Too often they are considered administrative busywork, of lower priority than clinical care or other types of documentation. There are always competing demands on time. New patients absolutely require a complete workup and full history and physical to be completed within 24 hours and existing patients require a note every day. By contrast, few hospitals require the discharge summary to be completed on the day of discharge. When faced with competing requirements when one has a hard deadline and the other doesn’t, it is easy to focus on the one with the deadline. Instead, it is critical to recognize the importance of the summary for patient outcomes. Clinicians should also take the time to critically assess their institution’s policies and procedures. Is there a requirement that the summary be done in a timely fashion? Is there a template that appropriately prioritizes information necessary for safe transitions in care (i.e. a focus on the discharge physical exam findings rather than the admission findings; a list of pending studies and needed follow-up)? Is the electronic medical record used to its full capacity? Does it automatically route summaries to outpatient clinicians? Does it automatically pull in pending studies and discharge vital signs?
Patients should recognize that their outpatient doctors might not know everything that happened to them in the hospital. They should ask for a copy of important documentation and carry it with them to their follow-up visits. All too often, that will be the only information their doctor will have about their hospitalization.
Medical Research: What recommendations do you have for future research as a result of this study?
Dr. Horwitz: As electronic health records get more sophisticated, and as clinicians and hospitals begin to recognize the importance of inpatient-outpatient communication at discharge, it is likely that discharge summary quality will improve. It will be important to study whether these improvements are associated with improved outcomes. It will also be important to study a variety of outcomes besides readmission. Do high quality discharge summaries reduce medication reconciliation errors? Loss to follow up? Duplicate studies? Do they improve primary care physician satisfaction? Many areas remain to explore.