Medication discrepancies are explained to be the ‘unsolved differences between regimens patients think they should be taking and those ordered by their physicians across different sites of care’ (Schnipper, 2006). Unfortunately medication discrepancies are said to be common occurrence, especially after hospitalizations, and are a frequent cause of adverse events (ADE’s). A study published in 2006 revealed that medication discrepancies were found to be the cause of slightly over half of all preventable ADE’s that occur within 30 days after a hospitalization discharge (Schnipper, 2006).
Significant changes in patient medication regimens are common during hospital stays. The proper reconciliation and timely transfer of new treatment regimens improve the continuity of hospital handoff of patient treatment and ultimately prevent the likelihood of ADE’s (Sunil et al. 2007). A study of hospitalized elders found that 40% of all admission medications were discontinued by discharge and 45% of all discharge medications were newly started during the hospitalization (Schnipper, 2006). This study outcome clearly reveals the overwhelming potential for ADEs and the need for sufficient communication at transition points.
The discharge summary is the most common method for documenting the diagnostic findings, hospital management, and arrangements for post discharge follow-up of the patient (Sunil et al. 2007). The Joint Commission on Accreditation of Health care Organizations (JCAHO) recommends that discharge summaries for patients should be completed and sent to the primary care physician within 30 days of a hospital discharge. However, it seems that despite the setting of this standard procedure, inadequate communication still exits. One of the JCAHO’s national patient safety goals is the reconciliation of medications at care transitions (Sunil et al. 007). To date, JCAHO mandates reconciliation of medication at the time of hospital admission and discharge to reduce discrepancies and avoidable harm to patients.
Study Objective The focus of this study is to investigate the satisfaction and timeliness of hospital communication to primary caregivers referencing medication regimen changes and reconciliation made during a patients’ stay. Concentration was placed on the 65 and older Medicare group. Methodology Three separate face-to-face interviews were conducted with various health care practitioners in the primary care setting including Dr. Francisco Neira, Christina Elders PA-C. and Dr. Lindsay Foote of Baylor Family Health Center. Questionnaires were distributed to various medical staff members in the primary care setting. The medical staff members involved in our investigation includes six Primary Care Physicians, four Physician Assistants, and five Registered Nurse Practitioners. The questionnaire and interviews focused on all of the major points of our objective: satisfaction with hospital communication, satisfaction with timeliness of discharge summaries, and the quality and degree of information received about medication regimen changes implemented in the hospital.
Interviews and Surveys The communication between primary care providers, i. e. Primary Care Practitioners (PCPs), and secondary care providers, i. e. hospitals is imperative to deliver quality health care to patients and in preventing avoidable hospital readmissions (HealthCare. gov, 2011). When asked about the process through which the health care providers receive the information regarding a patient’s hospital discharge, all practitioners interviewed had varied experiences with different hospitals. Dr.
Neira, a private practice PCP described the process as ‘time consuming and never ending. ’ He explained that most of his patients are Medicare patients and need immediate follow-up attention after a hospital admission. Unfortunately, he mentioned that he rarely gets any information about the hospitalization of his patients, let alone new information regarding changes in patient medication regimens. Dr. Neira emphasized that he reviews patients’ medications during their prescheduled office visits, which can usually be well over several months after their hospital stay.
Hospitals typically send patients home with a list of current medications and instructions to visit their primary care providers but Dr. Neira explained that more often than not, patients do not follow-up. He also admits that there are great hospitals in the Dallas/Ft. Worth area that do an excellent job of sending out information immediately upon discharge and even call the office to facilitate the scheduling of a follow-up visit (Neira, F. 2011, June 25. Personal interview). Physician Assistant, Cristina Elders shares Dr. Neira’s frustration over the issue of receiving discharge information from hospitals.
In order to reconcile her patients’ medication, she or other members of the office staff track down hospital personnel to receive the most accurate information. Christina explained that her goal is to get all of the new medication information in by the time the patient is done with the visit so she can be sure the patient’s health is not further compromised by a simple and avoidable medication regimen error. Christina described setting appropriate expectations with her patients and insists that while they are under her care, they are to bring in all medication bottles with them on every visit.
The office has instituted a ‘No Bottles. No Service. ’ rule in their large primary care office that cares for a large Medicare patient base. The providers in the office look over all medication bottles in which patients bring in to make sure patients are taking what they should (Christina, E. 2011, June 26. Personal interview). Christina admitted that there are many hospitals in the area that do in fact send timely hospital summaries into the office without a prompt to do so. She explained that the hospital discharge summaries vary from hospital to hospital and are mostly faxed in.
The survey results indicate that all practices usually receive discharge information via fax and 46% of the respondents receive information via Electronic Medical Records (EMR). The health care practitioners had strong opinions on how timely and complete discharge summary letters are presented. Dr. Lindsay Foote, a Family Practitioner at Baylor Family Medical Center in Rockwall, Texas describes her satisfaction with the description of drug regimen changes given in the hospital as varied. Dr.
Foote explained that all hospitals handle information differently and more likely than not, offer incomplete information. Many times she is left filling in the blanks or having to call the hospital to gain clarification. Dr. Foote’s frustration is not only limited to hospitals that are out of the ‘Baylor Network’ but also within the network. She explained that within Baylor’s award winning integrated network, there are limitations to the information available especially with regard to medication regimen changes (Foote, L. 2011, July 1. Personal interview).
Baylor Health Care System was recently named 18th among the nation’s top 100 intergraded health care networks (Baylor Health Care System, 2011). Dr. Foote acknowledges that the intra-network physician portal provides tremendous capability of care integration and communication but much of it is not utilized as the information is not updated as timely as desired and details regarding the reasoning for drug regimen changes are difficult to access. Dr. Foote explained that hospital admissions usually lead to significant drug regimen changes that if not followed up on, could lead to severe consequences to the patient.
Neither Dr. Neira nor Christina is linked in to an electronic medical/health record system (EMR/EHR) and most of their information is received via fax. Both Dr. Neira and Christina say that they rarely get an explanation of drug regimen changes and hope that a simple and effective solution exists that will help them care for their fragile Medicare patients. The survey results show that over half of the surveyed HPCs have the same problem. We had 15 medical practitioners as a part of our survey analysis. Our survey asked HCPs how often they receive ischarge summaries without a direct request from the hospital; 53% of the respondents answered that they receive discharge summaries only sometimes, 27% responded always, and 20% of the respondents answered that they never receive such information The Survey results also reveal that 40% of the health care practitioners were either dissatisfied or extremely dissatisfied with the quality of discharge letters as a whole. It is also interesting to point out that 53% of the respondents were undecided and only 7% felt satisfied with the quality of the summaries.
When asked specifically about the degree of information provided over drug regimen changes implemented in the hospital, 60% of respondents responded that they were dissatisfied, 27% were undecided, and 13% gave a satisfied response. Additionally, 46% of the respondents answered that they were dissatisfied with the timeliness of discharge summaries, 34% responded undecided, and 20% of the respondents were satisfied. The survey tool is located in Appendix A, and the results of the survey can be located in Appendix B.
All of the practitioners interviewed were asked to provide recommendations on how to improve the discharge communication process during the transition of care from the hospital back to the PCP. Some suggested having an electronic system that is accessible to all points of care and is consistently updated, noting that although EMR/EHR systems exist, they do not always talk to each other. Having a clear hospital contact for each patient file and more patient education regarding hospital drug changes were also mentioned.
All providers revealed that a streamline of discharge summary information across all hospitals will help since many hospitals provide different documentation and some hospitals do it better than most. All practitioners mentioned that the Children’s Medical Center of Dallas shares its information remarkably well and benchmarking their approach would be best. Children’s Medical Center has developed a reputation for delivering information back to the primary care providers that is easy to access, easy to understand, and available when needed.
Literature Review: Previous and Continuing Research The question of how the discharge process from the secondary entity (hospitals) can be better connected and understood by the primary entity (primary physicians), is often asked in health care. This particular topic has been researched extensively, some models with promising results, from research to implementation. One such case is Project RED, done by a research group at the Boston University Medical Center. Project RED stands for Re-Engineered Discharge.
This program has several components and is currently being implemented in hospitals across the United States. The main components of the project include the following; 1) Educate the patient about his or her diagnosis throughout the hospital stay 2) Make appointments for clinician follow-up and post-discharge testing 3) Discuss with the patient any tests or studies that have been completed in the hospital and determine who will be responsible for following up on the results 4) Organize post-discharge services 5) Confirm the Medication Plan ) Reconcile the discharge plan with national guidelines and critical pathways 7) Review the appropriate steps for what to do if a problem arises 8) Expedite transmission of the Discharge Resume (summary) to the physicians (and other services such as the visiting nurses) accepting responsibility for the patient’s care after discharge 9) Assess the degree of understanding by asking the patient to explain the details of the plan in their own words 10) Give the patient a written discharge plan at the time of discharge 11) Provide telephone reinforcement of the discharge plan and problem-solving 2-3 days after discharge.
Step 8 is a particular focus as it deals with the transmission of the discharge summary to physicians and other medical professionals who will be caring for the patient post-discharge. This step includes a discharge resume that addresses: 1) Reason for hospitalization with specific principal diagnosis 2) Significant findings (when creating this document, the original source documents – e. g. laboratory, radiology, operative reports, and medication administration records – should be in the transcriber’s immediate possession and be visible when it is necessary to transcribe information from one document to another. 3) Procedures performed and care, treatment, and services provided to the patient 4) The patient’s condition at discharge 5) A comprehensive and reconciled medication list (including allergies) 6) A list of acute medical issues, tests, and studies for which confirmed results are pending at the time of discharge and require follow-up 7) Information regarding input from consultative services, including rehabilitation therapy The RED intervention is founded on 11 discrete, mutually reinforcing components and has been proven to reduce re-hospitalizations and yields high rates of patient satisfaction.
In addition, virtual patient advocates are being tested with RED, and the program is being implemented at various hospitals with diverse patient populations. The critical part of this research is that the discharge plan is being sent to the physicians who will care for the patient post-discharge, in addition to the patient, with in-depth steps for support services with regard to the patient’s understanding of the discharge plan. Many questions revolve around the most accurate way to communicate with the health care professionals in charge of the patient’s care once they have been discharged.
The United States health system has tried to answer this question, and ease the burden of having to obtain and keep patient information and records by implementing an electronic medical records system. This particular approach has been conducted in other countries as well. One of the articles from the International Journal of Integrated Care focuses on information management conducted by nurses when patients are discharged from the hospital to home care. The study was conducted by doctoral candidates from the University of Oslo, in Oslo, Norway.
The study specifically draws on the concept of inter-organizational continuity of care, and addresses the contribution of the electronic patient record (EPR) with regard to the discharge process. A questionnaire was used addressing the information that hospitals and home care nurses exchange when patients need continuing care after hospitalization. The study found that hospital and home care nurses differed in the way they assessed the structure and content of the information they exchanged, before and after the EPR implementation.
The study concluded that there is a need to take account of the different organizational contexts in which the two nursing groups work in. In further development of the EPR and the overall electronic medical records process, it is essential to clarify the context-related information needs of various health care provider groups as part of the commitment to patient safety and the reduction and/or elimination of hospital readmissions. This research study requires further study of the impact, clarity, and effectiveness of context-related information among health care provider groups (e. . hospital care versus post hospital care), as well as the opportunity to implement change that will increase patient safety and reduce hospital readmissions. Conclusion Proper reconciliation of medication upon hospital discharge is imperative to deliver quality care to patients and keep them safe as research shows that medication discrepancies are extremely common after discharge. Guidelines mandated by JCAHO are designed to prevent such discrepancies and improve patient safety.
Hospitals have the responsibility to implement processes and systems that ensure each step of medication reconciliation is performed accurately and delivered to the next provider of care quickly. Our research revealed that there are significant areas of improvement needed in both how patient information concerning drug changes is received, as well as the quality of information provided by hospitals back to the primary care provider. Based on our survey results and interviews, we found that the satisfaction of HCPs vary greatly from practice to practice.
Most HCPs surveyed were generally dissatisfied with the quality and timeliness of information they receive from hospitals regarding any changes in a patient’s drug regimen, if they receive any information at all. The information received through our interviews led us to conclude that much of the satisfaction of information received was dependent on the following factors: 1. Hospital affiliation – HCPs with strong hospital affiliations and partnerships seem to have better working relationships with the hospitals.
This collaboration between the two points of care often leads to better coordination and clarification of a hospital discharge. 2. EMR/EHR systems- Offices that utilize some sort of electronic records system appear to have higher satisfaction rates as the use of information technology allows quick access to medication information. 3. Amount of Medicare patients-The 65 and older Medicare group includes the more chronically ill patient type with higher hospitalizations; these patients are usually on many medications and are at higher risk for medication discrepancies.
Offices with a higher Medicare clientele seem to be the most dissatisfied as the retrieval and quality of discharge information is especially imperative in keeping patients safe. Lastly, as the complex world of health care continues to evolve, programs such as Project RED have been established to help navigate the intricacies and show promise in providing greater patient safety. The problem can only be remedied with true collaboration and coordination between physicians, nurses, pharmacists, and patients.
References Boston University Medical Center. (2007-2011). Project RED. Retrieved from http://www.bu.edu/fammed/projectred/index.html Healthcare.gov (2011, April).Healthcare.gov Retrieved on June 29, 2011 from Partnership for patients. http://www.healthcare.gov/center/programs/partnership/index.html Helleso,R., Sorensen, L., Lorensen, M. (2005, July). Nurses’ information management at patients’ discharge from hospital to home care. International Journal of Integrated Care, 5, 1-14. Retrieved from http://www.ijic.org/index.php/ijic/article/viewFile/133/266 Kind, Amy J. H MD, Smith, Maureen A. MD, MPH, PhD. Documentation of mandated discharge summary components in transitions from acute to sub-acute care. Schnipper, J. L. (2006, March) Role of pharmacists counseling in preventing adverse drug events after hospitalization. Retrieved July 20, 2011 from University of California, San Francisco: http://hospitalmedicine.ucsf.edu/improve/literature/discharge_committee/reengineering_system/role_of_pharmacist_counseling_in_prevent_ade_after_hosp_schnipper_ama.pdf Sunil, Kripalani. MD. MSc, LeFevre, Frank MD, Philips, Christopher O. MD, MPH, Williams, Mark V. MD, Basaviah, Preetha MD, Baker, David W. MD, MPH. (2007, February) Deficits in communication and information transfer between hospital-based and primary care physicians; implications for patient safety and continuity of care. Retrieved from www.jama.ama-assn.org, June 14, 2011