Background: Effective communication at hospital discharge between inpatient and outpatient providers is critical to improving transitions of care and reducing hospital readmissions. A key part of transitions communication is the hospital discharge summary (DCS). Prior studies show that DCSs are often not available to primary care providers (PCPs) at the time of hospital follow-up and that those PCPs are therefore unaware of the patient’s hospitalization and the important details that need follow-up [1,2]. Use of the electronic medical record (EMR) to facilitate creation and forwarding a DCS to PCPs should be standard practice to address this communication gap at discharge . In this quality improvement study, we compare manual and automated methodologies for improving the rate of DCS routing to PCPs.
Methods: Study population included patients discharged from our academic medical center by hospital medicine services from 8/1/20-11/16/21. Routing of a DCS to the PCP is expected to occur when the attending physician or advance practice provider applies their finalizing signature. The baseline performance or historical control occurred from 8/1/20 – 12/1/20 and was a period where providers could manually route the DCS but the workflow was not prioritized or automated.The 1st intervention period was 12/1/20 – 9/1/21 and involved prioritizing the routing workflow by encouraging providers to manually route the DCS. This was supported by:• Provider education – Faculty meetings focused on the importance of routing DCS to improve transitions of care • Physician profiling – Using audit feedback and peer comparison by showing unblinded data of providers’ routing performance • Passive dissemination – Via weekly reminders to hospitalists of the importance of routing DCS• Reminder system – Creating a “Vanishing Tip” in the DCS template that reminded providers to manually route the DCS to the PCP upon final signature.The 2nd intervention period was 9/1/21 – 11/16/21 and focused on automating the DCS routing workflow to the PCP of record at the time of final signature on the DCS. This was an automated forced function of the routing workflow using EMR processes.
Results: In the baseline period, 21.9% of all patients and 24.1% of medical center affiliated primary care (APC) patients had the DCS routed to the PCP. The 1st intervention of prioritizing the manual routing with extensive education achieved a routing rate of 42.6% for all patients and 49.3% for APC patients. The 2nd intervention of automatic routing achieved a routing rate of 68.0% for all patients and 87.6% for APC patients. See Figures 1 and 2.
Conclusions: This study was conducted to understand how to improve the routing rates of discharge summaries to improve transitions of care and reduce readmissions. The 1st intervention involving educational efforts, reminder systems, and physician profiling achieved improvement in routing rates to the range of 42.6% – 49.3% but left a substantial opportunity. The 2nd intervention focused on automated routing using EMR processes, achieving a range of 68.0% – 87.6% routing of DCS, with the remaining unable to be routed, mainly because of PCPs missing in EMR. These results are consistent with the quality improvement concept that educational efforts to address quality issues by changing providers’ practice behavior have some impact, but in isolation are not always effective . More significant improvement can be obtained from changing to workflow automation like DCS routing as a forced function.