Background: Inter-hospital transfer (IHT, patient transfers between acute care hospitals) is common among hospitalized medical patients (1). However, few data describe which patients may be exposed to the risks of discontinuity of care from IHT without clear benefit (i.e., undergo potentially inappropriate IHT). Methods: The POINT Study, “Identification and Prevention of Potentially Inappropriate Inter-Hospital Transfers” [...]

Background: Accurate and timely discharge summaries are critical to safe transitions of hospitalized patients to the outpatient setting and reduce readmissions1–6. However, composing the hospital course (HC) section of the discharge summary is laborious and time consuming, contributing to increased documentation burden7,8, work outside of work9, and clinician burnout10,11. Recent retrospective studies demonstrated that large [...]

Background: Physical function (PF) impairment is a key determinant of hospital discharge disposition, yet real-time PF assessments remain underutilized in inpatient care. The Patient-Reported Outcomes Measurement Information System Physical Function 5-item tool (PROMIS PF5, or PF5) was embedded into the electronic health record (EHR) across 21 Kaiser Permanente Northern California (KPNC) hospitals to standardize PF [...]

Background: Inter-hospital transfer (IHT, patient transfers between acute care hospitals) is common among hospitalized medical patients (1). However, few data describe which patients may be exposed to the risks of discontinuity of care from IHT without clear benefit (i.e., undergo potentially inappropriate IHT). Methods: The POINT Study, “Identification and Prevention of Potentially Inappropriate Inter-Hospital Transfers” [...]

Background: Accurate and timely discharge summaries are critical to safe transitions of hospitalized patients to the outpatient setting and reduce readmissions1–6. However, composing the hospital course (HC) section of the discharge summary is laborious and time consuming, contributing to increased documentation burden7,8, work outside of work9, and clinician burnout10,11. Recent retrospective studies demonstrated that large [...]

Background: Physical function (PF) impairment is a key determinant of hospital discharge disposition, yet real-time PF assessments remain underutilized in inpatient care. The Patient-Reported Outcomes Measurement Information System Physical Function 5-item tool (PROMIS PF5, or PF5) was embedded into the electronic health record (EHR) across 21 Kaiser Permanente Northern California (KPNC) hospitals to standardize PF [...]