H
ospitalized patients are in-creasingly being cared for by physicians other than their primary care providers (PCPs).1,2 However, communication between physicians caring for hospitalizedpatients and those patients’ PCPs is often suboptimal, which can lead to diminished health care quality and safety.3 It is hoped that better communication between hospitalist physicians and PCPs both during
and after a patient’s hospitalization will improve quality of care and de-crease medical errors.4-6 However, a recent multicenter trial has shown that PCPs’ receipt of information re-garding their hospitalized patients had no effect on patient outcomes, suggesting that “The presence of any communication is not the same as the receipt of high-quality commu-nication, and only the latter may be capable of improving outcomes.”7 The characteristics and effects of such high-quality information are, as yet, undefined.
Numerous studies and reviews have made recommendations to im-prove transitions of care from the hospital to the ambulatory setting, mainly focusing on communicating with the patient’s PCP, document-ing changes in the patient’s medi-cation regimen occurring during the hospitalization, planning ade-quate care for the patient during the transition, and facilitating commu-nication between physician and pa-tient.4,5, 8-11 These recommendations tend to center on the hospitalists’ or the patients’ perspective but not that of PCPs.4,5, 8-11 Little work has been performed to elucidate what information PCPs might find useful during the hospitalization to facili-tate their patient’s continuing care.12 From the Department of Medicine (all) and Department of Biomedical Informatics (Dr Handler), University of Pittsburgh, Pittsburgh, PA.
Information Primary Care
Physicians Want to Receive About
Their Hospitalized Patients
Kenneth J. Smith, MD, MS; Sunday Clark, ScD, MPH; Wishwa N. Kapoor, MD, MPH;
Steven M. Handler, MD, PhD
BACKGROUND AND OBJECTIVES: Communication between
phy-sicians caring for hospitalized patients and those patients’ primary care providers (PCPs) is often suboptimal, which can lead to di-minished health care quality and safety. It is unclear what hospi-tal information PCPs would find most valuable in their patients’ continuing care, as is how and when they would prefer to receive such information.
METHODS: Using the modified Delphi survey methodology, we de-veloped a consensus list of information items PCPs want to receive about their hospitalized patients, using general internists and fam-ily physicians considered experts in primary care. Panelists rated items on a 5-point Likert scale signifying their level of agreement with the information’s importance and with the information com-munication mode. Consensus agreement or disagreement was de-termined using 95% confidence intervals.
RESULTS: Twelve physicians (five family physicians, seven gen-eral internists), averaging 19.6 years of primary care experience, participated in Delphi round 1; 41.6% (37 of 89) of the items were accepted by consensus, one item was rejected (receiving daily progress notes), and the remaining 51 items were equivo-cal. In round 2, nine physician panelists participated (four family physicians, five general internists), and six additional items were accepted. They generally preferred notification at the patient’s first hospital interaction and at discharge. No consensus was found re-garding communication mode; e-mail was most favored.
CONCLUSIONS: We found broad areas of consensus regarding
information PCPs wish to receive about their hospitalized patients that are generally consistent with previous surveys. Our findings also suggest that physicians are becoming more comfortable with patient-related electronic communications.
Additionally, despite the availability of newer communication modalities, such as e-mail and Web-based tools, little is known about communication preferences of PCPs when communi-cating with hospitalists about their hospitalized patients.12 Attempts to define “high-quality communication” should include the input of PCPs to guide the efficient transmittal and use of hospital information.
Since there is an incomplete state of knowledge regarding PCP com-munication preferences, we used an Internet-based two-round modified Delphi survey to develop a consensus list of the information items PCPs want to receive about their hospi-talized patients and how and when they prefer to receive this information.
Methods
For the purposes of our study, we drew candidate information items from the published literature, focus-ing on (1) communication between the hospital and the PCP and be-tween the physician and patient, (2) changes in medication regimens dur-ing the hospitalization, and (3) care planning during transitions, con-centrating on those data elements that PCPs might consider relevant in their patients’ post-hospital care.4, 5,8-11 We also used published data regarding communication pref-erences of PCPs who have worked with hospitalists to develop candi-date items.12 Our intent was to in-clude a broad range of information items that PCPs might find valuable in the continuing care of their pa-tients, from which our PCP expert panel could choose the most valuable items. Candidate items are shown in the survey (available from author on request). Items were organized into categories including (1) emer-gency department evaluation, (2) admission-related information (the first 24 hours of a hospital stay), (3) interim information (>24 hours of a hospital stay), (4) any acute change in condition (such as cardiac arrest, respiratory failure, or acute men-tal status change), and (5) hospimen-tal discharge. We also asked the PCP
expert panel for their preferences regarding communication modality (ie, e-mail, pager, phone, letter, direct communication to office staff).
To obtain a consensus on the items PCPs might find most use-ful regarding their hospitalized pa-tients, we used an Internet-based, two-round modified Delphi survey of PCPs who are considered experts in their respective fields of family medicine and general internal med-icine. The Delphi methodology is a structured group interaction process, directed in ‘‘rounds’’ of opinion col-lection and feedback.13,14 Research suggests that a modified Internet-based Delphi consensus method can provide accurate and reliable assessments of clinical or informa-tional parameters by consulting a panel of experts and subsequently accepting the group consensus as the best estimate of the answer to a par-ticular question.15,16 This methodol-ogy differs from the Delphi process developed by the RAND Corpora-tion, where face-to-face meetings are used to achieve consensus;13,14 however, the modified Delphi al-lows easier, geographically uncon-strained contact between experts.15 Survey rounds were completed con-fidentially, allowing participants to present and react to ideas without being biased by knowing the other participants’ identities. PCPs cho-sen for the panel were either fam-ily physicians or general internists, recommended as experts in primary care, with the aim of having a physi-cian panel representing various US regions, as well as both community and academic primary care practic-es. The goal was to have a similar number of participants from fami-ly medicine and internal medicine. Family physicians were recommend-ed by physician members of the Uni-versity of Pittsburgh Department of Family Medicine; general internists were recommended by general inter-nal medicine division chiefs at sev-eral university programs. We invited 16 family physicians and 14 general internists to participate. Panelists re-ceived no compensation.
Panelists were invited to partici-pate via e-mail, with a maximum of three attempts to enlist their par-ticipation. Those who agreed were sent, via e-mail, the link to the sur-vey website. The sursur-vey consisted of all the candidate information items; participants were asked to rate each item on a 5-point Likert scale (from 1=strongly disagree to 5=strongly agree) based on their level of agree-ment with the information item’s importance in a patient’s continu-ing care. We also asked them to use the same 5-point Likert scale to rate their agreement with statements re-garding the communication modal-ity they prefer for information on their hospitalized patients. During the first round, participants were also given the option to suggest ad-ditional items; if two or more pan-elists suggested the same item be added, it would be included in the second round of the survey.15,17 The study was completed in March and April 2010.
Once round 1 of the Delphi was completed, results were tabulated and 95% confidence intervals (CIs) calculated for each item. Similar to previous studies, an item whose low-er 95% confidence limit was >4.0 (in-dicating consensus agreement) was denoted as accepted, and items with an upper 95% confidence limit <3.0 (indicating consensus disagreement) were rejected.15,17 Remaining items that were neither accepted nor re-jected were denoted as equivocal, and were included in round 2. In the Delphi second round, panelists received their own previous item re-sponses and item average scores for all panelists. After completion, round 2 scores and 95% CIs were calculat-ed, and additional items were accept-ed or rejectaccept-ed by consensus basaccept-ed on the criteria above. STATA version 11.0 (StataCorp, College Station, TX) was used for statistical analy-ses. Based on our prior work with Delphi panels,15,18 we felt it would be difficult to sustain interest among our physician panelists and retain them in sufficient numbers beyond two Delphi rounds. This study was
reviewed and considered exempt by the University of Pittsburgh Institu-tional Review Board, and informed consent was not necessary for study participation.
Results
Twelve physicians (five family physi-cians, seven general internists) par-ticipated in round 1 of the Delphi panel; five (42%) practice in commu-nity settings (the remainder practic-ing at urban, academic centers), and nine (75%) had their patients admit-ted regularly to a hospitalist service (of the remaining PCPs, two cared for some hospitalized patients, and one had patients admitted to other non-hospitalist services). They had an average of 19.6 years (standard deviation=8.3; range=8–30) of prima-ry care practice experience.
In round 1, based on the criteria outlined above, 41.6% (37 of 89) of the information items were accepted by consensus, one item was rejected (receiving daily progress notes), and the remaining 51 items were equivo-cal. No additional information items were suggested by two or more pan-elists. Nine of the PCPs who par-ticipated in round 1 (four family physicians, five general internists) participated in round 2, which con-sisted of the 51 equivocal items. In this round, 11.8% (6 of 51) additional items were accepted by consensus, with no consensus for acceptance or rejection found for the remaining items. All accepted items are shown in Table 1.
As shown in Table 1, the panel generally preferred notification at the patient’s first hospital interac-tion (eg, in the emergency depart-ment) and at discharge, without much contact in between, except for notification in the event of medical crises, such as cardiac arrest or re-spiratory failure. During the pre-admission and pre-admission phases, PCPs preferred to receive multi-ple data elements pertaining to the emergency department visit (phy-sician documentation, laboratories, radiology, and medications), notifica-tion of admitting diagnoses, and
con-PCPs preferred to receive a brief description of the hospital course (rather than an extensive one), dis-charge medication and medication reconciliation data, key findings and test results during the hospitaliza-tion, a listing of pending laborato-ries and other tests, and follow-up plans, among other data elements. After discharge, PCPs preferred to receive the results of pending labo-ratory, radiology, and diagnostic stud-ies.
PCPs came to no consensus garding their preferred mode of re-ceiving hospital information (Table 2). E-mail was most favored, with fax being the next most favored mode; regular mail was least favored. Trends against consensus acceptance or rejection were observed in round 2 compared to round 1.
Discussion
We found that PCPs prefer most communication regarding their hos-pitalized patients at the beginning and the end of a patient’s hospital-ization and that the information be concise and center on key findings, medications, and follow-up plans. During a patient’s hospitalization, PCPs only wanted to be notified about medical crises; they did not want to receive daily hospital prog-ress notes. While e-mail was the most favored mode of communica-tion, the panel did not come to a con-sensus on how they would prefer to receive communications about their hospitalized patients.
Our findings are consistent with published recommendations for im-proving care transitions at hospital discharge.4,5 These recommendations include communicating the present-ing problem, key findpresent-ings and test results, the final diagnoses, discharge medications and changes in medica-tions, follow-up plans, and pending tests on the day of discharge, fol-lowed by a more detailed discharge summary. The recommended dis-charge summary should be avail-able within 1 week and contain additional information: a brief hos-pital course, functional status at
dis-documentation of patient education and understanding, and anticipated problems and suggested interven-tions.
Our findings are also consistent, for the most part, with a 1998 sur-vey of PCPs, where more than half of PCPs said they would prefer to com-municate with hospitalists at admis-sion, at discharge, at the time of a major change in status (eg, a trans-fer to ICU or a change in resuscita-tion status).12 However, our results did not support notification at the time of major procedures, such as coronary or operative interventions, which was favored in that survey.12 Our panel favored receiving this in-formation at discharge, as with most other information pertaining to a pa-tient’s hospital stay.
The prior survey indicated that PCPs preferred to receive infor-mation via telephone rather than e-mail;12 in our survey, e-mail was most preferred, although no consen-sus was reached. We expect that e-mail will continue to become more acceptable with time, as might other electronic means of communication, such as web-based communication systems. Our findings, however, could certainly be biased in favor of e-mail given the e-mail-based recruitment process we used for our panel.
Also in keeping with prior sur-veys,19,20 PCPs are interested in receiving information about their pa-tients’ emergency department visits, an area where information transmit-tal to PCPs often falls short.21,22 In our survey, we made no distinction between emergency department vis-its that resulted in hospitalization and those that did not (survey avail-able from authors upon request). In one study, most physicians felt that emergency department visit infor-mation was essential in the continu-ing care of their patients.20 Another study found that use of a Web-based standardized communication sys-tem between an emergency depart-ment and family physicians led to more frequent and more useful in-formation exchange.23 Efforts to im-prove hospital communication with
Table 1: Information Primary Care Physicians Favored Receiving From Hospitals
Mean 95% CI
Pre-admission Status
Be notified of the patient’s Emergency Department (ED) visit 4.4 4.0–4.8 Receive physician documentation from the ED visit 4.7 4.4–5.0 Receive consultant physician evaluation 4.4 4.0–4.8 Receive ED medications discharged on 4.7 4.4–5.0 Receive ED laboratory study results and pending results 4.5 4.1–4.9 Receive ED radiology studies and reports 4.6 4.3–4.9 Receive ED diagnostic studies (other) and reports 4.6 4.3–4.9 Receive discharge instructions from the ED visit† 4.6 4.2–5.0
Admission-related information (data generated within the first 24 hours of admission)
Be notified of the patient’s admitting diagnosis(es) 4.4 4.0–4.8 Receive consultant evaluation† 4.4 4.0–4.8
Change in status information (occurring anytime after admission)
Be notified of medical crises (e.g., cardiac arrest, respiratory failure) 4.6 4.3–4.9
Discharge-related information (defined as information sent on the day of discharge)
Receive presenting problem 4.6 4.3–4.9 Receive key findings and test results 4.8 4.6–5.0 Receive discharge diagnosis(es) 4.7 4.3–5.0 Receive discharge medications 4.9 4.7–5.0 Receive comparison of discharge medications with admission medications (ie, medication
reconciliation)† 4.8 4.4–5.0
Receive list of changes in dosage and/or frequency in previous prescribed medications and
rationale for changes 4.6 4.3–4.9
Receive list of medications started during the hospitalization including rationale for
prescribing† 4.8 4.4–5.0
Receive list of medications discontinued during the hospitalization and rationale for
discontinuing 4.6 4.3–4.9
Receive pending laboratory and tests 4.6 4.2–5.0
Receive follow-up plan 4.8 4.5–5.0
Receive recommendations of subspecialty consultants 4.7 4.3–5.0
Information included in/with a discharge summary
Receive discharge diagnosis(es) 4.9 4.7–5.0 Receive name/contact information of the discharging physician† 4.6 4.2–5.0 Receive brief hospital course† 4.8 4.4–5.0
Receive lab results 4.7 4.4–5.0
Receive major procedures/treatments performed 4.9 4.7–5.0 Receive results of procedures 4.5 4.2–4.8 Receive responses to treatments 4.5 4.1–4.9 Receive recommendations of subspecialty consultants 4.8 4.6–5.0 Receive discharge medications 4.9 4.7–5.0 Receive comparison of discharge medications with admission medications 4.6 4.3–4.9
information about emergency de-partment visits to PCPs, given the perceived need for and usefulness of these data.
We did not include electronic med-ical records (EMRs) as a means of communication in our survey under the assumption that PCPs and hos-pitals are not necessarily part of the same health care system and, even if they are, they may not have com-patible EMR systems or EMR at all. In hospitals, EMR systems could au-tomatically compile information and
send it, at the prescribed times and in clear and concise formats, to PCPs in the mode that they prefer to re-ceive it, be it via EMR (if available), e-mail, or other means. We would not expect that PCPs’ preferred informa-tion would change based on mode of delivery. Automating the informa-tion sent from the hospital, rather than depending on hospital person-nel to obtain and deliver it, might be preferred if automatically extracted data could be reliably and reproduc-ibly sent to PCPs.
This study has limitations. We chose PCPs to participate in the Delphi panel based on colleagues’ recommendations, not on objective criteria. We took a number of steps in an attempt to minimize bias re-lated to participant selection. We in-cluded both family physicians and general internists so that a broader range of PCPs would be represent-ed in our expert panel and for the same reasons assured that physi-cians in both community and aca-demic practices and from different Table 1: Continued
Mean 95% CI
Information included in/with a discharge summary (continued)
Receive reasons for changes and indications for newly prescribed medications 4.5 4.2–4.8 Receive drug allergies; adverse drug reactions 4.7 4.4–5.0 Receive patient’s functional status at discharge 4.6 4.3–4.9 Receive patient’s cognitive status at discharge 4.6 4.3–4.9 Receive resuscitation/code status and other end-of-life issues 4.8 4.4–5.0 Receive pending laboratories and tests 4.8 4.4–5.0
Receive follow-up plan 4.9 4.7–5.0
Receive future appointments, procedures, and laboratory studies 4.7 4.4–5.0
Post discharge (defined as information generated following discharge)
Receive results of pending laboratory studies 4.8 4.4–5.0 Receive results of pending radiology studies 4.8 4.6–5.0 Receive results of pending diagnostic studies 4.8 4.6–5.0
† Panel consensus was not reached until Round 2 of the Delphi survey.
Means based on 5-point Likert scale with 1=strongly disagree and 5=strongly agree CI—confidence interval
Table 2: Primary Care Provider Preferences for Communication With the Hospital
Communication Preferences Mean 95% CI
Communications from the hospital should be via e-mail 4.2 3.4–5.0 Communications from the hospital should be via fax 3.4 2.7–4.1 Communications from the hospital should be via pager 3.0 2.5–3.5 Communications from the hospital should be via phone 2.9 2.3–3.5 Communications from the hospital should be via regular mail 2.3 1.7–3.0 Communications from the hospital should be routed through my office staff 3.1 2.4–3.8
Means based on 5-point Likert scale with 1=strongly disagree and 5=strongly agree CI—confidence interval
geographic regions were included. We are limited, however, by low response rates, but low response rates among physicians in survey-based research are common. It is not clear how many experts are needed to support a Delphi proce-dure, although it is suggested that fewer experts are needed when their backgrounds are similar.24 Another limitation, as mentioned above, is the electronic nature of our recruitment process and sur-vey procedures. Finally, our Del-phi procedure, unlike some other Delphi protocols, did not allow for direct face-to-face or telephone contact between panelists and hence may have hindered con-sensus being found on more sur-vey items.
We found broad areas of con-sensus regarding information PCPs wish to receive about their hospitalized patients. These find-ings are generally consistent with previous surveys. Our results also suggest that PCPs prefer to re-ceive information about their hos-pitalized patients at the beginning and end of the hospital stay, with less communication during the hospital course. While we found no consensus on how PCPs prefer to receive information, limiting the conclusions that can be made, e-mail was most favored, suggesting that physicians may be becoming more comfortable with electronic communications regarding their patients. In addition, electronic communication tools have the po-tential to facilitate PCPs’ commu-nication, allowing them to provide the information and perspective inherent in a patient continuity relationship and enhancing their patients’ care; future work inves-tigating the results of heightened two-way communication between PCPs and hospitals is warranted. Finally, in an era where hospital-ists appear to be a growing and enduring component of medical care, incorporating communication with and data from hospitalists into the workflow of office-based
physicians and their trainees will be an important aspect of their practice, as well as an educational challenge at all levels of training. Whether modern communication systems can efficiently and effec-tively transmit information that PCPs find valuable, facilitate in-teraction between office- and hos-pital-based physicians, and, most importantly, improve patient care requires further directed study in these areas.
ACKNOWLEDGMENTS: Funding for this project was received from the US Agency for Healthcare Research and Quality (R18 HS018151 and R01HS018721).
CORRESPONDING AUTHOR: Address cor-respondence to Dr Smith, University of Pittsburgh, Department of Medicine, 200 Meyran Ave, Suite 200, Pittsburgh, PA 15213. 412-647-4794. Fax: 412-246-6954. [email protected].
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