Currently, healthcare systems rarely provide ideal transitions of care for discharged patients,[1] resulting in fragmented care,[2, 3, 4, 5] significant patient uncertainty about how to manage at home,[6, 7] and frequent adverse events.[8, 9] These factors are so commonly experienced by discharged patients that they are recognizable as a postdischarge syndrome.[10]

One element important for reducing the postdischarge risk of adverse events is provision of adequate follow‐up.[11, 12] However, supplying this care is challenging in the modern era, and it will become progressively more difficult to achieve. In 2004, 50% of readmitted Medicare fee‐for‐service patients had no postdischarge visit within 30 days of their discharge,[9] likely due in part to difficulty arranging such care. Changes in insurance coverage and demographics are expected to result in more than 100 million newly insured patients by 2019, yet the primary‐care workforce is projected to begin shrinking by 2016.[13, 14] In the increasingly uncommon situation that a primary‐care clinician is available promptly after discharge, information transfer is often inadequate[4, 15, 16, 17] and can be exacerbated by the growing discontinuity between inpatient and outpatient care.[2, 3, 4] Efforts to increase the supply of primary‐care clinicians and thereby improve early access to postdischarge care are important for the future, but hospitals, particularly those penalized for high risk‐adjusted readmission rates, are seeking novel solutions now.

One increasingly common innovation is to extend the role of inpatient providers (usually hospitalists) into the postdischarge period.[18] Preliminary evidence suggests improved continuity[19] and access[20] achieved by providing this care may decrease postdischarge adverse events,[19, 20, 21] though evidence is conflicting.[22]

As a closed, multilevel healthcare system, the Denver VA Medical Center is uniquely positioned to evaluate the influence of alternative postdischarge‐care strategies on subsequent adverse events. Discharged patients are seen in a well‐established hospitalist‐run postdischarge clinic (PDC), a robust urgent‐care system (UC), or by a large primary‐care provider (PCP) practice. The purpose of this study was to evaluate whether patients seen in a hospitalist‐run PDC have reduced adverse outcomes in the 30 days following hospital discharge compared with follow‐up with the patient's PCP or in an UC clinic.

METHODS

RESULTS

9952 patients who met criteria were discharged during this time period; however, 48.9% did not follow up with one of these clinics within 30 days, leaving 5085 patients in our analysis. Of these, 538 followed up in PDC (10.6%), 1848 followed up with their PCP (36.3%), and 2699 followed up in UC (53.1%). Table 1 presents predischarge characteristics of these patients. Patients seen in PDC were older and had a more significant comorbidity burden.

Patients seen in PDC had a mean 2.4‐day shorter LOS than those seen by their PCPs (PDC: 3.8 days, UC: 5.0 days, PCP: 6.2 days; P=0.04 for comparison). Neither the percentage of patients admitted to the ICU during their index hospitalization nor the ICU LOS was different between groups. Patients were seen earlier postdischarge in PDC than in other types of follow‐up (PDC: 5.0 days, UC: 9.4 days, PCP: 13.7 days; P<0.01 for comparison). In univariate analysis, there was no difference between groups in the composite 30‐day outcome (Table 2). Analysis of the individual components of the primary outcome revealed significant differences in readmission rates, with PDC having the highest rate.

Univariate analyses conducted on predischarge characteristics after multinomial propensity scoring revealed significant differences between groups no longer existed for the variables that were included in the propensity score (age, Elixhauser score, and inpatient stays prior to visit; Table 1).

In multivariate analysis comparing PDC to PCP follow‐up, there was no difference in the composite outcome after controlling for propensity score and time to outpatient visit (odds ratio [OR]: 1.07, 95% confidence interval [CI]: 0.81‐1.40). Similar results were obtained in comparing PDC with UC (OR: 1.05, 95% CI: 0.82‐1.34) and in multinomial logistic regression comparing PDC with other types of follow‐up (PDC vs PCP: OR: 1.01, 95% CI: 0.78‐1.31; PDC vs UC: OR: 0.99, 95% CI: 0.78‐1.26).

Restricting the multivariate analysis to those patients discharged with one of the 5 discharge DRGs most associated with readmission did not alter our findings regarding the primary outcome. We also found no change in the composite outcome or any subcomponent of the composite outcome when restricting the analysis to 7‐day outcomes or when excluding scheduled readmissions (which represented <5% of all readmission).

DISCUSSION

A hospitalist‐run postdischarge clinic did not reduce a composite of 30‐day postdischarge adverse outcomes in our study when compared with primary‐care or urgent‐care follow‐up. In fact, patients who followed up in PDC had a small increase in 30‐day readmissions. However, they also were sicker at baseline, considered higher risk by the discharging physician, were able to be seen significantly earlier, and had an associated 2.4‐day shorter hospital LOS than patients seen by their PCPs.

Our findings do not confirm those of prior research in this area, which indicated outpatient follow‐up by the same physician who was the treating inpatient physician was linked to lower mortality rates, hospital readmissions, and ED utilization.[19, 20, 21] In fact, in our study, there was a significant (albeit small) increase in 30‐day readmissions in patients seen in PDC. There are significant challenges to the generalizability and validity of these prior studies. In one study, inpatient care was provided by outpatient primary‐care doctors in Canada,[19] a payer and care model rare in the United States.[25] In a second, usual care was not specified, and it is likely the reduction in ED visits resulted from provision of follow‐up care of any kind compared with those who did not follow up after discharge.[20] In a third, the PDC was part of a larger bundle of postdischarge interventions, and it only reduced ED visits when compared with patients who did not have follow‐up; rates of ED visits were similar in a comparison with PCP follow‐up.[21]

There are several possible explanations for the lack of improvement in 30‐day adverse outcomes with a hospitalist‐run PDC. First, although early access to early postdischarge care was improved and evidence suggests this is important in reducing readmissions,[11, 12] in populations similar to that studied, more postdischarge care has also been linked to increased readmissions.[22] This may be due to more frequent re‐evaluation of fragile, chronically ill patients, presenting more options for readmission. Second, the intervention currently only addresses some components of the Ideal Transition of Care[1] (Figure 1) and may benefit from an enhanced visit structure using a multidisciplinary approach. Third, the intervention took place in the context of a robust primary‐care system with a universal electronic medical record; the effects of improved access and continuity may be magnified in a system without these advantages. Fourth, there was a low readmission rate overall, and it is unclear how many of these readmissions were preventable. Finally, it may be that although the initial postdischarge care was adequate, readmissions occurred after the first visit, suggesting subsequent care during the 30 days postdischarge could have been improved.

Figure 1

The most likely explanation for the substantially decreased LOS associated with follow‐up in PDC is that inpatient physicians who knew they could see their own patients early in the postdischarge process were more tolerant of uncertainty surrounding the patients' clinical course.

For example, a frequent clinical conundrum for hospitalists is when to discharge patients improving on diuretic therapy for a heart failure exacerbation or antibiotics for cellulitis. Provided a PDC, these hospitalists may choose to discharge a patient still actively being treated, because they may feel they have access to early follow‐up to change course if needed as well as the ability to see the patient themselves, allowing precise evaluation of the change in their condition. Without this clinic, the hospitalist may wonder when postdischarge follow‐up will occur. They may be more hesitant to discharge a patient who has not fully completed treatment for fear he or she will still appear decompensated to the postdischarge provider (though greatly improved from admission), or will not have timely‐enough follow‐up to change treatment if the condition worsens.

Our finding that the LOS was still shorter when comparing PDC with UC suggests continuity may be a significant component of this effect. It seems unlikely that patients following up in PDC had less complex hospitalizations given similar ICU exposure and LOS, as well as older age and larger baseline comorbidity burden.

The LOS seen in patients who followed up in PDC was lower than Medicare rates[26] but similar to reported rates at other VA acute‐care hospitals.[27] It is consistent with prior findings that hospitalist care reduces LOS,[26] though the magnitude in our study was much larger than that in prior reports. Prior studies have suggested this decreased LOS is linked to increased adverse postdischarge outcomes, such as ED visits and readmissions, as well as increased costs and decreased discharges to home.[28] The PDC was not associated with increased postdischarge adverse events measured, though a formal cost analysis and analysis of other postdischarge outcomes, such as placement in a skilled nursing or rehabilitation facility after return home, could be assessed in future work.

The findings of our study should be interpreted in the context of the study design. Our study was retrospective, observational, and single‐center. There may have been additional baseline differences between groups predisposing to bias we did not capture in the propensity score. For example, we could not measure rates of attendance at the different clinics and cannot rule out that outcomes associated with PDC were also associated with increased attendance rates. However, none of the clinics had mechanisms in place to improve follow‐up rates; patients referred to PDC were those considered highest risk for readmission and were sicker at baseline, making it very unlikely that they were predisposed to attend clinic more frequently and/or to have better outcomes; and even if PDC improved follow‐up rates, this would be a significant contribution given the limitations of primary‐care access. Our propensity score could not perfectly mimic randomization to a treatment assignment, but rather to treatment received, because of this limitation.

We did not ascertain ED visits or readmissions outside the VA system; it is possible these differentially affected one group more than another, though this seems unlikely. Our patient population was representative of veteran populations elsewhere who are at high risk of adverse postdischarge outcomes, but our findings may not be generalizable to younger, more ethnically diverse populations or to women.

CONCLUSIONS

Provision of postdischarge care by hospitalists may reduce LOS without increasing postdischarge adverse events. Further work is required to evaluate the role of hospitalist‐run PDCs in healthcare systems with more limited postdischarge access to care, to formally evaluate the costs associated with extending hospitalists to the outpatient setting, and to prospectively evaluate the role of a PDC compared with other kinds of hospital follow‐up.

Currently, healthcare systems rarely provide ideal transitions of care for discharged patients,[1] resulting in fragmented care,[2, 3, 4, 5] significant patient uncertainty about how to manage at home,[6, 7] and frequent adverse events.[8, 9] These factors are so commonly experienced by discharged patients that they are recognizable as a postdischarge syndrome.[10]

One element important for reducing the postdischarge risk of adverse events is provision of adequate follow‐up.[11, 12] However, supplying this care is challenging in the modern era, and it will become progressively more difficult to achieve. In 2004, 50% of readmitted Medicare fee‐for‐service patients had no postdischarge visit within 30 days of their discharge,[9] likely due in part to difficulty arranging such care. Changes in insurance coverage and demographics are expected to result in more than 100 million newly insured patients by 2019, yet the primary‐care workforce is projected to begin shrinking by 2016.[13, 14] In the increasingly uncommon situation that a primary‐care clinician is available promptly after discharge, information transfer is often inadequate[4, 15, 16, 17] and can be exacerbated by the growing discontinuity between inpatient and outpatient care.[2, 3, 4] Efforts to increase the supply of primary‐care clinicians and thereby improve early access to postdischarge care are important for the future, but hospitals, particularly those penalized for high risk‐adjusted readmission rates, are seeking novel solutions now.

One increasingly common innovation is to extend the role of inpatient providers (usually hospitalists) into the postdischarge period.[18] Preliminary evidence suggests improved continuity[19] and access[20] achieved by providing this care may decrease postdischarge adverse events,[19, 20, 21] though evidence is conflicting.[22]

As a closed, multilevel healthcare system, the Denver VA Medical Center is uniquely positioned to evaluate the influence of alternative postdischarge‐care strategies on subsequent adverse events. Discharged patients are seen in a well‐established hospitalist‐run postdischarge clinic (PDC), a robust urgent‐care system (UC), or by a large primary‐care provider (PCP) practice. The purpose of this study was to evaluate whether patients seen in a hospitalist‐run PDC have reduced adverse outcomes in the 30 days following hospital discharge compared with follow‐up with the patient's PCP or in an UC clinic.

METHODS

RESULTS

9952 patients who met criteria were discharged during this time period; however, 48.9% did not follow up with one of these clinics within 30 days, leaving 5085 patients in our analysis. Of these, 538 followed up in PDC (10.6%), 1848 followed up with their PCP (36.3%), and 2699 followed up in UC (53.1%). Table 1 presents predischarge characteristics of these patients. Patients seen in PDC were older and had a more significant comorbidity burden.

Patients seen in PDC had a mean 2.4‐day shorter LOS than those seen by their PCPs (PDC: 3.8 days, UC: 5.0 days, PCP: 6.2 days; P=0.04 for comparison). Neither the percentage of patients admitted to the ICU during their index hospitalization nor the ICU LOS was different between groups. Patients were seen earlier postdischarge in PDC than in other types of follow‐up (PDC: 5.0 days, UC: 9.4 days, PCP: 13.7 days; P<0.01 for comparison). In univariate analysis, there was no difference between groups in the composite 30‐day outcome (Table 2). Analysis of the individual components of the primary outcome revealed significant differences in readmission rates, with PDC having the highest rate.

Univariate analyses conducted on predischarge characteristics after multinomial propensity scoring revealed significant differences between groups no longer existed for the variables that were included in the propensity score (age, Elixhauser score, and inpatient stays prior to visit; Table 1).

In multivariate analysis comparing PDC to PCP follow‐up, there was no difference in the composite outcome after controlling for propensity score and time to outpatient visit (odds ratio [OR]: 1.07, 95% confidence interval [CI]: 0.81‐1.40). Similar results were obtained in comparing PDC with UC (OR: 1.05, 95% CI: 0.82‐1.34) and in multinomial logistic regression comparing PDC with other types of follow‐up (PDC vs PCP: OR: 1.01, 95% CI: 0.78‐1.31; PDC vs UC: OR: 0.99, 95% CI: 0.78‐1.26).

Restricting the multivariate analysis to those patients discharged with one of the 5 discharge DRGs most associated with readmission did not alter our findings regarding the primary outcome. We also found no change in the composite outcome or any subcomponent of the composite outcome when restricting the analysis to 7‐day outcomes or when excluding scheduled readmissions (which represented <5% of all readmission).

DISCUSSION

A hospitalist‐run postdischarge clinic did not reduce a composite of 30‐day postdischarge adverse outcomes in our study when compared with primary‐care or urgent‐care follow‐up. In fact, patients who followed up in PDC had a small increase in 30‐day readmissions. However, they also were sicker at baseline, considered higher risk by the discharging physician, were able to be seen significantly earlier, and had an associated 2.4‐day shorter hospital LOS than patients seen by their PCPs.

Our findings do not confirm those of prior research in this area, which indicated outpatient follow‐up by the same physician who was the treating inpatient physician was linked to lower mortality rates, hospital readmissions, and ED utilization.[19, 20, 21] In fact, in our study, there was a significant (albeit small) increase in 30‐day readmissions in patients seen in PDC. There are significant challenges to the generalizability and validity of these prior studies. In one study, inpatient care was provided by outpatient primary‐care doctors in Canada,[19] a payer and care model rare in the United States.[25] In a second, usual care was not specified, and it is likely the reduction in ED visits resulted from provision of follow‐up care of any kind compared with those who did not follow up after discharge.[20] In a third, the PDC was part of a larger bundle of postdischarge interventions, and it only reduced ED visits when compared with patients who did not have follow‐up; rates of ED visits were similar in a comparison with PCP follow‐up.[21]

There are several possible explanations for the lack of improvement in 30‐day adverse outcomes with a hospitalist‐run PDC. First, although early access to early postdischarge care was improved and evidence suggests this is important in reducing readmissions,[11, 12] in populations similar to that studied, more postdischarge care has also been linked to increased readmissions.[22] This may be due to more frequent re‐evaluation of fragile, chronically ill patients, presenting more options for readmission. Second, the intervention currently only addresses some components of the Ideal Transition of Care[1] (Figure 1) and may benefit from an enhanced visit structure using a multidisciplinary approach. Third, the intervention took place in the context of a robust primary‐care system with a universal electronic medical record; the effects of improved access and continuity may be magnified in a system without these advantages. Fourth, there was a low readmission rate overall, and it is unclear how many of these readmissions were preventable. Finally, it may be that although the initial postdischarge care was adequate, readmissions occurred after the first visit, suggesting subsequent care during the 30 days postdischarge could have been improved.

Figure 1

The most likely explanation for the substantially decreased LOS associated with follow‐up in PDC is that inpatient physicians who knew they could see their own patients early in the postdischarge process were more tolerant of uncertainty surrounding the patients' clinical course.

For example, a frequent clinical conundrum for hospitalists is when to discharge patients improving on diuretic therapy for a heart failure exacerbation or antibiotics for cellulitis. Provided a PDC, these hospitalists may choose to discharge a patient still actively being treated, because they may feel they have access to early follow‐up to change course if needed as well as the ability to see the patient themselves, allowing precise evaluation of the change in their condition. Without this clinic, the hospitalist may wonder when postdischarge follow‐up will occur. They may be more hesitant to discharge a patient who has not fully completed treatment for fear he or she will still appear decompensated to the postdischarge provider (though greatly improved from admission), or will not have timely‐enough follow‐up to change treatment if the condition worsens.

Our finding that the LOS was still shorter when comparing PDC with UC suggests continuity may be a significant component of this effect. It seems unlikely that patients following up in PDC had less complex hospitalizations given similar ICU exposure and LOS, as well as older age and larger baseline comorbidity burden.

The LOS seen in patients who followed up in PDC was lower than Medicare rates[26] but similar to reported rates at other VA acute‐care hospitals.[27] It is consistent with prior findings that hospitalist care reduces LOS,[26] though the magnitude in our study was much larger than that in prior reports. Prior studies have suggested this decreased LOS is linked to increased adverse postdischarge outcomes, such as ED visits and readmissions, as well as increased costs and decreased discharges to home.[28] The PDC was not associated with increased postdischarge adverse events measured, though a formal cost analysis and analysis of other postdischarge outcomes, such as placement in a skilled nursing or rehabilitation facility after return home, could be assessed in future work.

The findings of our study should be interpreted in the context of the study design. Our study was retrospective, observational, and single‐center. There may have been additional baseline differences between groups predisposing to bias we did not capture in the propensity score. For example, we could not measure rates of attendance at the different clinics and cannot rule out that outcomes associated with PDC were also associated with increased attendance rates. However, none of the clinics had mechanisms in place to improve follow‐up rates; patients referred to PDC were those considered highest risk for readmission and were sicker at baseline, making it very unlikely that they were predisposed to attend clinic more frequently and/or to have better outcomes; and even if PDC improved follow‐up rates, this would be a significant contribution given the limitations of primary‐care access. Our propensity score could not perfectly mimic randomization to a treatment assignment, but rather to treatment received, because of this limitation.

We did not ascertain ED visits or readmissions outside the VA system; it is possible these differentially affected one group more than another, though this seems unlikely. Our patient population was representative of veteran populations elsewhere who are at high risk of adverse postdischarge outcomes, but our findings may not be generalizable to younger, more ethnically diverse populations or to women.

CONCLUSIONS

Provision of postdischarge care by hospitalists may reduce LOS without increasing postdischarge adverse events. Further work is required to evaluate the role of hospitalist‐run PDCs in healthcare systems with more limited postdischarge access to care, to formally evaluate the costs associated with extending hospitalists to the outpatient setting, and to prospectively evaluate the role of a PDC compared with other kinds of hospital follow‐up.

Currently, healthcare systems rarely provide ideal transitions of care for discharged patients,[1] resulting in fragmented care,[2, 3, 4, 5] significant patient uncertainty about how to manage at home,[6, 7] and frequent adverse events.[8, 9] These factors are so commonly experienced by discharged patients that they are recognizable as a postdischarge syndrome.[10]

One element important for reducing the postdischarge risk of adverse events is provision of adequate follow‐up.[11, 12] However, supplying this care is challenging in the modern era, and it will become progressively more difficult to achieve. In 2004, 50% of readmitted Medicare fee‐for‐service patients had no postdischarge visit within 30 days of their discharge,[9] likely due in part to difficulty arranging such care. Changes in insurance coverage and demographics are expected to result in more than 100 million newly insured patients by 2019, yet the primary‐care workforce is projected to begin shrinking by 2016.[13, 14] In the increasingly uncommon situation that a primary‐care clinician is available promptly after discharge, information transfer is often inadequate[4, 15, 16, 17] and can be exacerbated by the growing discontinuity between inpatient and outpatient care.[2, 3, 4] Efforts to increase the supply of primary‐care clinicians and thereby improve early access to postdischarge care are important for the future, but hospitals, particularly those penalized for high risk‐adjusted readmission rates, are seeking novel solutions now.

One increasingly common innovation is to extend the role of inpatient providers (usually hospitalists) into the postdischarge period.[18] Preliminary evidence suggests improved continuity[19] and access[20] achieved by providing this care may decrease postdischarge adverse events,[19, 20, 21] though evidence is conflicting.[22]

As a closed, multilevel healthcare system, the Denver VA Medical Center is uniquely positioned to evaluate the influence of alternative postdischarge‐care strategies on subsequent adverse events. Discharged patients are seen in a well‐established hospitalist‐run postdischarge clinic (PDC), a robust urgent‐care system (UC), or by a large primary‐care provider (PCP) practice. The purpose of this study was to evaluate whether patients seen in a hospitalist‐run PDC have reduced adverse outcomes in the 30 days following hospital discharge compared with follow‐up with the patient's PCP or in an UC clinic.

METHODS

RESULTS

9952 patients who met criteria were discharged during this time period; however, 48.9% did not follow up with one of these clinics within 30 days, leaving 5085 patients in our analysis. Of these, 538 followed up in PDC (10.6%), 1848 followed up with their PCP (36.3%), and 2699 followed up in UC (53.1%). Table 1 presents predischarge characteristics of these patients. Patients seen in PDC were older and had a more significant comorbidity burden.

Patients seen in PDC had a mean 2.4‐day shorter LOS than those seen by their PCPs (PDC: 3.8 days, UC: 5.0 days, PCP: 6.2 days; P=0.04 for comparison). Neither the percentage of patients admitted to the ICU during their index hospitalization nor the ICU LOS was different between groups. Patients were seen earlier postdischarge in PDC than in other types of follow‐up (PDC: 5.0 days, UC: 9.4 days, PCP: 13.7 days; P<0.01 for comparison). In univariate analysis, there was no difference between groups in the composite 30‐day outcome (Table 2). Analysis of the individual components of the primary outcome revealed significant differences in readmission rates, with PDC having the highest rate.

Univariate analyses conducted on predischarge characteristics after multinomial propensity scoring revealed significant differences between groups no longer existed for the variables that were included in the propensity score (age, Elixhauser score, and inpatient stays prior to visit; Table 1).

In multivariate analysis comparing PDC to PCP follow‐up, there was no difference in the composite outcome after controlling for propensity score and time to outpatient visit (odds ratio [OR]: 1.07, 95% confidence interval [CI]: 0.81‐1.40). Similar results were obtained in comparing PDC with UC (OR: 1.05, 95% CI: 0.82‐1.34) and in multinomial logistic regression comparing PDC with other types of follow‐up (PDC vs PCP: OR: 1.01, 95% CI: 0.78‐1.31; PDC vs UC: OR: 0.99, 95% CI: 0.78‐1.26).

Restricting the multivariate analysis to those patients discharged with one of the 5 discharge DRGs most associated with readmission did not alter our findings regarding the primary outcome. We also found no change in the composite outcome or any subcomponent of the composite outcome when restricting the analysis to 7‐day outcomes or when excluding scheduled readmissions (which represented <5% of all readmission).

DISCUSSION

A hospitalist‐run postdischarge clinic did not reduce a composite of 30‐day postdischarge adverse outcomes in our study when compared with primary‐care or urgent‐care follow‐up. In fact, patients who followed up in PDC had a small increase in 30‐day readmissions. However, they also were sicker at baseline, considered higher risk by the discharging physician, were able to be seen significantly earlier, and had an associated 2.4‐day shorter hospital LOS than patients seen by their PCPs.

Our findings do not confirm those of prior research in this area, which indicated outpatient follow‐up by the same physician who was the treating inpatient physician was linked to lower mortality rates, hospital readmissions, and ED utilization.[19, 20, 21] In fact, in our study, there was a significant (albeit small) increase in 30‐day readmissions in patients seen in PDC. There are significant challenges to the generalizability and validity of these prior studies. In one study, inpatient care was provided by outpatient primary‐care doctors in Canada,[19] a payer and care model rare in the United States.[25] In a second, usual care was not specified, and it is likely the reduction in ED visits resulted from provision of follow‐up care of any kind compared with those who did not follow up after discharge.[20] In a third, the PDC was part of a larger bundle of postdischarge interventions, and it only reduced ED visits when compared with patients who did not have follow‐up; rates of ED visits were similar in a comparison with PCP follow‐up.[21]

There are several possible explanations for the lack of improvement in 30‐day adverse outcomes with a hospitalist‐run PDC. First, although early access to early postdischarge care was improved and evidence suggests this is important in reducing readmissions,[11, 12] in populations similar to that studied, more postdischarge care has also been linked to increased readmissions.[22] This may be due to more frequent re‐evaluation of fragile, chronically ill patients, presenting more options for readmission. Second, the intervention currently only addresses some components of the Ideal Transition of Care[1] (Figure 1) and may benefit from an enhanced visit structure using a multidisciplinary approach. Third, the intervention took place in the context of a robust primary‐care system with a universal electronic medical record; the effects of improved access and continuity may be magnified in a system without these advantages. Fourth, there was a low readmission rate overall, and it is unclear how many of these readmissions were preventable. Finally, it may be that although the initial postdischarge care was adequate, readmissions occurred after the first visit, suggesting subsequent care during the 30 days postdischarge could have been improved.

Figure 1

The most likely explanation for the substantially decreased LOS associated with follow‐up in PDC is that inpatient physicians who knew they could see their own patients early in the postdischarge process were more tolerant of uncertainty surrounding the patients' clinical course.

For example, a frequent clinical conundrum for hospitalists is when to discharge patients improving on diuretic therapy for a heart failure exacerbation or antibiotics for cellulitis. Provided a PDC, these hospitalists may choose to discharge a patient still actively being treated, because they may feel they have access to early follow‐up to change course if needed as well as the ability to see the patient themselves, allowing precise evaluation of the change in their condition. Without this clinic, the hospitalist may wonder when postdischarge follow‐up will occur. They may be more hesitant to discharge a patient who has not fully completed treatment for fear he or she will still appear decompensated to the postdischarge provider (though greatly improved from admission), or will not have timely‐enough follow‐up to change treatment if the condition worsens.

Our finding that the LOS was still shorter when comparing PDC with UC suggests continuity may be a significant component of this effect. It seems unlikely that patients following up in PDC had less complex hospitalizations given similar ICU exposure and LOS, as well as older age and larger baseline comorbidity burden.

The LOS seen in patients who followed up in PDC was lower than Medicare rates[26] but similar to reported rates at other VA acute‐care hospitals.[27] It is consistent with prior findings that hospitalist care reduces LOS,[26] though the magnitude in our study was much larger than that in prior reports. Prior studies have suggested this decreased LOS is linked to increased adverse postdischarge outcomes, such as ED visits and readmissions, as well as increased costs and decreased discharges to home.[28] The PDC was not associated with increased postdischarge adverse events measured, though a formal cost analysis and analysis of other postdischarge outcomes, such as placement in a skilled nursing or rehabilitation facility after return home, could be assessed in future work.

The findings of our study should be interpreted in the context of the study design. Our study was retrospective, observational, and single‐center. There may have been additional baseline differences between groups predisposing to bias we did not capture in the propensity score. For example, we could not measure rates of attendance at the different clinics and cannot rule out that outcomes associated with PDC were also associated with increased attendance rates. However, none of the clinics had mechanisms in place to improve follow‐up rates; patients referred to PDC were those considered highest risk for readmission and were sicker at baseline, making it very unlikely that they were predisposed to attend clinic more frequently and/or to have better outcomes; and even if PDC improved follow‐up rates, this would be a significant contribution given the limitations of primary‐care access. Our propensity score could not perfectly mimic randomization to a treatment assignment, but rather to treatment received, because of this limitation.

We did not ascertain ED visits or readmissions outside the VA system; it is possible these differentially affected one group more than another, though this seems unlikely. Our patient population was representative of veteran populations elsewhere who are at high risk of adverse postdischarge outcomes, but our findings may not be generalizable to younger, more ethnically diverse populations or to women.

CONCLUSIONS

Provision of postdischarge care by hospitalists may reduce LOS without increasing postdischarge adverse events. Further work is required to evaluate the role of hospitalist‐run PDCs in healthcare systems with more limited postdischarge access to care, to formally evaluate the costs associated with extending hospitalists to the outpatient setting, and to prospectively evaluate the role of a PDC compared with other kinds of hospital follow‐up.

Medication errors occur frequently when patients transition care between providers, such as the transition from hospital to home.[1] Approximately 50% of about 3 million adults per year over 65 years of age transitioning from hospital to home experience a medication discrepancy.[1] At hospital discharge, patients with complex medical problems are prescribed multiple medications with complex dosing and schedules. To add to this complexity, many patients also have cognitive impairment, variable health literacy, and limited social and financial support. Patients with medication discrepancies have significantly higher rates of rehospitalization compared to those without medication discrepancies.[2] Thus, interventions that focus on patients at greater risk of medication discrepancies may identify those at greater risk of subsequent rehospitalization and potentially reduce the rates of readmissions.[3]

There is limited evidence to date on the effectiveness of interventions to decrease post‐hospitalization medication discrepancies.[3, 4, 5, 6] Previous transitional care interventions have been expensive and difficult to sustain due to the need for multiple additional transitional care personnel (e.g., care managers, nurses, pharmacists, transitional care coaches).[7, 8, 9, 10] Moreover, these additional personnel may further fragment the care of hospitalized patients with additional handoffs.

As both hospitalists and outpatient primary care physicians (PCPs) are being expected to care for larger numbers of increasingly sicker patients, the communication handoff of patient information at discharge remains a challenge.[11] Both patients and PCPs often obtain incomplete or inaccurate information and instructions at discharge. Follow‐up appointments are often missed or delayed.[12] Many hospital‐based interventions do not directly involve the PCP or take advantage of the already established PCPpatient relationship.

We conducted a pilot study examining whether enhancing PCP communication with patients at hospital discharge would impact medication discrepancies and improve the safety of the patient as they transitioned home from the hospital.

METHODS

The PCP‐Enhanced Discharge Communication Intervention

Research staff and the principal investigator met with hospitalists and REACH outpatient physicians in groups to inform them of the study prior to beginning. When the patient was nearing discharge from the hospital, hospitalists were asked to phone the PCP to discuss the patient's discharge plan and facilitate clinical handoffs to the outpatient setting. Research staff paged the hospitalists with the PCP's contact information and reminded them to contact the PCP. Following the hospitalistPCP phone call, the PCP contacted the patient within 24 hours of discharge, either in person while in the hospital or by phone at home. The PCP confirmed medications and clarified any posthospital confusion. The contact flexibility (phone or by person and within 24 hours) was planned as PCPs had other responsibilities that would not allow them to be present at the actual discharge. Physicians were asked to review medications and follow‐up plans, but phone conversations were not recorded. PCPs were given a laminated card that contained points to discuss on discharge (Figure 1). PCPs were compensated with a $5 coffee shop gift card for their time to call patients. This intervention did not involve any additional healthcare personnel.

Figure 1

RESULTS

DISCUSSION

Our results provide evidence that contact with PCPs within 24 hours of hospital discharge can be effective in decreasing medication discrepancies. The PCP‐Enhanced Discharge Communication Intervention was designed to investigate the value of improving existing lines of communication at discharge without involving any additional healthcare personnel. As a lean discharge intervention, the PCP, the hospitalist, and the patient were the main components to this intervention.

This study was limited in that the sample size was small and that we enrolled consecutive patients. Due to the small sample size, we did not examine hospital readmissions. Further studies are needed to examine whether primary care involvement at discharge would affect hospital readmissions. Another limitation of this study was that the control group was not randomized or preselected. Our study compared those subjects who received a phone call from their PCP to those subjects who did not. Although we instructed PCPs with a standardized script, we did not record or ensure that the phone call‐up occurred as such. There is potential variability in how the PCPs conducted their follow‐up with patients, and we are unable to measure what was effective and ineffective in reducing medication discrepancies. Another limitation was that the determination of the severity of the medication discrepancy was done by medication involved as opposed to by physician review and adjudication. The study would have been strengthened by interviewing the outpatient physicians on the amount of harm each discrepancy would or did cause the patient.

The most frequent reason for discrepancy was intentional nonadherence. Prior research has shown that intentional nonadherence of medications at hospital discharge is linked to health literacy.[14] One may postulate that patients with adequate health literacy feel enabled to go against medical advice and chose to not take medications as prescribed.

In our study, patients had the most medication discrepancies in the severe medications category, which involved cardiac, pulmonary, and diabetic medications, compared with the mild and moderate category. This finding may reflect the frequency that these medications are prescribed but are consistent with findings of Coleman et al.[2] The finding highlights the need to ensure adequate education and understanding of medication regimens for these complex patients. Patients with cardiac, pulmonary, and diabetic disease may benefit from personalized discharge instructions and a more structured and organized medication reconciliation process.

Our study found that males were more likely to have a medication discrepancy than females, which has not been found in previous studies on medication discrepancies. One study on Medicare beneficiaries with congestive heart failure found that men were much more likely to be readmitted than woman within 6 months of discharge.[15] The reason for the increased risk of medication discrepancy in males is unknown. Gender differences in health have frequently been reported, with men having higher rates of morbidity and mortality than women.[16, 17] The differences are thought to be due to the reluctance of men to seek medical help and consult medical practitioners when needed. It has been known that women use health services more than men, and are more likely than men to report a chronic illness.[18] When men do present with symptoms, it is often later in the stage of a disease than women and when treatment is less likely to be successful.[19] It may be that men in this study population had more medication discrepancies as they were reluctant to seek help or ask for clarification regarding medications at discharge.

Of those enrolled, 36% of patients were contacted by their PCP within 48 hours of discharge. It is unclear if the PCP attempted but was unable to reach the patient or did not attempt to call the patient. Although PCPs were compensated with a $5 coffee shop gift card, a larger compensation may insure completion of the patient contact. Further research is needed to determine the reasons why PCPs were not able to complete the phone call.

From a policy standpoint, hospitals that focus solely on hospital‐based transition interventions are potentially missing half the problem. The hospital acts as a sender or pitcher, and the PCP acts as a receiver or catcher. The receiver needs to be included in the discharge process for a successful patient transition to home. With recent billing changes for transition coding, the Center for Medicare and Medicaid Services recognizes this relationship.[20] Outpatient PCPs are able to bill for bundled follow‐up phone calls and appointments. Instead of paying additional staff to make 48‐hour postdischarge phone calls, hospitals should consider partnering with PCPs to ensure a more organized discharge.

Our results showed that PCP communication with patients within 24 hours of discharge was associated with decreased medication discrepancies. The PCP is vital to ensuring a safe transition home from the hospital. Because many patients have an established relationship with their PCP, a bond of trust exists that is often missing with hospital‐employed transitional staff. Patients pay attention when a known physician contacts them directly. In our study, patients may have felt comfortable addressing their concerns and questions with their trusted PCP. Subsequently, patients may have been more attuned to the answers their PCP gave and avoided medication errors. Our results further demonstrate the importance of PCP involvement in the hospital discharge process to improve the care of our patients.

Medication errors occur frequently when patients transition care between providers, such as the transition from hospital to home.[1] Approximately 50% of about 3 million adults per year over 65 years of age transitioning from hospital to home experience a medication discrepancy.[1] At hospital discharge, patients with complex medical problems are prescribed multiple medications with complex dosing and schedules. To add to this complexity, many patients also have cognitive impairment, variable health literacy, and limited social and financial support. Patients with medication discrepancies have significantly higher rates of rehospitalization compared to those without medication discrepancies.[2] Thus, interventions that focus on patients at greater risk of medication discrepancies may identify those at greater risk of subsequent rehospitalization and potentially reduce the rates of readmissions.[3]

There is limited evidence to date on the effectiveness of interventions to decrease post‐hospitalization medication discrepancies.[3, 4, 5, 6] Previous transitional care interventions have been expensive and difficult to sustain due to the need for multiple additional transitional care personnel (e.g., care managers, nurses, pharmacists, transitional care coaches).[7, 8, 9, 10] Moreover, these additional personnel may further fragment the care of hospitalized patients with additional handoffs.

As both hospitalists and outpatient primary care physicians (PCPs) are being expected to care for larger numbers of increasingly sicker patients, the communication handoff of patient information at discharge remains a challenge.[11] Both patients and PCPs often obtain incomplete or inaccurate information and instructions at discharge. Follow‐up appointments are often missed or delayed.[12] Many hospital‐based interventions do not directly involve the PCP or take advantage of the already established PCPpatient relationship.

We conducted a pilot study examining whether enhancing PCP communication with patients at hospital discharge would impact medication discrepancies and improve the safety of the patient as they transitioned home from the hospital.

METHODS

The PCP‐Enhanced Discharge Communication Intervention

Research staff and the principal investigator met with hospitalists and REACH outpatient physicians in groups to inform them of the study prior to beginning. When the patient was nearing discharge from the hospital, hospitalists were asked to phone the PCP to discuss the patient's discharge plan and facilitate clinical handoffs to the outpatient setting. Research staff paged the hospitalists with the PCP's contact information and reminded them to contact the PCP. Following the hospitalistPCP phone call, the PCP contacted the patient within 24 hours of discharge, either in person while in the hospital or by phone at home. The PCP confirmed medications and clarified any posthospital confusion. The contact flexibility (phone or by person and within 24 hours) was planned as PCPs had other responsibilities that would not allow them to be present at the actual discharge. Physicians were asked to review medications and follow‐up plans, but phone conversations were not recorded. PCPs were given a laminated card that contained points to discuss on discharge (Figure 1). PCPs were compensated with a $5 coffee shop gift card for their time to call patients. This intervention did not involve any additional healthcare personnel.

Figure 1

RESULTS

DISCUSSION

Our results provide evidence that contact with PCPs within 24 hours of hospital discharge can be effective in decreasing medication discrepancies. The PCP‐Enhanced Discharge Communication Intervention was designed to investigate the value of improving existing lines of communication at discharge without involving any additional healthcare personnel. As a lean discharge intervention, the PCP, the hospitalist, and the patient were the main components to this intervention.

This study was limited in that the sample size was small and that we enrolled consecutive patients. Due to the small sample size, we did not examine hospital readmissions. Further studies are needed to examine whether primary care involvement at discharge would affect hospital readmissions. Another limitation of this study was that the control group was not randomized or preselected. Our study compared those subjects who received a phone call from their PCP to those subjects who did not. Although we instructed PCPs with a standardized script, we did not record or ensure that the phone call‐up occurred as such. There is potential variability in how the PCPs conducted their follow‐up with patients, and we are unable to measure what was effective and ineffective in reducing medication discrepancies. Another limitation was that the determination of the severity of the medication discrepancy was done by medication involved as opposed to by physician review and adjudication. The study would have been strengthened by interviewing the outpatient physicians on the amount of harm each discrepancy would or did cause the patient.

The most frequent reason for discrepancy was intentional nonadherence. Prior research has shown that intentional nonadherence of medications at hospital discharge is linked to health literacy.[14] One may postulate that patients with adequate health literacy feel enabled to go against medical advice and chose to not take medications as prescribed.

In our study, patients had the most medication discrepancies in the severe medications category, which involved cardiac, pulmonary, and diabetic medications, compared with the mild and moderate category. This finding may reflect the frequency that these medications are prescribed but are consistent with findings of Coleman et al.[2] The finding highlights the need to ensure adequate education and understanding of medication regimens for these complex patients. Patients with cardiac, pulmonary, and diabetic disease may benefit from personalized discharge instructions and a more structured and organized medication reconciliation process.

Our study found that males were more likely to have a medication discrepancy than females, which has not been found in previous studies on medication discrepancies. One study on Medicare beneficiaries with congestive heart failure found that men were much more likely to be readmitted than woman within 6 months of discharge.[15] The reason for the increased risk of medication discrepancy in males is unknown. Gender differences in health have frequently been reported, with men having higher rates of morbidity and mortality than women.[16, 17] The differences are thought to be due to the reluctance of men to seek medical help and consult medical practitioners when needed. It has been known that women use health services more than men, and are more likely than men to report a chronic illness.[18] When men do present with symptoms, it is often later in the stage of a disease than women and when treatment is less likely to be successful.[19] It may be that men in this study population had more medication discrepancies as they were reluctant to seek help or ask for clarification regarding medications at discharge.

Of those enrolled, 36% of patients were contacted by their PCP within 48 hours of discharge. It is unclear if the PCP attempted but was unable to reach the patient or did not attempt to call the patient. Although PCPs were compensated with a $5 coffee shop gift card, a larger compensation may insure completion of the patient contact. Further research is needed to determine the reasons why PCPs were not able to complete the phone call.

From a policy standpoint, hospitals that focus solely on hospital‐based transition interventions are potentially missing half the problem. The hospital acts as a sender or pitcher, and the PCP acts as a receiver or catcher. The receiver needs to be included in the discharge process for a successful patient transition to home. With recent billing changes for transition coding, the Center for Medicare and Medicaid Services recognizes this relationship.[20] Outpatient PCPs are able to bill for bundled follow‐up phone calls and appointments. Instead of paying additional staff to make 48‐hour postdischarge phone calls, hospitals should consider partnering with PCPs to ensure a more organized discharge.

Our results showed that PCP communication with patients within 24 hours of discharge was associated with decreased medication discrepancies. The PCP is vital to ensuring a safe transition home from the hospital. Because many patients have an established relationship with their PCP, a bond of trust exists that is often missing with hospital‐employed transitional staff. Patients pay attention when a known physician contacts them directly. In our study, patients may have felt comfortable addressing their concerns and questions with their trusted PCP. Subsequently, patients may have been more attuned to the answers their PCP gave and avoided medication errors. Our results further demonstrate the importance of PCP involvement in the hospital discharge process to improve the care of our patients.

Medication errors occur frequently when patients transition care between providers, such as the transition from hospital to home.[1] Approximately 50% of about 3 million adults per year over 65 years of age transitioning from hospital to home experience a medication discrepancy.[1] At hospital discharge, patients with complex medical problems are prescribed multiple medications with complex dosing and schedules. To add to this complexity, many patients also have cognitive impairment, variable health literacy, and limited social and financial support. Patients with medication discrepancies have significantly higher rates of rehospitalization compared to those without medication discrepancies.[2] Thus, interventions that focus on patients at greater risk of medication discrepancies may identify those at greater risk of subsequent rehospitalization and potentially reduce the rates of readmissions.[3]

There is limited evidence to date on the effectiveness of interventions to decrease post‐hospitalization medication discrepancies.[3, 4, 5, 6] Previous transitional care interventions have been expensive and difficult to sustain due to the need for multiple additional transitional care personnel (e.g., care managers, nurses, pharmacists, transitional care coaches).[7, 8, 9, 10] Moreover, these additional personnel may further fragment the care of hospitalized patients with additional handoffs.

As both hospitalists and outpatient primary care physicians (PCPs) are being expected to care for larger numbers of increasingly sicker patients, the communication handoff of patient information at discharge remains a challenge.[11] Both patients and PCPs often obtain incomplete or inaccurate information and instructions at discharge. Follow‐up appointments are often missed or delayed.[12] Many hospital‐based interventions do not directly involve the PCP or take advantage of the already established PCPpatient relationship.

We conducted a pilot study examining whether enhancing PCP communication with patients at hospital discharge would impact medication discrepancies and improve the safety of the patient as they transitioned home from the hospital.

METHODS

The PCP‐Enhanced Discharge Communication Intervention

Research staff and the principal investigator met with hospitalists and REACH outpatient physicians in groups to inform them of the study prior to beginning. When the patient was nearing discharge from the hospital, hospitalists were asked to phone the PCP to discuss the patient's discharge plan and facilitate clinical handoffs to the outpatient setting. Research staff paged the hospitalists with the PCP's contact information and reminded them to contact the PCP. Following the hospitalistPCP phone call, the PCP contacted the patient within 24 hours of discharge, either in person while in the hospital or by phone at home. The PCP confirmed medications and clarified any posthospital confusion. The contact flexibility (phone or by person and within 24 hours) was planned as PCPs had other responsibilities that would not allow them to be present at the actual discharge. Physicians were asked to review medications and follow‐up plans, but phone conversations were not recorded. PCPs were given a laminated card that contained points to discuss on discharge (Figure 1). PCPs were compensated with a $5 coffee shop gift card for their time to call patients. This intervention did not involve any additional healthcare personnel.

Figure 1

RESULTS

DISCUSSION

Our results provide evidence that contact with PCPs within 24 hours of hospital discharge can be effective in decreasing medication discrepancies. The PCP‐Enhanced Discharge Communication Intervention was designed to investigate the value of improving existing lines of communication at discharge without involving any additional healthcare personnel. As a lean discharge intervention, the PCP, the hospitalist, and the patient were the main components to this intervention.

This study was limited in that the sample size was small and that we enrolled consecutive patients. Due to the small sample size, we did not examine hospital readmissions. Further studies are needed to examine whether primary care involvement at discharge would affect hospital readmissions. Another limitation of this study was that the control group was not randomized or preselected. Our study compared those subjects who received a phone call from their PCP to those subjects who did not. Although we instructed PCPs with a standardized script, we did not record or ensure that the phone call‐up occurred as such. There is potential variability in how the PCPs conducted their follow‐up with patients, and we are unable to measure what was effective and ineffective in reducing medication discrepancies. Another limitation was that the determination of the severity of the medication discrepancy was done by medication involved as opposed to by physician review and adjudication. The study would have been strengthened by interviewing the outpatient physicians on the amount of harm each discrepancy would or did cause the patient.

The most frequent reason for discrepancy was intentional nonadherence. Prior research has shown that intentional nonadherence of medications at hospital discharge is linked to health literacy.[14] One may postulate that patients with adequate health literacy feel enabled to go against medical advice and chose to not take medications as prescribed.

In our study, patients had the most medication discrepancies in the severe medications category, which involved cardiac, pulmonary, and diabetic medications, compared with the mild and moderate category. This finding may reflect the frequency that these medications are prescribed but are consistent with findings of Coleman et al.[2] The finding highlights the need to ensure adequate education and understanding of medication regimens for these complex patients. Patients with cardiac, pulmonary, and diabetic disease may benefit from personalized discharge instructions and a more structured and organized medication reconciliation process.

Our study found that males were more likely to have a medication discrepancy than females, which has not been found in previous studies on medication discrepancies. One study on Medicare beneficiaries with congestive heart failure found that men were much more likely to be readmitted than woman within 6 months of discharge.[15] The reason for the increased risk of medication discrepancy in males is unknown. Gender differences in health have frequently been reported, with men having higher rates of morbidity and mortality than women.[16, 17] The differences are thought to be due to the reluctance of men to seek medical help and consult medical practitioners when needed. It has been known that women use health services more than men, and are more likely than men to report a chronic illness.[18] When men do present with symptoms, it is often later in the stage of a disease than women and when treatment is less likely to be successful.[19] It may be that men in this study population had more medication discrepancies as they were reluctant to seek help or ask for clarification regarding medications at discharge.

Of those enrolled, 36% of patients were contacted by their PCP within 48 hours of discharge. It is unclear if the PCP attempted but was unable to reach the patient or did not attempt to call the patient. Although PCPs were compensated with a $5 coffee shop gift card, a larger compensation may insure completion of the patient contact. Further research is needed to determine the reasons why PCPs were not able to complete the phone call.

From a policy standpoint, hospitals that focus solely on hospital‐based transition interventions are potentially missing half the problem. The hospital acts as a sender or pitcher, and the PCP acts as a receiver or catcher. The receiver needs to be included in the discharge process for a successful patient transition to home. With recent billing changes for transition coding, the Center for Medicare and Medicaid Services recognizes this relationship.[20] Outpatient PCPs are able to bill for bundled follow‐up phone calls and appointments. Instead of paying additional staff to make 48‐hour postdischarge phone calls, hospitals should consider partnering with PCPs to ensure a more organized discharge.

Our results showed that PCP communication with patients within 24 hours of discharge was associated with decreased medication discrepancies. The PCP is vital to ensuring a safe transition home from the hospital. Because many patients have an established relationship with their PCP, a bond of trust exists that is often missing with hospital‐employed transitional staff. Patients pay attention when a known physician contacts them directly. In our study, patients may have felt comfortable addressing their concerns and questions with their trusted PCP. Subsequently, patients may have been more attuned to the answers their PCP gave and avoided medication errors. Our results further demonstrate the importance of PCP involvement in the hospital discharge process to improve the care of our patients.

In 1968, Weed highlighted the importance of medical documentation when he proposed a single format for notes.[1, 2] Since then, sweeping changes in the technology, the purposes, and the requirements of clinical record keeping have encouraged steady growth of a literature devoted to the chart. Specifically, over the past half century, computers, lawsuits, regulations, and the use of documentation as a tool of billing have all contributed to the transformation of hospital records. In addition, mounting pressure to shorten inpatient stays, the vastly increased complexity of care, and a growing number of diagnostic possibilities have combined to make medical documentation far more prolific and far less leisurely. All these changes have stimulated a boom in documentation research coinciding, productively, with an era of rapid advances in the conduct of clinical trials and statistical rigor. However, in important respects research into medical documentation today is not asking the right questions, either in the formulation of hypotheses or in the choice of methodology. Forms of clinical communication that do not involve order sets or notes are widespread, growing in sophistication, and increasingly relevant to new concepts of healthcare as a team enterprise; but documentation research has not embraced this development. At the same time, methodologically, the field suffers from a persistent professional bias in the choice of research outcomes, a bias that limits the interpretation of results by neglecting what happens to the patient.

In assessing the chart as a communication device and the effect of changes in documentation, it is increasingly necessary to study direct interpersonal communication as an alternative and partner to writing notes. In particular, 3 recent developments in healthcare emphasize the importance of broadening our concepts of clinical communication. First, the need for discussion in the medical record has become less pressing because of technical improvements in person‐to‐person communication. Second, the electronic health record, by creating discipline‐defined chart views, has helped equalize the stature of different healthcare disciplines but also Balkanized the chart, making direct interdisciplinary communication more necessary. Third, changes in reimbursement are redefining medical goals in such a way that only teams of healthcare providers in close and constant personal communication can achieve them.

Rapid adoption of electronic health records has encouraged researchers studying documentation or information technology to focus on computer formats as defining the range of all possible communication strategies. And certainly there is a broad range of formats: electronic progress notes may be free text or multiple choice, typed or dictated, copy forwarded or composed daily, institutionally templated or self‐templated, furnished with or free from prompts and pop‐ups. However, it is not only, and perhaps not even principally, the electronic record that has changed how clinicians communicate with each other. The technology of discussion over the last 2 decades has become instant, utterly mobile, device independent, and capable of connecting all the patient's caregivers at once to each other and to the medical record in text, picture, and sound. That the same communications upheaval has visited practically every other aspect of our lives diminishes perhaps the visibility of this new virtual team in healthcare but not its importance.

The electronic record certainly plays a role in facilitating communication, through simultaneous chart access and in many other ways, but even more significant is the effect that computerization has had on equalizing the roles of different disciplines and by doing so in fragmenting the medical record. A computerized record expands and reorganizes the chart, changing it from a single authoritative book read by all to an almost limitless array of chart views, each read by some. All viewers (patient, clinician or researcher, administrator, reviewer or coder) can, with equal claim to consulting the chart, categorize, compare, combine, and format data elements from 1 or many encounters, whether inpatient or ambulatory. Typically, an electronic item of patient information may have several authors and uses but has no owner. Data are entered by protocol and in different guises into many aspects of patient care as components of notes, flow sheets, summaries, pop‐ups, and order sets unique to each of a number of disciplines. As the electronic record equalizes but also separates members of the healthcare team, interdisciplinary personal communication becomes more, not less, important.

Recent and impending reimbursement reform proves also to be a means of democratizing medical care and enforcing better interdisciplinary communication. The basis for hospital reimbursement has evolved over decades from day rates to payments for specific diseases, a system under which profit margins are in theory determined by the interdisciplinary efficiency with which diseases are managed by all care givers and the accuracy with which that management is documented. The next, seemingly inexorable, step in the evolution of reimbursement will result in further democratization of care givers: a single combined disease episode payment will be divided among all those involved in a course of treatment that may span many months and require many disciplines and many types of intervention. Payment reform makes the success of a visiting nurse as important to the net reimbursement of a disease episode as the success of an orthopedic surgeon; for if the visiting nurse does not do well the patient will be readmitted or require more office services. In this sense, payment reform, like the electronic record, tends both to equalize the importance of different healthcare roles and to require their enhanced communication.

As these changes in technology and reimbursement evolve, the study of medical documentation must increasingly address medical communication more generally. It is entirely possible, for example, that an individual daily progress note, whose preparation consumes so many hours and removes caretakers from patients, will no longer serve any demonstrable purpose.[3, 4] It may be that consensus summaries will prove more useful in clarifying one's own thinking and incorporating that of others than will a daily, solo chart soliloquy in free or imported text. It is conceivable that contrasting views will be best presented not as a debate in the progress notes but as a plan mutually agreed upon earlier in the decision‐making process. These are the kind of broader questions that investigators in medical documentation should be pursuing.

Another problem in studies of documentation is a pervasive professional bias in the choice of end points. Studies tend to evaluate documentary practices not by their effect on patients but by their impact on physicians or nurses. Success is measured by clinician satisfaction, percent adoption, and note length or timing; note quality is judged using a checklist derived from professional surveys.[5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15] End points like these will often make 1 document look better than another in a results section, but it is the relation between communication strategies and healthcare outcomes that determines whether 1 approach or another is of benefit to the patient.

For example, an important current debate is whether free text adds essential nuance to a note or is simply nostalgia, a relic of the 3‐ring binder.[16, 17, 18] This debate can be resolved convincingly only if improvement with the use or abolition of free text is measured in terms of patient outcomes or resource consumption. Again, if it is important to know whether progress notes of a particular length or structure create less handover confusion, then changes in medical error rates is a more persuasive way to evaluate this issue than a change in physician opinion. It may be a good question whether briefer notes will free nurses and doctors to spend more time at the bedside, but along with recording bedside time that study should also measure improvement in reacting to important changes of clinical status. With today's technology, group phone discussions could perhaps successfully replace examining each other's notes, but the measure of success should be improved hospital efficiency or a decline in errors and readmissions.

The questions we ask in our research today create the treatments and policies of tomorrow. Our studies must address communications in a larger sense, must encompass all the settings in which an episode of care occurs, and must focus on patient outcomes and use of resources. The measured end points of an intervention should of course be sensitive to the particular setting where the intervention takes place, or else small and location‐specific gains will be missed. However, real health effects and robust measures of efficiency must take the place of word counts, inclusion checklists, and clinician adoption or satisfaction in the design of documentation studies.

A great national experiment is underway involving the deployment of information technology, the expansion and empowerment of healthcare teams, and the retargeting of economic incentives. The experimental hypothesis is that technology will increase medical efficiency and will benefit patient well‐being only if these are in fact the purposes, and if teamwork is the principal means, of providing medical care. We should seize this time of change as an opportunity to measure and demonstrably improve the contribution of medical documentation and communication to the efficient and long‐term remission of disease.

In 1968, Weed highlighted the importance of medical documentation when he proposed a single format for notes.[1, 2] Since then, sweeping changes in the technology, the purposes, and the requirements of clinical record keeping have encouraged steady growth of a literature devoted to the chart. Specifically, over the past half century, computers, lawsuits, regulations, and the use of documentation as a tool of billing have all contributed to the transformation of hospital records. In addition, mounting pressure to shorten inpatient stays, the vastly increased complexity of care, and a growing number of diagnostic possibilities have combined to make medical documentation far more prolific and far less leisurely. All these changes have stimulated a boom in documentation research coinciding, productively, with an era of rapid advances in the conduct of clinical trials and statistical rigor. However, in important respects research into medical documentation today is not asking the right questions, either in the formulation of hypotheses or in the choice of methodology. Forms of clinical communication that do not involve order sets or notes are widespread, growing in sophistication, and increasingly relevant to new concepts of healthcare as a team enterprise; but documentation research has not embraced this development. At the same time, methodologically, the field suffers from a persistent professional bias in the choice of research outcomes, a bias that limits the interpretation of results by neglecting what happens to the patient.

In assessing the chart as a communication device and the effect of changes in documentation, it is increasingly necessary to study direct interpersonal communication as an alternative and partner to writing notes. In particular, 3 recent developments in healthcare emphasize the importance of broadening our concepts of clinical communication. First, the need for discussion in the medical record has become less pressing because of technical improvements in person‐to‐person communication. Second, the electronic health record, by creating discipline‐defined chart views, has helped equalize the stature of different healthcare disciplines but also Balkanized the chart, making direct interdisciplinary communication more necessary. Third, changes in reimbursement are redefining medical goals in such a way that only teams of healthcare providers in close and constant personal communication can achieve them.

Rapid adoption of electronic health records has encouraged researchers studying documentation or information technology to focus on computer formats as defining the range of all possible communication strategies. And certainly there is a broad range of formats: electronic progress notes may be free text or multiple choice, typed or dictated, copy forwarded or composed daily, institutionally templated or self‐templated, furnished with or free from prompts and pop‐ups. However, it is not only, and perhaps not even principally, the electronic record that has changed how clinicians communicate with each other. The technology of discussion over the last 2 decades has become instant, utterly mobile, device independent, and capable of connecting all the patient's caregivers at once to each other and to the medical record in text, picture, and sound. That the same communications upheaval has visited practically every other aspect of our lives diminishes perhaps the visibility of this new virtual team in healthcare but not its importance.

The electronic record certainly plays a role in facilitating communication, through simultaneous chart access and in many other ways, but even more significant is the effect that computerization has had on equalizing the roles of different disciplines and by doing so in fragmenting the medical record. A computerized record expands and reorganizes the chart, changing it from a single authoritative book read by all to an almost limitless array of chart views, each read by some. All viewers (patient, clinician or researcher, administrator, reviewer or coder) can, with equal claim to consulting the chart, categorize, compare, combine, and format data elements from 1 or many encounters, whether inpatient or ambulatory. Typically, an electronic item of patient information may have several authors and uses but has no owner. Data are entered by protocol and in different guises into many aspects of patient care as components of notes, flow sheets, summaries, pop‐ups, and order sets unique to each of a number of disciplines. As the electronic record equalizes but also separates members of the healthcare team, interdisciplinary personal communication becomes more, not less, important.

Recent and impending reimbursement reform proves also to be a means of democratizing medical care and enforcing better interdisciplinary communication. The basis for hospital reimbursement has evolved over decades from day rates to payments for specific diseases, a system under which profit margins are in theory determined by the interdisciplinary efficiency with which diseases are managed by all care givers and the accuracy with which that management is documented. The next, seemingly inexorable, step in the evolution of reimbursement will result in further democratization of care givers: a single combined disease episode payment will be divided among all those involved in a course of treatment that may span many months and require many disciplines and many types of intervention. Payment reform makes the success of a visiting nurse as important to the net reimbursement of a disease episode as the success of an orthopedic surgeon; for if the visiting nurse does not do well the patient will be readmitted or require more office services. In this sense, payment reform, like the electronic record, tends both to equalize the importance of different healthcare roles and to require their enhanced communication.

As these changes in technology and reimbursement evolve, the study of medical documentation must increasingly address medical communication more generally. It is entirely possible, for example, that an individual daily progress note, whose preparation consumes so many hours and removes caretakers from patients, will no longer serve any demonstrable purpose.[3, 4] It may be that consensus summaries will prove more useful in clarifying one's own thinking and incorporating that of others than will a daily, solo chart soliloquy in free or imported text. It is conceivable that contrasting views will be best presented not as a debate in the progress notes but as a plan mutually agreed upon earlier in the decision‐making process. These are the kind of broader questions that investigators in medical documentation should be pursuing.

Another problem in studies of documentation is a pervasive professional bias in the choice of end points. Studies tend to evaluate documentary practices not by their effect on patients but by their impact on physicians or nurses. Success is measured by clinician satisfaction, percent adoption, and note length or timing; note quality is judged using a checklist derived from professional surveys.[5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15] End points like these will often make 1 document look better than another in a results section, but it is the relation between communication strategies and healthcare outcomes that determines whether 1 approach or another is of benefit to the patient.

For example, an important current debate is whether free text adds essential nuance to a note or is simply nostalgia, a relic of the 3‐ring binder.[16, 17, 18] This debate can be resolved convincingly only if improvement with the use or abolition of free text is measured in terms of patient outcomes or resource consumption. Again, if it is important to know whether progress notes of a particular length or structure create less handover confusion, then changes in medical error rates is a more persuasive way to evaluate this issue than a change in physician opinion. It may be a good question whether briefer notes will free nurses and doctors to spend more time at the bedside, but along with recording bedside time that study should also measure improvement in reacting to important changes of clinical status. With today's technology, group phone discussions could perhaps successfully replace examining each other's notes, but the measure of success should be improved hospital efficiency or a decline in errors and readmissions.

The questions we ask in our research today create the treatments and policies of tomorrow. Our studies must address communications in a larger sense, must encompass all the settings in which an episode of care occurs, and must focus on patient outcomes and use of resources. The measured end points of an intervention should of course be sensitive to the particular setting where the intervention takes place, or else small and location‐specific gains will be missed. However, real health effects and robust measures of efficiency must take the place of word counts, inclusion checklists, and clinician adoption or satisfaction in the design of documentation studies.

A great national experiment is underway involving the deployment of information technology, the expansion and empowerment of healthcare teams, and the retargeting of economic incentives. The experimental hypothesis is that technology will increase medical efficiency and will benefit patient well‐being only if these are in fact the purposes, and if teamwork is the principal means, of providing medical care. We should seize this time of change as an opportunity to measure and demonstrably improve the contribution of medical documentation and communication to the efficient and long‐term remission of disease.

In 1968, Weed highlighted the importance of medical documentation when he proposed a single format for notes.[1, 2] Since then, sweeping changes in the technology, the purposes, and the requirements of clinical record keeping have encouraged steady growth of a literature devoted to the chart. Specifically, over the past half century, computers, lawsuits, regulations, and the use of documentation as a tool of billing have all contributed to the transformation of hospital records. In addition, mounting pressure to shorten inpatient stays, the vastly increased complexity of care, and a growing number of diagnostic possibilities have combined to make medical documentation far more prolific and far less leisurely. All these changes have stimulated a boom in documentation research coinciding, productively, with an era of rapid advances in the conduct of clinical trials and statistical rigor. However, in important respects research into medical documentation today is not asking the right questions, either in the formulation of hypotheses or in the choice of methodology. Forms of clinical communication that do not involve order sets or notes are widespread, growing in sophistication, and increasingly relevant to new concepts of healthcare as a team enterprise; but documentation research has not embraced this development. At the same time, methodologically, the field suffers from a persistent professional bias in the choice of research outcomes, a bias that limits the interpretation of results by neglecting what happens to the patient.

In assessing the chart as a communication device and the effect of changes in documentation, it is increasingly necessary to study direct interpersonal communication as an alternative and partner to writing notes. In particular, 3 recent developments in healthcare emphasize the importance of broadening our concepts of clinical communication. First, the need for discussion in the medical record has become less pressing because of technical improvements in person‐to‐person communication. Second, the electronic health record, by creating discipline‐defined chart views, has helped equalize the stature of different healthcare disciplines but also Balkanized the chart, making direct interdisciplinary communication more necessary. Third, changes in reimbursement are redefining medical goals in such a way that only teams of healthcare providers in close and constant personal communication can achieve them.

Rapid adoption of electronic health records has encouraged researchers studying documentation or information technology to focus on computer formats as defining the range of all possible communication strategies. And certainly there is a broad range of formats: electronic progress notes may be free text or multiple choice, typed or dictated, copy forwarded or composed daily, institutionally templated or self‐templated, furnished with or free from prompts and pop‐ups. However, it is not only, and perhaps not even principally, the electronic record that has changed how clinicians communicate with each other. The technology of discussion over the last 2 decades has become instant, utterly mobile, device independent, and capable of connecting all the patient's caregivers at once to each other and to the medical record in text, picture, and sound. That the same communications upheaval has visited practically every other aspect of our lives diminishes perhaps the visibility of this new virtual team in healthcare but not its importance.

The electronic record certainly plays a role in facilitating communication, through simultaneous chart access and in many other ways, but even more significant is the effect that computerization has had on equalizing the roles of different disciplines and by doing so in fragmenting the medical record. A computerized record expands and reorganizes the chart, changing it from a single authoritative book read by all to an almost limitless array of chart views, each read by some. All viewers (patient, clinician or researcher, administrator, reviewer or coder) can, with equal claim to consulting the chart, categorize, compare, combine, and format data elements from 1 or many encounters, whether inpatient or ambulatory. Typically, an electronic item of patient information may have several authors and uses but has no owner. Data are entered by protocol and in different guises into many aspects of patient care as components of notes, flow sheets, summaries, pop‐ups, and order sets unique to each of a number of disciplines. As the electronic record equalizes but also separates members of the healthcare team, interdisciplinary personal communication becomes more, not less, important.

Recent and impending reimbursement reform proves also to be a means of democratizing medical care and enforcing better interdisciplinary communication. The basis for hospital reimbursement has evolved over decades from day rates to payments for specific diseases, a system under which profit margins are in theory determined by the interdisciplinary efficiency with which diseases are managed by all care givers and the accuracy with which that management is documented. The next, seemingly inexorable, step in the evolution of reimbursement will result in further democratization of care givers: a single combined disease episode payment will be divided among all those involved in a course of treatment that may span many months and require many disciplines and many types of intervention. Payment reform makes the success of a visiting nurse as important to the net reimbursement of a disease episode as the success of an orthopedic surgeon; for if the visiting nurse does not do well the patient will be readmitted or require more office services. In this sense, payment reform, like the electronic record, tends both to equalize the importance of different healthcare roles and to require their enhanced communication.

As these changes in technology and reimbursement evolve, the study of medical documentation must increasingly address medical communication more generally. It is entirely possible, for example, that an individual daily progress note, whose preparation consumes so many hours and removes caretakers from patients, will no longer serve any demonstrable purpose.[3, 4] It may be that consensus summaries will prove more useful in clarifying one's own thinking and incorporating that of others than will a daily, solo chart soliloquy in free or imported text. It is conceivable that contrasting views will be best presented not as a debate in the progress notes but as a plan mutually agreed upon earlier in the decision‐making process. These are the kind of broader questions that investigators in medical documentation should be pursuing.

Another problem in studies of documentation is a pervasive professional bias in the choice of end points. Studies tend to evaluate documentary practices not by their effect on patients but by their impact on physicians or nurses. Success is measured by clinician satisfaction, percent adoption, and note length or timing; note quality is judged using a checklist derived from professional surveys.[5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15] End points like these will often make 1 document look better than another in a results section, but it is the relation between communication strategies and healthcare outcomes that determines whether 1 approach or another is of benefit to the patient.

For example, an important current debate is whether free text adds essential nuance to a note or is simply nostalgia, a relic of the 3‐ring binder.[16, 17, 18] This debate can be resolved convincingly only if improvement with the use or abolition of free text is measured in terms of patient outcomes or resource consumption. Again, if it is important to know whether progress notes of a particular length or structure create less handover confusion, then changes in medical error rates is a more persuasive way to evaluate this issue than a change in physician opinion. It may be a good question whether briefer notes will free nurses and doctors to spend more time at the bedside, but along with recording bedside time that study should also measure improvement in reacting to important changes of clinical status. With today's technology, group phone discussions could perhaps successfully replace examining each other's notes, but the measure of success should be improved hospital efficiency or a decline in errors and readmissions.

The questions we ask in our research today create the treatments and policies of tomorrow. Our studies must address communications in a larger sense, must encompass all the settings in which an episode of care occurs, and must focus on patient outcomes and use of resources. The measured end points of an intervention should of course be sensitive to the particular setting where the intervention takes place, or else small and location‐specific gains will be missed. However, real health effects and robust measures of efficiency must take the place of word counts, inclusion checklists, and clinician adoption or satisfaction in the design of documentation studies.

A great national experiment is underway involving the deployment of information technology, the expansion and empowerment of healthcare teams, and the retargeting of economic incentives. The experimental hypothesis is that technology will increase medical efficiency and will benefit patient well‐being only if these are in fact the purposes, and if teamwork is the principal means, of providing medical care. We should seize this time of change as an opportunity to measure and demonstrably improve the contribution of medical documentation and communication to the efficient and long‐term remission of disease.