In discussing hospitalist models, it is essential to keep in mind the relationships between hospitalists and the wider pediatric community. Communication is at the forefront of any hospitalist model and can be the Achilles’ heel of an otherwise high-quality program. Excellent communication to and from primary care physicians (PCPs) can help a program thrive and prosper. PCPs who are kept in the loop regarding their patients’ hospital courses will likely support and continue to utilize the hospitalist service. By communicating in an effective and timely manner, one of the major potential downsides (loss of valuable information) of a hospitalist service can be avoided.
Communication can positively or negatively affect a variety of issues, including but not limited to quality of care, cost of care, patient and physician satisfaction, and liability. With excellent communication, the transition from inpatient to outpatient settings (including transitional care units, chronic care facilities, and rehabilitation hospitals) can be smooth, with minimal to no loss of information.
The concept of assuming care for other physicians’ patients and then returning their care to the PCPs at discharge is an integral component of all hospitalist models. This is generally accomplished via a formal handoff, which is one of the more controversial and variable aspects of hospital medicine. The intentional creation of discontinuity of care permits a physician (hospitalist) to be present in the hospital for an extended period to manage inpatients throughout the day. This ongoing presence is one of the biggest advantages of the hospitalist model. As with most things, however, one must accept the good with the bad. As a result of the handoff, the PCP, with whom the patient has fostered a trusting relationship and who knows the patient’s medical history best, is not caring for the patient when he or she is most ill. This situation can result in a loss of essential information (“voltage drop”) from the outpatient to the inpatient setting and vice versa. Complex and expensive laboratory and radiology data, as well as vital information concerning possible medical allergies, medications, code status, and patient’s likes and dislikes, can be lost or poorly or miscommunicated during the transfer. This could result in a variety of negative outcomes—some relatively benign, and others potentially life threatening.
With excellent communication between the PCP and the hospitalist, voltage drop can be minimized. In a study of 400 discharged patients, researchers found that 19% of patients suffered adverse events soon after discharge; about half of these events would have been preventable if communication had been adequate.1 The Value in Inpatient Pediatrics (VIP) network has sought to standardize the discharge communication process with their “Pediatric Hospitalists Collaborate to Improve Discharge Communication” project. Additionally, The Pediatric Research in Inpatient Settings (PRIS) network is working on handoffs in the academic setting with their I-PASS project. To date, no standard for communication between the hospitalist and the PCP has been set, and there is significant variation from practice to practice.
Communication may occur in person, via telephone, fax, e-mail, text or internet, or sometimes not at all. Maintaining compliance with Health Insurance Portability and Accountability Act (HIPAA) standards adds another challenge to the process. A task force formed by the Society of Hospital Medicine and the Society of General Internal Medicine to address continuity-of-care issues found that more than a quarter of PCPs do not receive discharge summaries on their patients. Additionally, the task force discovered that more than half of discharged patients made contact with their PCPs before the PCPs had received any discharge information—many PCPs did not even know that their patients had been admitted to the hospital. Only 17% of those surveyed stated that hospitalists had notified them before their patients were discharged to home.
The growth of information technology and easy access to e-mail, the internet, faxes, wireless communications, and handheld devices have created many effective modes of communication. New computer and handheld device programs to address communication issues have been developing at a rapid pace, and many of them are quite useful. Template-driven discharge summaries can simplify the process and help ensure that essential information is communicated. The technology to create real-time communication exists, although many hospitalist programs have not made the leap because of cost (both financial and time), unwillingness to change, lack of administrative support, inadequate staffing, or a variety of other reasons. The information communicated, such as discharge summaries or laboratory reports, should be filtered appropriately to maximize the efficiency of communication and reduce the time commitment for PCPs. Some information, such as social issues and end-of-life care discussions, does not lend itself well to electronic communication, and in these situations, the value of the telephone or face-to-face communication should not be overlooked.
“Social rounds” by the PCP, either by phone or in person, are an excellent patient satisfaction tool and can help erode the voltage-loss issue and increase the family’s confidence in the hospitalist. One effective technique is for the hospitalist to call the PCP while in the patient’s room so that the family can hear that everyone is on the same page. Similarly, including the PCP in complicated social and medical discussions, such as end-of-life care, code status, case conferences, and major medical or surgical decisions, can be useful to all involved. Telemedicine has not been routinely implemented to communicate with PCPs but with easy access to programs such as Google Talk, Facetime and Skype this technology may be promising. One needs to be cognizant that the PCP will be dealing with the aftermath of the hospitalization. By working as a team, the PCP and the hospitalist can maximize the advantages of hospital medicine while minimizing its disadvantages.
The AMA recently published a white paper, There and Home Again, Safely,2 that addresses the PCP’s responsibilities in transitions of care in and out of the hospital setting. It makes clear that communication around patient care is a bi-directional dialogue so that it is reasonable for the hospitalist to have an expectation of communication from the PCP.