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Physician Handoffs and Electronic Tools

Can physician handoffs in hospitals be improved with electronic tools?

That was the thrust of research conducted in 2014 by a group that looked at different research projects from 2008 to 2014.[1] Specifically, the researchers wanted to see the evidence on the effectiveness of electronic solutions used to support shift-to-shift handoffs.

Handoffs are a potentially life-threatening event. According to the Joint Commission in 2013, 63.5% of all adverse events involved miscommunication between health care providers. In fact, in a hospital survey by the Agency for Health Care Research and Quality in 2014 53% of the respondents endorsed the statement – “important patient care information is often lost during shift changes” and 47% endorsed the statement – “shift changes are problematic for patients in this hospital.”

IMPROVEMENTS TO PHYSICIAN HANDOFFS

The researchers found 37 unique articles with relevant research related to electronic tools designed to support physician shift-to-shift handoffs. In 22% of the included studies, respondents reported increased or improved handoff content, while the same number also reported high provider satisfaction with the use of an electronic handoff system. Other studies showed similar results. For example, in one study residents used three different handoff protocols (written, electronic and face-to-face) and they self-reported face-to-face handoffs had the lowest protocol deviations, while written handoffs had the highest. Electronic handoffs fell in the middle.

In other studies, perceptions of patient safety with respect to electronic tools were studied. In nine studies, for example, 24% of the participants perceptions of better patient safety, quality of care, better patient management and fewer near misses were reported. However, another study showed no statistical difference between using electronic tools and improved patient safety.

In terms of time devoted to activities related to handoffs, most studies showed reductions in time spent on the activity, while other studies reported that participants overwhelmingly reported that they would use the electronic system over other systems. Another study reported that 78% of respondents said that an electronic handoff system improved communications.

PHYSICIAN HANDOFFS AND PATIENT OUTCOMES

Patient outcomes were also analyzed.

One measured general medical emergency team calls and weekend discharges 12 months prior to and 12 months after implementation of an electronic handoff system, finding a decrease in calls and increase in weekend discharges. Another study found a significant decrease in median length of stay after 2 weeks of implementation of an electronic handoff system.

BARRIERS TO ELECTRONIC PHYSICIAN HANDOFF SYSTEMS

Some of the studies also noted the barriers to implementation of electronic shift-to-shift handoff system. Some of those included:

  • Clinical resistance to change
  • Perception that the handoff tool might interfere with direct physician communication
  • Duplication of work or more work
  • Errors created by free-text entry
  • Cost
  • Lack of integration with HER
  • Lack of specialty-specific format

Based on the results of their literature review, the researchers suggested that those designing electronic handoff tools to optimize the amount of data pulled from existing records, eliminating error introduced by humans retyping information. They also suggested key stakeholders be included in design efforts, and they emphasized the opportunity for user feedback and adequate training.

Their overall conclusion – the majority of the 37 studies had results supporting electronic handoff tools.

[1]J Grad Med Educ. 2015 Jun;7(2):174-80. doi: 10.4300/JGME-D-14-00205.1.
Evaluating Outcomes of Electronic Tools Supporting Physician Shift-to-Shift Handoffs: A Systematic Review.
Davis J, Riesenberg LA, Mardis M, Donnelly J, Benningfield B, Youngstrom M, Vetter I.
[2]The Joint Commission. 2014. Sentinel event data: root causes by event type.http://www.jointcommission.org/assets/1/18/Root_Causes_by_Event_Type_2004-2Q_2014.pdf. Accessed October 10, 2014.

To learn about patient assignment software — ASSIGN for Physicians — designed to improve continuity of care, click here

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Continuity of Care in Hospital Medicine

Continuity of care continues to be an important concept in hospital medicine. Not only has it been demonstrated to improve patient satisfaction, but there’s plenty of evidence to suggest that it improves health outcomes as well.[1] Furthermore, continuity of care has been associated with a reduction in resource utilization and costs and was even woven into the fabric of the Affordable Care Act (ACA).[2]

But the concept has meant different things to different people, and its use in hospital medicine has proven to be somewhat sporadic. For example, it wasn’t unusual for continuity of care to mean that a primary care physician would follow his or her patient to the hospital and check up on that person’s progress or care. In those circumstances, the primary physician would often consult with each specialist and be kept informed, often in face-to-face meetings, with the patient’s diagnosis or treatment.

Times have certainly changed.

Now, most primary physicians no longer follow their patients to the hospital. Instead, an attending physician at the hospital (a hospitalist or some other designated physician) has overall responsibility for care of that patient and the primary physician is typically kept appraised of care through electronic communications, usually after the fact. Meanwhile, while the hospitalist is now the one who is in regular contact with the specialists and consultants, there are still communication gaps.

Continuity of Care & Discharge

This is particularly true for discharge.

For example, one study indicated that direct communication between hospital physicians and primary care physicians occurred infrequently (3%-20%). In addition, discharge summaries also lacked important information, such as diagnostic test results, treatment or hospital course, discharge medications, patient or family counseling and follow-up plans.

Researchers concluded that “deficits in communication and information transfer at hospital discharge are common and may adversely affect patient care.” [3] New models of collaborative care have been proposed, but implementation has been slow. [4] Once again, the ideal of a continuous thread of continuity of care has yet to be realized.

This is of particular concern for care of older patients, who often face a plethora of fragmented care as they age and seek more help for a variety of ailments. Interpersonal continuity of care is particularly valued by older and more complex patients with worse health status, and higher continuity of care is directly associated with greater patient satisfaction, trust in a clinician, a greater sense of security and partnership in their care. [5]

Trust clearly plays an important role in healthcare. For example, a patient (and his or her family) is more like to accept the recommendations of treatment if trust is high. Conversely, a lack of trust may put treatment in serious jeopardy. How much does trust affect care? In one study of primary physicians in the United States and the United Kingdom, patients were asked how long they had been seeing their primary physician and whether or not that length had any impact on their trust of that physician. The results – the length of time in the relationship and the importance of continuity were the strongest predictors of trust.

Continuity of Care & Patient Assignments

In the hospital environment, it’s not unusual for a patient to be assigned a completely new physician on back-to-back days. Furthermore, it’s also not unusual for the physician or assignment handling assignments to know which physician might have attended to a particular patient in previous days, primarily because that information is generally not available during the assignment process. Rather, a patient list is generated from the EHR that morning and then the process of matching physicians up with patients begins anew.

What could be a new paradigm for better handling continuity of care within hospital medicine? One solution would be a robust software program that not only keeps track of physician assignments from one day to the next, but also uses that information to actually assign patients to physicians who have seen them in the past. This can even be done for readmissions as well.

In other words, patient Betty Jones would be assigned Dr. Taylor again because the software program would have remembered that while Ms. Jones was in the hospital once before, it was Dr. Taylor who was her attending and automatically makes the connection again (assuming, of course, Ms. Jones was happy with Dr. Taylor and was glad to see the same physician again).

This way of handling continuity of care does several things.

First, it provides that level of security and comfort that patients are often looking for. Hospitals are scary places for patients and their families. A familiar face can go a long way towards comforting the sick. Second, it helps the physician. Good care often begins at the personal level, where physicians get to know and understand a person (and his or her family).

That familiarity speeds up diagnosis and treatment and it provides a certain level of satisfaction to the physician as well. Taking care of people is a lot more rewarding when there’s continuity and familiarity.

No software program will solve the myriad of issues surrounding continuity of care, both within and outside the hospital setting, nor does it guarantee better outcomes. But it could be one more way in which technology works hand-in-hand with the personal touch to help make healthcare work better for all. That in itself would be a good step forward.

[1]Ann Fam Med. 2004 Sep; 2(5): 452–454.
doi: 10.1370/afm.84
Patient-Physician Shared Experiences and Value Patients Place on Continuity of Care
Arch G. Mainous, III, PhD, Meredith A. Goodwin, PhD, and Kurt C. Stange, MD, PhD
[2] www.ajmc.com/journals/issue/1999/1999…/jun99-869p727-734/
Continuity of Care: Is it Cost-Effective? Michele Raddish, MD, MPH; Susan D. Horn, PhD; Phoebe D. Sharkey, PhD.
[3] JAMA. 2007;297(8):831-841. doi:10.1001/jama.297.8.831
Deficits in Communication and Information Transfer Between Hospital-Based and Primary Care Physicians
Implications for Patient Safety and Continuity of Care
Sunil Kripalani, MD, MSc; Frank LeFevre, MD; Christopher O. Phillips, MD, MPH; et al
[4] The New England Journal of Medicine; Boston372.4 (Jan 22, 2015): 308-309.
Bridging the Hospitalist-Primary Care Divide through Collaborative Care
Goroll, Allan H, MD, Hunt, Daniel P, MD
[5] doi: 10.1370/afm.1739 Ann Fam Med March/April 2015 vol. 13 no. 2 123-129
Effect of Continuity of Care on Hospital Utilization for Seniors With Multiple Medical Conditions in an Integrated Health Care System, Elizabeth A. Bayliss, MD, MSPH, Jennifer L. Ellis, MSPH, Jo Ann Shoup, MA, Chan Zeng, PhD, Deanna B. McQuillan, MA1 and John F. Steiner, MD, MPH

To learn about how our patient assignment software — ASSIGN for Physicians — can improve continuity of care, click here