Written by the Discharge Summary Tracking System project team 
Our local community health centers are bustling with the activity of primary care providers answering their patients’ vital inquiries. But what happens if their question regards a hospital visit of which the provider was never informed?
“My patient exclaimed, ‘I’ve been shot!’” said primary care doctor Heidi Miller. “He had been hospitalized last week for this bullet wound and discharged with the instructions: ‘follow-up with PCP.’ He had nerve damage to his leg, he couldn’t pick up his foot, and he tented the bullet beneath his skin, asking me, ‘Are you going to take this out?’ I had no idea he had been injured, what was done already in the hospital, and what I was supposed to do next.”
Problems with communication between hospital and primary care physicians have been noted in many studies nationally. A review of over 65 studies on this topic done in 2007 found that direct communication between these providers occurred 20% of the time or less and that this affected the quality of care in approximately one-quarter of follow-up visits. A 2014 provider survey by Elna Nagasako and Emily Schenk from Washington University School of Medicine (WUSM) in collaboration with the St. Louis Integrated Health Network (IHN) found that community health center providers in the St. Louis region described similar issues.
Discharge summaries are one important tool for handoffs to be successful. These summaries contain information about why a patient went to the hospital, what happened during the stay, and what medications the patient should take when he or she goes home. These summaries are completed when the patient leaves the hospital and are intended to be sent to the providers who will take care of the patient after he or she leaves.
However, as one health center provider commented, “I think everything is being sent or phone calls are being made but it’s just not getting to us; it’s something in the middle that’s stopping the communication or blocking it… some are just falling through the cracks and aren’t getting to us.”
The Discharge Summary Tracking System project, funded by a Washington University Faculty Practice Plan grant awarded to Dr. Nagasako, is a multi-organization collaboration convened by the St. Louis Integrated Health Network with the goal of improving discharge summary transmission from WUSM faculty at Barnes- Jewish Hospital (BJH) to community health center providers.
“The St. Louis Integrated Health Network’s mission is to improve the accessibility, quality, and affordability of healthcare for the uninsured and underinsured. Collectively the members of the IHN support over 200,000 of the region’s most vulnerable patients. Partnerships between community-based providers, academic institutions, public health, and hospital systems in the area of quality improvement are crucial for achieving this goal,” says Bethany Johnson-Javois, St. Louis Integrated Health Network CEO.
As a part of this project, a team from the St. Louis Integrated Health Network, Washington University School of Medicine, BJC Healthcare, Affinia Healthcare, Barnes Jewish Hospital, and Family Care Health Centers held a 3-day quality improvement event in Fall 2015 focused on this issue. Facilitation was provided by BJC Transformation Support, a group of consultants in process improvement, led by Rodney Mullins.
Bringing together the people involved in a process to solve a problem collaboratively is a key tenet of Lean, the process improvement method used in the event. Originally used in the automotive industry, Lean focuses on identifying and eliminating eight types of waste in processes. Event activities included learning about the Lean method of process improvement, mapping out the current processes, and creating an action plan.
“The health center and hospital staff at the frontlines of patient care has so much expertise to share. Having the knowledge of these staff was critical to identifying problems and solutions during the event,” said Dr. Nagasako.
Participants had multiple “a-ha” moments prompted by discussions with their partners caring for the same local patient population. One of these insights was the key role of the patient as the identifier of their healthcare providers. Even if the registrar has information about the provider in the electronic health record, the patient may say they do not identify that person as a primary care provider.
As one participant relayed, “If we ask, ‘Who do you see when you have a cold?’ patients sometimes say, ‘I see my cardiologist.’”
The insights from this joint Rapid Improvement Event generated 20 recommended action steps in 6 opportunity areas. One of these was to coordinate regular provider information updates between the Affinia Healthcare and Family Care Health Centers and BJC’s provider data management center to ensure that discharge information is sent to the right place continually.
In another action step, BJH provided ‘Read-Only’ hospital electronic health record access to the appropriate health center staff so that clinical information could be retrieved when and where it was needed for patient care.
“Communication from hospitals on behalf of our primary care patients has absolutely stepped up. We still need improvements and ongoing support, but the broad collaborative spirit of this project was a catalyst.” said Dr. Miller.
Preliminary data collected by the project team members Emily Schenk and Amanda Stoermer shows a significant increase in the percentage of discharge summaries available in the participating community
health center records. Next steps for this project include partnering with the IHN’s Transitions of Care Task Force to sustain and spread these improvements.
In addition to directly working to improve care for community health center patients through improved discharge communication, the event also helped to build relationships between the front-line providers who care for some of the region’s most vulnerable patients.
“This meeting of the minds… served as a networking opportunity to actually share ideas with the very people on the receiving and giving ends of various patient centered processes we are all a part of daily,” commented Danielle Landers, an IHN community referral coordinator at Barnes-Jewish Hospital.
- Elna Nagasako, MD, PhD, MPH; DSTS Study PI; Washington University School of Medicine, Assistant Professor of Medicine
- Emily Schenk, BA; DSTS Project Coordinator; Washington University School of Medicine, Clinical Research Project Coordinator
- Bethany Johnson-Javois, MSW; St. Louis Integrated Health Network, CEO
- Heidi Miller, MD; St. Louis Integrated Health Network, Consultant; St. Louis Integrated Health Network Transitions of Care Task Force, Facilitator
- Amanda Stoermer, MSW; St. Louis Integrated Health Network, Outcomes and Information Manager