Effective communication between inpatient and primary care providers (PCPs) is important for safe transition of care for hospitalized patients. In 2017, communication with PCPs was prioritized for the pediatric hospital medicine division. Our primary aim was to improve documented attempted communication with PCPs within 72 hours of discharge from 41% to at least 60% by January 1, 2018, and maintain this performance through 2019.
This study included all inpatient encounters discharged by a pediatric hospital medicine provider from March 2017 to April 2020. An electronic health record phrase debuted March 2017. Successful documentation was defined as any attempt to contact the PCP, regardless of whether actual communication occurred. Group and individual audit and feedback occurred in July 2017 to April 2020. Provider communication was financially incentivized in July 2018 to June 2019. An annotated P-chart for the proportion of encounters with documented PCP communication occurring within 72 hours was established. Special-cause variation was determined by using Shewhart rules.
The mean proportion of encounters with documented PCP communication increased from 41% at baseline (March 2017 through July 2017) to 60% in August 2017 and 66% in December 2017. After the financial incentive was removed in July 2019, documentation decreased to 54%. Phone calls with clinic staff were the most common communication method (40% to 71%). Direct conversations with the PCP occurred rarely (0% to 3%).
Even when coupled with audit and feedback with EHR interventions, our work suggests that shifting to external financial motivation may hinder sustainability of behavior change to improve attempted documented PCP communication.
Effective communication between inpatient and outpatient providers is critically important to safe transitions of care for hospitalized patients.1 The need for effective communication at the time of discharge is an essential aspect of inpatient care coordination for pediatric hospitalists.2 The onus of such discharge communication falls largely on hospitalists, given that primary care providers (PCPs) often report difficulty with obtaining the contact information of the hospitalist caring for their patient.3,4 More than half of adverse events during the discharge period may be attributable to poor communication between inpatient providers and PCPs.5
In a previous study, researchers reported that 72% of PCPs feel that they receive timely communication from hospitalists regarding discharged patients and just 65% feel that this communication contains the necessary information required to care for patients after discharge.6 In general, PCPs express lower satisfaction with the quality of discharge communication when compared with their hospitalist counterparts.7 Laboratory results, medication changes, follow-up appointments, and imaging studies are just a few of the potential information needs that must be communicated to PCPs on discharge and some adult studies have identified pending laboratory results as a potential risk to patient safety.8,9 Such communication may encompass various modalities, ranging from face-to-face and telephone calls to the PCP and/or supporting staff to direct e-mails or electronic messages through the electronic health record (EHR).10
Researchers in previous studies have examined methods by which communication can be improved between hospitalists and PCPs.11,12 More recently, the EHR has been leveraged to improve PCP communication. A study by Destino et al13 detailed an effective quality improvement (QI) intervention in which workflows were standardized and enhanced by using the EHR to achieve 7 months of sustained, improved communication with PCPs within 7 days of discharge from 59.1% to 76.7%.13 The utility of financial incentives for pediatric quality measures is not well-studied, although some researchers suggest they may be associated with improvement.14,15 In 2015, a study by Tejedor-Sojo et al revealed that coupling audit and feedback with physician incentive compensation improved communication with PCPs within 48 hours of discharge from 57% to 93%.16 Although financial incentive compensation may be effective in changing physician practice during the time of incentivization, lasting effects on physician practice are not well-evaluated.17
Our division encourages communication with the PCP’s office, and preferably the PCP’s themselves, at the time of discharge, but before 2017 no formal expectation of such communication existed. In early 2017, the need for formalized communication with PCPs in the community was emphasized as a priority for the pediatric hospital medicine (PHM) division. Our primary aim was to improve our documented attempted communication with PCPs within 72 hours of discharge from the PHM service from a baseline of 41% to at least 60% by January 1, 2018, and to maintain the same level of performance through 2019. Our secondary aim was to determine the role of financial incentives in sustaining timely discharge communication.
This project occurred at a 145-bed freestanding children’s hospital with 4133 average annual discharges from the hospitalist service. The hospitalist division consisted of 15 physicians and 10 advanced practice providers at the time of the initial intervention and is part of an academic multispecialty physician practice. This practice includes within its compensation plan an incentive mechanism for the design and execution of quality improvement projects that is worth up to 2.5% of physician base salary for meeting all required project performance metrics. Proposals are developed within and across divisions and approved by the appropriate academic department chairs and practice plan leadership.
Our division had historically used telephone calls to communicate with a PCP’s office on discharge. Although senior physicians in the group had well-established relationships with community pediatricians, including their personal contact information, younger physicians in our group often had difficulty contacting these same PCPs.
In March 2017, a team of 3 hospital medicine physicians, 1 nurse practitioner, and an informaticist performed in-depth literature review to identify successful implementation strategies and appropriate benchmarks for discharge communication. Potential interventions focused on several key drivers that encompassed the format, timing, and operationalizing of discharge communication with PCP’s and their offices (Fig 1).
Tracking and reporting of discharge communication would occur through the EHR (Epic Systems, Verona, WI). A standardized PCP communication phrase was developed in collaboration with information technology personnel. This phrase was designed to be used on discharge and documented within the daily progress note or discharge summary. The first portion of the phrase required physicians to choose the method of communication: (1) a telephone call to the PCPs office; (2) a secure message through the EHR; (3) in-person communication; or (4) “other,” which would then require manual entry by the hospitalist to detail how communication occurred. If a telephone call occurred, the phrase would require details regarding who was spoken to: (1) the PCP; (2) a different provider; or (3) a nurse. Options for leaving a message and an unanswered call were also included. (Fig 2)
On the basis of their review, the planning team’s primary proposed intervention was prospective audit and feedback.16 Monthly data were presented at division meetings by a member of the project team every 2 weeks to identify barriers to success. The first portion of each division meeting was dedicated to reviewing our group’s up-to-date aggregate performance with time available for open discussion and feedback about the project’s successes and opportunities for improvement. The data were presented as percentages representing the proportion of encounters with documented communication within 72 hours of discharge. Meeting agendas included this information so that the group could discuss trends in performance frequently, regardless of intervention timing. New interventions and changes were developed on the basis of this feedback. Individual performance was discussed with providers when an individual was below goal. This individualized feedback occurred as needed, although all division members reviewed individual performance during semiannual reviews with the division chief. Individual performance was otherwise not available to other division members.
Although the project did not officially launch until July 1, 2017, variations on the communication phrase had been in use before the official launch date and, thus, some baseline data were available before July 1. Division members were aware of this project and were regularly updated in the months leading up to implementation, with some hospitalists using the phrase before July 1. After project implementation, data were initially collected from July 2017 to November 2017, at which time it was noted that consistent communication with PCPs for children discharged during the weekend was a significant barrier to goal performance. As a second intervention, weekend communication processes were altered by promoting communication with on-call PCPs and by encouraging communication on Monday mornings. Data were then collected from November 2017 to July 2018 without further changes to implemented interventions. In July 2018, there were 7 new hires to our PHM division and additional training was provided to them in September 2018 regarding our PCP communication project.
From July 1, 2018, to June 30, 2019, PCP discharge communication was incentivized through the physician practice plan. This financial incentive was removed in July 2019 when the division selected an alternative project for financial incentive. However, the remaining interventions (audit and feedback, EHR communication phrase) were continued. Data were then collected from July 2019 through April 2020.
All patients discharged from the PHM service were included in this study. Patients discharged by another service were excluded. Goal performance of documented discharge communication was defined as an overall attempted communication rate of at least 60% within 72 hours of discharge. To qualify, providers had to use the EHR phrase in a note; free-text documentation was not counted. Compliant use of the phrase included use in the patient’s discharge summary (if the patient was hospitalized for 2 or more days), the last progress note of the hospitalization (if the patient was discharged <2 days from admission) or a separate short progress note if documented within 72 hours of discharge. Therefore, all patients who had documentation of PCP communication occurring within 72 hours of discharge were included in the numerator of our outcome measure. Late documentation occurring after 72 hours did not qualify as successful documentation.
Although direct communication with the PCP was preferred, this project was focused on overall communication to the PCP’s office. As such, unsuccessful communication attempts (included leaving a voicemail, no answer when called, or lack of text matching any pattern in the other categories) were still considered acceptable documentation. Our goal of 60% was chosen because it was consistent with available literature regarding achievable communication rates with initial QI interventions.11,12,16 A previous study revealed that achievable performance benchmarks vary on the basis of the infrastructure in place to support discharge communication and that, even in settings with significant administrative and EHR support, appropriate discharge communication occurred only 80% of the time.12 Our process was entirely dependent on the hospitalist to initiate and document communication. Although researchers in a previous study used 48 hours or 2 calendar days as adherence criteria, our time period of 72 hours was chosen to account for late Friday discharges wherein a PCP may not be contacted until Monday morning.11
Discharge date, provider, and contents of notes containing the EHR phrase were reported for all qualifying patient encounters from March 2017 through April 2020. EHR reports were generated monthly to audit phrase use. Reports included provider-level compliance with phrase use within 72 hours of discharge.
EHR documentation phrases were categorized by type of communication as described above. Use of these categories were analyzed each month as a proportion over the course of the study. To compare the variation across providers over the course of the study, median and interquartile range of individual provider performance were graphed by month. Statistical process control chart means for the proportion of encounters with documented PCP communication within 72 hours were established and adjusted by using Shewhart rules as implemented by the qcc statistical process control package in R.18 All analyses were conducted by using R v. 3.6.3 (R Core Team, Vienna, Austria).
This project was deemed not human subjects research by our institutional review board.
Documented Communication Compliance
The baseline data collection from March 2017 to June 2017 included 1383 discharges. Because the EHR phrase was not in development before March, no baseline data were available before this. Monthly data plus 3-σ control limits are presented in Fig 3. Special-cause variation indicated a shift in proportion of documented communication with PCPs within 72 hours from a baseline mean of 41% to 60% a month after project implementation (July 2017). July 2017 to June 2018 included 4206 discharges. After implementing changes for weekend discharges (November 2017), there was another upward shift in proportion of encounters with documented communication to a mean of 66%.
The financial incentive was implemented from July 2018 to June 2019, which included 4379 discharges. When the financial incentive was removed in July 2019, there was a shift to a mean of 54% with no further variations detected through April 2020. June 2019 to April 2020 included 3776 discharges. Documented communication compliance remained at or above performance goals for 22 months (September 2017 to June 2019) of the study period.
Methods of PCP Communication
Phone calls with clinic staff other than the PCP were the most common method of communication documented by hospitalists in any given month (40% to 71%). In-person and/or direct telephone conversations with the PCP occurred rarely (0% to 3%). Secure EHR messages were the second most common method of communication through all intervention periods (21% to 47%). An increasing number of faxes were used as communication from September 2018 onward (4.5% to 9% versus 0% to 3%). With the exception of 1 month, unsuccessful communication occurred <10% of the time.
Using improvement methodology, we successfully increased documented discharge communication with PCPs. Within 3 months of project implementation, we increased our mean documented PCP communication within 72 hours of discharge to 60% and later to 66%, which was at or above the goal of 60%. Furthermore, we sustained goal performance for 22 months. Finally, we observed a decrease in documented discharge communication with PCPs after removal of the financial incentive.
Our documented communication compliance at the start of this project is similar to previously published studies.4,11,19 Consistent with another study, verbal communication and secure EHR messages were the preferred methods of communication.11 Although direct verbal communication with the PCP occurred rarely, secure messages to PCP’s constituted 25% to 50% of monthly communications. These messages are routed directly to providers and many times PCP’s respond to these messages. However, this finding highlights an important ongoing gap wherein a number of discharge communications do not involve PCPs directly (in any given month, only 0% to 3% of documentation indicated direct, verbal communication with the PCP), which could lead to inadequate communication to the PCP. Improvements in documented communication were achieved without resources external to our division, including residents, which researchers in a separate study used for achieving improvement goals.12 With our study, we build on previous work by providing longitudinal observations of physician behavior over 40 months.
Our experience offers novel insight into the potential impact of financial incentives on physician performance by describing provider performance patterns before, during, and after removal of a financial incentive. Studies have revealed an inconsistent impact of financial incentives on physician behavior, and there are limited data on the role of financial incentives in pediatric quality measures.14,15,17 Tejedor-Sojo et al previously reported on using a financial incentive to increase discharge communication beyond rates achieved with audit and feedback alone.16 When our financial incentive was added to existing audit and feedback, we did not observe significant changes to physician communication practices, which were already exceeding our goal of 60%. After withdrawal of the incentive, there was a decrease in compliance (from a mean of 66% to 54%). We did not meet our goal of 60% after removal of this incentive, despite ongoing audit and feedback. We also observed increased variability in provider-specific adherence to performance goals during this time, which likely represented an overall lack of compliance with our communication targets. Thus, we build on previous work by showing that withdrawing a financial incentive from an implementation package may significantly decrease adherence to recommended practices. Furthermore, our study suggests that implementation of a financial incentive may, in fact, be harmful in the context of other quality improvement initiatives.
Financial incentives may impact individuals’ intrinsic motivations to perform an activity.20 Our data suggest that we had successfully established intrinsic motivation with audit and feedback and a shared value that effective communication with outpatient providers was safe and high-value care. Internal motivation based on such values has previously been documented as an important aspect of physician behavior.21 However, an external force, the financial incentive, was added that may have shifted the focus of provider behavior. Consistent with behavioral economics and human motivation, the replacement of this internal motivation and autonomy by an external financial incentive may have inadvertently disrupted our improvements in communication.22 As a result, we may have kept our intrinsic motivation lower than it should have been to achieve a monetary reward. When the financial incentive was removed, a separate, new QI project was started that was financially incentivized. This new, incentivized project may have created a competing interest that further diverted the attention from PCP communication.
Our group used audit and feedback as the primary intervention tool for this project, although this was implemented simultaneously with the EHR tool and thus improvements in documented communication were likely multifactorial. Ongoing performance was presented at division meetings every 2 weeks to encourage discussion and planning for changes to our communication approach. Although individual providers were not aware of others’ performance, they were aware of the division’s collective performance compared with their own. Previous reports support the use of audit and feedback to improve physician practice, including discharge communication to PCPs.11,16,23,24
Our project provides additional insight by demonstrating the feasibility and value of leveraging EHR resources to efficiently track and analyze discharge communication at the provider level. Specifically, by working with our institution’s information technology team and an informaticist, we were able to provide a straightforward, reproducible, auditable, and standardized method of documenting communication with a PCP and tracking detailed provider performance. Researchers in previous studies relied on a variety of systems to facilitate and document communication with a PCP, including a hospital call center, use of housestaff, and EHR documentation.11,12,16
This study has several limitations. Our EHR phrase can be used by providers at any time, including before communicating with a PCP. It is possible that some documentation occurred without actual communication. Given the large number of discharges from the division, there was no feasible way to confirm that EHR documentation indicated that such communication truly occurred. We did not evaluate PCP satisfaction or perceptions of our communication project and therefore we cannot make conclusions from the standpoint of PCPs. We also used functionality inherent to our EHR, such as secure messages, which may not exist in every EHR and may not be regularly accessed by PCPs outside the system. The effect of our interventions on patient care outcomes was not measured in any way; we did not collect data related to readmissions or adverse patient outcomes as part of this study. We also did not collect any data assessing race, ethnicity or language. Finally, our project was performed at a tertiary children’s hospital; thus, our experience may not be generalizable to other hospital settings.
Our work collectively supports audit and feedback with EHR interventions as a successful method by which to improve PCP communication but also suggests that shifting to external financial motivation may hinder sustainability of behavior change, particularly if the incentive is later removed. Future directions include further modification of our EHR to make documentation of communication a requirement of the discharge process, including potentially making such documentation a required part of the discharge summary. In addition, further work is underway on a division scorecard to make PCP communication a sustainable and longitudinal metric.
The authors acknowledge the entire division of PHM for their participation in this project: Allison Ashford, MD, Chelsea Bloom, MD, Whitney Bossert, MD, Jason Burrows, MD, Jodi Cantrell, MD, Lindsay Cassidy, MSN, APRN-NP, Melissa England, MD, Amy Goldstein, MD, Jacqueline Hanks, DNP, APRN-NP, Claire Ives, MD, Gregory Johnson, MD, Stefanie Kammrad, DNP, APRN-NP, Diane Kocovsky, MSN, APRN-NP, Gary Lerner, MD, Katie MacKrell, MD, Lauren Maskin, MD, Ann Melling, MS, PA-C, Kristina Mueller, DNP, APRN-NP, Sara Moussa, MD, Aleisha Nabower, MD, Trudie Owens, MSN, APRN-NP, Emily Pietrantone, MSN, APRN-NP, Meghan Potthoff, PhD, APRN-NP, Valerie Rinehart, MD, Natalie Shafer, DNP, APRN-NP, Lisa Sieczkowski, MD, Sheilah Snyder, MD, Shubra Srinivas, MD, Brenda Weidner, MD, Jessica Wollberg, MSN, APRN-NP, Katie Zander, MSN, APRN-NP.
FUNDING: Dr McCulloh and Ms Kerns receive support from the Office of the Director of the National Institutes of Health under award UG1OD024953. The remaining authors did not receive funding. The funder/sponsor did not participate in the work. Funded by the National Institutes of Health (NIH).
COMPANION PAPER: Companions to this article can be found online at www.hosppeds.org/cgi/doi/10.1542/hpeds.2020-005421, www.hosppeds.org/cgi/doi/10.1542/hpeds.2020-005637, and www.hosppeds.org/cgi/doi/10.1542/hpeds.2021-006188
Drs Goodrich, Dolter and Snow conceptualized and designed the study, participated in data collection, drafted the initial manuscript, and approved the final manuscript as submitted; Drs Stoolman and McCulloh assisted in the study design, reviewed and revised the manuscript, and approved the final manuscript as submitted; Ms Kerns participated in data analysis, reviewed and revised the manuscript, and approved the final manuscript as submitted; and all authors approved the final manuscript as submitted.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no conflicts of interest to disclose.
FINANCIAL DISCLOSURE: Dr McCulloh from time to time provides advice on legal matters. The remaining authors have indicated that they have no financial relationships relevant to this article to disclose.