Doctors are conflicted about sharing discharge summaries with patients

Whether it lasted hours or months, every hospital stay is chronicled in that one final document: the proverbial baton passed from a patient’s hospital doctor to his primary care provider better known as a discharge summary.

This report has always been available to patients after they fill out a decent amount of paperwork. In mid-July, Massachusetts General Hospital began sharing discharge summaries with all patients through an online portal. The move came as a surprise to many doctors, prompting discussion about the purpose of these summaries and the implications of sharing them openly.

The intent of this new transparency, according to an email from the hospital’s health information services, is to “help patients make healthier and more informed decisions about their care.” Beyond the ethical argument that patients ought to have easy access to information about them (which is the norm in countries like France), there’s a practical benefit to sharing discharge summaries. Knowing the specifics of your medical issues (say, that you have atrial fibrillation, not just “a funny heart rhythm”) and of your hospital course, you’re better-equipped for Google self-diagnosis. More importantly, you can be a resource and an advocate for your care when you see doctors down the road, especially if they don’t have access to records from your previous providers.

So why are doctors conflicted? Maybe it’s the fear that patients will be offended by what we write about them (“An obese woman appearing older than her stated age”). That patients won’t understand our jargon or that we’ll be forced to write as if we were talking to patients, displacing the primary role of the document. (Early research on open notes has shown that such fears may be unfounded.)

Part of the hesitation comes, I think, from our history of difficulty writing them well. A 2007 review of dozens of studies on the subject found major flaws in these documents: they often missed key information like a patient’s main diagnosis, a list of medications to take after leaving the hospital, and laboratory test results that were pending at the time of discharge. We know that the summaries are often wordy or redundant – the victims of cut-and-paste – or overly brief.

There is also the issue of promptness. The majority of summaries examined in the review didn’t reach the outpatient doctors in time for the follow-up visit (defeating much of the purpose) or in some cases, at all. More recently, since insurers began rewarding hospitals for getting the summaries done on time, the rates of summaries finished within 24 or 48 hours of a patient’s departure have risen dramatically. But with any push for quantity, quality may have taken even more of a hit.

Coming from a practice in which our patients can access all of our notes, I’m probably more comfortable than average with my words being shared. I see this, instead, an opportunity for doctors to hone our medical reasoning on a document that now enjoys an expanded audience. I’m working with a team of similarly-minded residents (trainees, after all, are responsible for a major share of the summaries written in teaching hospitals like ours) to think about how we can write and promote better quality discharge summaries despite the time pressures. The result, we hope, will create smoother transitions for all of our patients.

Ishani Ganguli is a journalist and an internal medicine-primary care resident who blogs at The Boston Globe’s Short White Coat, where this article originally appeared. 

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  • guest

    This is a timely article for me, since just this week I reviewed the records for a series of physical therapy treatments that my child had had, and when I did, discovered that the treating therapist had documented that we were a “non-compliant family” and that PT should not be continued for my child. This was a completely different message than what we had been told verbally by the therapist, who merely said that the treatment was over.

    On the one hand, discovering that documentation enabled me to call the clinic director and suggest a process improvement for their practice: namely, that if an individual therapist plans to provide 90-120 minute treatment sessions to a patient, that information should be made available to the patient’s family and to the schedulers, so that they don’t tell the patient/family when they call to schedule sessions that the sessions will last 60-75 minutes. Our child was picked up from his sessions too early, as a result of that miscommunication, and so our family was labeled “non-compliant.”

    On the other hand, I am keenly aware that I have (ironically, since I am a physician) terrible health insurance, that the clinic is paid very poorly for services to us and that anyone who treats us is forced to go through multiple iterations of annoying authorization paperwork, So my calling to clarify the compliance concern probably did not endear us to the clinic at all, although the conversation was very cordial and professional on both sides.

    Although the powers that be would like to frame some of the problems with our healthcare system as problems that can be solved if patients are “empowered” to get involved and advocate for better care for themselves, the bottom line is that that quality of care is not being paid for by insurers. Patients can advocate to receive a better level of care than is being paid for, but the ultimate result will continue to be, on some level, resentful providers.

    • rbthe4th2

      “Patients can advocate to receive a better level of care than is being paid for, but the ultimate result will continue to be, on some level, resentful providers.”
      EXACTLY what I have found. Advocating for myself to get in, questions on diagnosis, what tests are being done, all cause docs who don’t want to treat me. If I can find information that is peer reviewed medical literature and give it to you, and you can’t follow it, makes me wonder …

  • karen3

    Would have been handy to the ER doc to have known that I had a post-op heart attack and an anoxic event when i presented a week after discharge with tachycardia. I’m sure the ER doc would have appreciated those details.

    When mom was discharged with no mention of a growing lung tumor, no mention of an infectious disease that required precautions and a quadrupled dose of heart medication that no one told us about– resulting in serious complications — having been given the discharge summary would have been helpful in resolving problems in advance. Ultimately, its about the patient, and if you can’t tell the patient what you are telling your colleagues, there is a problem with you, the doctor.

    • guest

      Unfortunately, there is growing pressure for doctors to produce the discharge summary before the patient walks out the door on the day of discharge. With that type of time pressure, the quality of the discharge summary suffers, since the doctor is attempting to complete a very complex document, usually in the morning when things in a hospital are at their most hectic, and frequently while also trying to deal with clinical emergencies and new admissions.

      • karen3

        Well having it done before the patient leaves so it can be a communication and continuity of care tool is when it is most valuable. After the event, who cares? it’s pointless, non-value added, paperwork.

        And if its “too complex” and too difficult for the doctor to get it written down correctly before the patient leaves, aren’t the verbal instruction to the patient, perhaps not feeling the best, a bit much to expect them to remember and communicate correctly?

        • guest

          I don’t think anybody disagrees that having the discharge summary done before the patient leaves is a worthy goal. The problem, like almost everything else in medicine these days, is that it’s an unfunded mandate. That is, a decree has been issued that it must be done, but resources have not been put in place to ensure that it gets done well. In this case, the resources would probably be assigning a nurse practitioner to review the chart the morning of discharge and dictate a complete and timely summary of the patient’s treatment.
          At my hospital, we had that resource in place, and it worked extremely well. Our discharge summaries were comprehensive, well organized, accurate and completed in a timely fashion. Then the hospital decided that it couldn’t justify paying the NP to do discharge summaries and it would be “just as easy ” for the docs to enter them into the EMR prior to discharge. We have been informally told by our department chair that our discharge summaries are no longer expected to be that complete. You get what you pay for, one way or the other.

          • W Joseph Ketcherside, MD

            Sorry, but docs have always been required to compete a discharge summary, so there is no “unfunded mandate”. And all your work is expected to be complete, correct and professional – your department chair is full of crap.

            Your issue seems to be with completing the summary in a timely fashion, since the requirement for the summary itself is not new. I will submit to you that this is just an issue of scheduling and personal preference. You know when you have patients to discharge, so rearrange your day. It’s not set in stone.

            The fastest time to complete the summary is when it is fresh in your mind. The longer you wait after discharge – until it is convenient for you – the longer it takes to review the chart and remember what you are saying. And tell me how that is a better summary?

            If the point of the discharge summary is to ensure a good transition of care for you patient, then you need to do it when they leave. Otherwise its just something you do to get paid.

          • guest

            Sorry, you are certainly welcome to think what you want, but since it appears that you have not actively practiced medicine (or surgery) in quite some time, your opinion is rather difficult to take seriously.

            The only really effective leaders in medicine are going to be the ones who are still involved in doing the actual work.

          • W Joseph Ketcherside, MD

            Oh, @Guest, you are missing the boat. The doc in the room is not the only player in patient care. And I actively practice medical informatics in the trenches every day.

            Since you don’t have the confidence in your opinion to use your name I’m afraid it’s more difficult to take your opinion seriously.

            Instead of ad hominem attacks on the writer, try addressing my issues themselves.

          • guest

            I would be happy to address any relevant issues you may want to bring up, but I don’t think it’s a good use of my time to address quarrelsome judgments based on a partial reading of my post.

            And I stand by my original comment, which was not an ad hominem attack at all, but a common-sense observation: if you are not actively engaged in the work yourself, or direct visual assessment of the work as it’s performed, you are not really in a position to comment meaningfully about what’s possible or what’s not within that workflow.

  • Personiform

    Open Notes is definitely the future. It is proven to enhance care, and improve outcomes. It is consistent with the broader, long-term goal of transparency and openness. The problem is how long it will take for something like this to become the norm. Democratization of sharing health records – people sharing their health records however they want – could drastically speed up the process of transformation. #medyear

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