Despite remarkable advances in medicine, the handoff of a patient from one physician to another has long been a weak link in the chain of care. Vital information routinely falls through the cracks, and physicians are often confused about who is responsible for follow-up.
The Growth in the Number of Hospitalists
The growth in the number of hospitalists has been nothing less than impressive. About 3500 physicians described themselves as hospitalists in the year 2000. Now, there are more than 52,000, according to the Society of Hospital Medicine.
During a typical hospital stay, a patient may be seen by 3 or 4 hospitalists and one or more specialists. Handoffs between hospitalists may not convey critical information and efforts to reach physicians in other specialties are sometimes unsuccessful.
Although malpractice insurers and patient safety experts believe that hospitalists have significantly improved hospital care, an estimated 80% of serious medical errors involve miscommunication between caregivers when shifts change in hospitals, when one doctor refers a patient to another, and when patients are discharged, resulting in severe patient injury or death, delays in treatment, and increased length of stay in the hospital.
Malpractice insurers are paying out billions of dollars in awards and settlements because of preventable errors during the handoff process. Improper handoff is not only due to providers who lack ‘people skills,’ patients with language or comprehension deficits, or communication that is misspoken or misunderstood; errors often occur because information is unrecorded, misdirected, never received, never retrieved, or ignored. Essentially, every mode and system by which patients and caregivers share health-related information is vulnerable to failure.
In an analysis of more than 23,000 medical malpractice claims at Harvard-affiliated hospitals, more than 30% of the cases include a breakdown in communication. There were more than 7100 cases in which vital facts, figures or findings got lost between providers who had that information and those who needed it, resulting in more than 1700 deaths and $1.7 billion in malpractice payouts.
Doctors on both sides of the handoff are at legal risk when mishaps occur. If a lawsuit occurs, the plaintiff’s attorney will initially sue everyone involved in the patient’s care and then sort out accountability later. Years after the event, a jury may decide who is really liable for fumbling the patient handoff. Trial lawyers don’t care who writes the check. All they have to prove is that the team was dysfunctional and not communicating with each other.
The classic fumble in the patient handoff is when the specialist thinks the primary care doctor is going to take care of some aspect of follow-up, and the primary care doctor thinks the specialist is handling it.
Electronic Health Records: Blessing or Curse?
In theory, the use of electronic health records where all physicians involved in the patient’s care can see each other’s notes should reduce communication and handoff errors. But in practice, the systems are hardly foolproof.
Some systems don’t connect well with each other. In some larger hospitals, primary care and specialty doctors use the same system. Even then, there may be different systems for labs, outpatient imaging, and so on, and the information could be on a different system.
It’s not uncommon for the system to route data to the wrong receiver. A test result, lab value, or radiology report is sent to the wrong provider far too often. So it’s never seen. It’s just out there in no man’s land and isn’t reported to the patient. If the information is critical, it’s important to make sure it was received. Ask the next doctor to confirm that he saw it. Sometimes, providers need to pick up the phone to make sure the information was received.
Important clinical information can be difficult to locate in electronic health records or be obscured by lengthy progress notes resulting from copy and paste over-documentation. Vital information isn’t always highlighted and incidental findings that could be crucial are buried. For example, a patient goes to the emergency department after an auto accident. Radiographs show that there may be a rib fracture. But the radiologist also notes a small shadow on the lower left lobe of the lung. That finding gets put at the bottom of the report, or maybe another screen. When the patient is finally diagnosed with lung cancer 3 years later, they go back and look at the old film. The finding was there, but wasn’t seen because of the cumbersome electronic record.
Electronic medical records have fundamentally changed not just the way providers document, but workflow and even the way they think. Providers talk to each other a lot less these days. Nurse and doctor teams can go an entire shift without ever speaking to each other, resulting in a lack of interactive brainstorming with each other—the ability to bounce ideas off each other. Instead, they make the handoff to a computer and then expect the computer to hand off to the intended receiver.
Electronic health systems aren’t easy to navigate. There are lots of screens involved, drop-down menus are difficult to use, and the systems aren’t intuitive.Things get lost in all of the data that electronic systems demand. Often, there is just user error.
The culture of a hospital or medical community can have a big impact on whether a handoff is more likely to succeed or fail. There’s been a growing attention to how the organizational culture affects the risk at the handoff. Hierarchical cultures are likely to have greater problems because the staff is afraid to ask questions. Residents may be afraid to appear uninformed or even stupid if they raise issues.