Fumbling the handoff

It's first and goal, 30 seconds left in the final quarter and you are behind by 6 points. You play it safe with a dive play down the A gap and your running back fumbles and the other team recovers. Game over.

The same thing happens every day in the halls of hospitals, outpatient clinics and ERs at enormous cost. Doctors fumble the handoff of a patient from one care delivery setting to the next, sacrificing quality and cost. Whether during a shift change, a consultation, a transfer or a discharge to home, a rehabilitation center or an outpatient follow-up setting, the handoffs are sloppy. Handoff care processes and slippage are one of the biggest inefficiencies in healthcare and need to be addressed. ?Indeed, the omission of critical information and the transfer of erroneous information during handoffs contribute to two of every three “sentinel events,” as reported in the April 2016 issue of the?American Journal of Medical Quality.

The latest example comes from a study of end of rotation care on an internal medicine service. ?In this multicenter cohort study of 230 701 patients admitted to internal medicine services in 10 Veterans Affairs hospitals, end-of-rotation house staff transition in care was associated with significantly higher in-hospital mortality (3.5% for intern only transition vs 2.0% for control and 4.0% for intern + resident transition vs 2.1% for control). The association was significantly stronger following institution of ACGME duty hour regulations.

Turnovers increase when we expect patients to take the hand off after discharge.

Despite the number of hand-off tools, studies have repeatedly shown the inefficiencies and wastage when one doctor refers to another. Emergency departments struggle to find follow-up care for their patients. Patients and their caregivers are befuddled when they don't get adequate handoff instructions following hospital discharge. Few systems exist to track physician referral management and provide the analytics necessary to manage referrals and minimize leakage.

Handoff errors happen for many reasons:

1. There are at least 5 participants that can break the chain: the sender, the receiver, the patient, the third party intermediary and the referral platform user interface
2. The communication is not standardized
3. The system relies on people to do what they are supposed to do instead of automating or templating the communications whenever possible to minimize workflow disruption
4. There are too many unnecessary appointments or the referral is inappropriate
5. There is no sense of urgency to fix the problem
6. The stakeholders don't appreciate the clinical and economic costs of a dropped handoff
7. Tracking systems are poor
8. There is no global health information cyberbrain to coordinate and transmit accurate cross border information
9. Nomenclature is not standardized
10. We will never be able to aggregate the infinite expansion of medical information for a given patient. The challenge is to determine the minimal amount of information necessary to accomplish the clinical handoff goal
11. More people need to be in the conversation than there used to be. Instead of a doctor communicating with another doctor or patient, now medical care teams need to communicate with patient care communities, in some instances, on the other side of a country or an ocean.
12. Often, no one knows who is the captain of the medical team or patient care community ship and, therefore, should be the designated sender or receiver.

Post acute care discharge planning, e.g. to a rehabilitation or skilled nursing facility or home, is fraught with problems that result in delay patient recovery, waste and family angst.

Here are five best practices for achieving a robust discharge process. The lack of data interoperability remains a stubborn problem impeding our efforts to achieve them.

Like any communication problem, the issue has as much to do with the sender as the receiver, as well as the content and method of communication. All the factors need to be addressed and incorporated into EMRs and other forms of digital health communications. We need a whole product medical handoff solution.

Our ability to do so will determine whether we go undefeated or fail to make the playoffs for another season. Next time, when you are in the red zone, think about an iPASS (?I-PASS stands for?illness severity,?patient summary,?action list,?situation awareness and contingency planning, and?synthesis by receiver.) instead of a running play.

Arlen Meyers, MD, MBA is the President and CEO of the Society of Physician Entrepreneurs on Substack and Editor of Digital Health Entrepreneurship