Where are my patients? It is time to automate notification of hospital use to primary care practices

Authors, Primary Moran,W. P.;Davis,K. S.;Moran,T. J.;Newman,R.;Mauldin,P. D.
Title Primary Where are my patients? It is time to automate notification of hospital use to primary care practices.
Periodical Full Southern Medical Journal
Pub Year 2012
Volume 105
issue 1
Start Page 18-23
Abstract The hospital-to-community transition is fraught with risks for patients, with 30-day readmission rates of 20% for Medicare patients. Poorly coordinated transitions of care translate to unplanned readmission costs to Medicare of more than $17 billion/year. Calls for better physician communication to improve care coordination abound; however, primary care physicians cannot better coordinate care when, in many cases, they are not even aware that their patients have been admitted to the hospital. During the past 30 years, we have made little progress in systematically improving communication between hospital and posthospital providers to coordinate postdischarge care. Hospitals and physicians need better tools to coordinate care transitions. It is time to automate the hospital discharge notification process, notify practice staff, and stop expecting physician-to-physician communication. Notification can be efficiently supported by computerized systems that do not rely on physicians to "close the loop" back to primary care. We present four clinical programs in which automated notification of primary care staff was used to ensure appropriate follow-up and coordination of care for patients. These automated systems use a secure online Web site or an encrypted e-mail notification system that alerts clinicians and practice staff to hospital registration of the patient. In each program, notification triggers a nurse-directed clinical assessment and care coordination plan and helps ensure timely primary care follow-up. We believe automated notification is a necessary tool to support coordination of care in the new delivery models such as the patient-centered medical home.
Publisher Not Available
Place of Publication United States
Author/Address Division of General Internal Medicine and Geriatrics, Medical University of South Carolina, Charleston, SC 29425-0591, USA. moranw@musc.edu
PubMed Link
Reference Type(s) Journal Article
Topic Tag(s) Care Coordination;System Approach to Quality and Safety;Health Information Technology;Implementation
Special Population(s) Medicare Beneficiaries
Case Study Yes
Commentary/Opinion Piece No
Historical Publication No
Key/Foundational Article No
Literature Review No
Article Rating No
Summary of Article Rating No