Understanding variation of available medical records for patients transferred to the University of Utah

From the 2021 HVPAA National Conference

Taryn Young (University of Utah Department of Internal Medicine), Michael Hagan, Sandi Gulbransen, Steve Hunsaker, Kencee Graves

Background

The University of Utah Health System (U Health) is the only academic medical system in the intermountain west. In 2019, U Health cared for almost 30,000 admissions, and approximately 9,600 were transferred in (33%). Studies have shown that patients who are transferred between hospitals are more likely to be admitted to an ICU and are more likely to die within 30 days. U Health data shows that 40-60% of patients who die at U Health were transferred here. The transfer process lacks standardization broadly, and many physicians believe that uniform data sharing may improve patient outcomes.

Objective

The purpose of this project is to develop a standardized protocol for affiliated hospital systems associated with U Health to communicate critical information for patients who are transferred to U Health for inpatient care.

Methods

We performed a retrospective review of medical records for patients transferred to the U Health Internal Medicine Hospitalist Service. Using data submitted from U Health to Vizient Inc., we obtained the medical record numbers, date of admission, and date of discharge for each patient. This provided 576 records, which were then randomly assigned for manual review. A group of physicians, including intensivists, hospitalists and residents defined a priori what components of the medical record were essential for patient care. We then reviewed 53 charts to determine the presence or absence of these components.

Results

Of the 53 charts selected, 9 were identified as transfers from one U Health to another and were excluded. Six of the charts had no outside medical records available at all. More than 90% of reviewed medical records had allergies and lab results from outside available (CBC, Chemistry). Vital signs were available approximately 80% of the time. The essential components that were transferred less than 10% of the time were echocardiogram results, information on what pharmacy the patient used, and the patient’s infection prevention isolation status.

Conclusions

While a few components of the medical record were transferred with the patient most of the time, there is a large amount of variability in the availability of the rest of the medical records for patients transferred to U Health from outside medical facilities. This variability can lead to repeated tests, higher health care costs, medical error and potentially longer length of stay.

Clinical Implications

This work adds clear expectations of what chart elements should be present for any patient transferring from a referring institution to a general medicine hospitalist service. Our data review provides actionable information to these institutions, and establishes a framework to standardize information sharing between institutions. Our hope is that standardizing medical record sharing will improve the transitions of care and patient outcomes.

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