Hospital Readmissions: Success of Electronic Health Record Follow-Ups

By Pamela D Wilson CSA, CG, MS, BS/BA

Due to the Affordable Care Act, hospital committees and related programs are widespread with staff diligently working to reduce re-hospitalization rates of older adults or face escalating financial penalties. Many studies are underway locally and nationally investigating a variety of methods to improve care.  Potential issues have been identified as:  drug interactions, lack of follow up with primary care physicians and lack of follow through on post care whether this be with home health, physical therapy, community based care, medical treatments or lab tests.

A study completed by Gurwitz (2014) focusing on electronic communication between hospitals and the outpatient physician office did not demonstrate an increase in follow-up visits with a primary care physician or a reduction in the risk of re-hospitalization. How it is possible that all of these practical and well thought out efforts failed to show improvement?

What efforts may not have been included in this effort that if included would have resulted in success? If you are currently on a committee working on re-hospitalization what outcomes are you witnessing? How might insight into this benefit you?

A controlled trial by Gurwitz (2014) reports that the transition between the inpatient hospital setting and a return to home in the community represents a period of high risk for older adults living in the community.  Notably, this transition often results in adverse events within 3 weeks of a hospital discharge.

Those of us working in healthcare would agree. Yet how can we change the outcome of this transition so that our patients or clients do not return to the hospital within 30 days? Is this aspect really within our control?

One of the main goals of this trial was to implement an automated system to send information from the hospital to the patient’s primary care provider office advising of information relating to hospital discharge including medications, recommendations, lab tests, appointment reminders and information related to the individual care of the patient.  As mentioned above, this communication failed to show progress in facilitating patient appointments with the primary care physician or decreasing re-hospitalization rates.

For those of you working on similar committees, this information may be helpful from a number of aspects.

  • Questions were raised relative to the volume of information transmitted to primary care practices. While many offices now have patient portals, did the sheer volume of communication overwhelm physician office staff to the point that they failed to pay attention to alerts and information? Are primary care physician offices staffed with sufficient personnel to manage this information?
  • Would this type of program be better served if patients were ranked by the highest likelihood of re-hospitalization, thus allowing critical information to be transmitted, rather than transmitting information on all patients who may be at low risk of re-hospitalization? If all information is sent, is there a way to flag patients by medical priority?
  • Admittedly this study did not involve the patient or family caregiver.  How might involving the patient and the patient’s family better support follow up medical appointments and lower re-hospitalization rates?

Hospital, medical offices and medical providers are working diligently to solve the issue of re-hospitalization. However how much of the result lies in the control of the consumer — the patient?  Is the solution a combination of communication between medical providers and communication with those receiving care? Or is the solution turning the ship, so to speak, to educate consumers on their level of personal responsibility relative to their health and follow up care?

Like hospitals, should consumers be penalized by insurance companies for a lack of follow up care and for engaging in poor health habits?  How might this action support a significant change in personal beliefs and habits about health that then might correspond to changes in the hospital and medical care system? In my opinion the solution to re-hospitalization will not occur through one way penalties and communication. The solution is to hold the health care system and consumers equally accountable for reducing healthcare costs and improving outcomes.

That being said, many family caregivers, who are a critical part of this equation, possess low health literacy or may not be available to provide support.  In situations where we, The Care Navigator, are involved to provide care oversight we communicate directly with discharge planners in hospitals and rehabilitation centers and with primary care physician offices to ensure that all details of follow up care, medical appointments and future tests are completed. In these situations, the individual or the family realizes the importance and value of this type of coordination.

While it may not be possible for all families to pay privately for this type of support, educating consumers and patients regarding their level of personal responsibility relative to health and follow up care may support an increase in health literacy and an increase in family support to ensure improved health.


Gurwitz, J., Field, T., Ogarek, J., Tjia, J., Cutrona S., Harrold, L., Gagne, S., Preusse, P., Donovan, J., Kanaan, A., Reed, G., Garber, L. (2014) An electronic health record – based intervention to increase follow-up office visits and decrease rehospitalization in older adults. JAGS 62:865-871. Doi: 10.1111/jgs.12798

©2014 Pamela D. Wilson, All Rights Reserved. 

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