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Int J Clin Pract. 2015 Nov; 69(xi): 1257–1267.

Communication in healthcare: a narrative review of the literature and practical recommendations

P. Vermeir, ^{1 , 2} D. Vandijck, ^{1 , iii , 4} S. Degroote, ^{one , 3} R. Peleman, ^{2 , five} R. Verhaeghe, ^{3 , 5} E. Mortier, ^v Grand. Hallaert, ^v S. Van Daele, ⁵ W. Buylaert, ^{5 , six} and D. Vogelaers ^{one , 2 , 5}

P. Vermeir

¹Department of Full general Internal Medicine, Ghent University Hospital, Ghent, Belgium

^twoDepartment of Internal Medicine, Ghent University Hospital, Ghent, Belgium

D. Vandijck

^oneDepartment of Full general Internal Medicine, Ghent University Infirmary, Ghent, Belgium

³Department of Public Wellness, Ghent University Hospital, Ghent, Kingdom of belgium

^ivSection of Business Economics, Hasselt Academy, Diepenbeek, Belgium

S. Degroote

^aneDepartment of Full general Internal Medicine, Ghent Academy Hospital, Ghent, Belgium

³Department of Public Health, Ghent Academy Hospital, Ghent, Belgium

R. Peleman

²Department of Internal Medicine, Ghent University Hospital, Ghent, Belgium

^vFaculty of Medicine and Wellness Sciences, Ghent Academy Hospital, Ghent, Belgium

R. Verhaeghe

³Department of Public Health, Ghent University Infirmary, Ghent, Belgium

^fiveFaculty of Medicine and Health Sciences, Ghent University Hospital, Ghent, Belgium

Eastward. Mortier

⁵Faculty of Medicine and Health Sciences, Ghent University Infirmary, Ghent, Belgium

G. Hallaert

^fiveFaculty of Medicine and Wellness Sciences, Ghent University Infirmary, Ghent, Belgium

S. Van Daele

⁵Faculty of Medicine and Health Sciences, Ghent University Hospital, Ghent, Belgium

W. Buylaert

⁵Kinesthesia of Medicine and Wellness Sciences, Ghent University Hospital, Ghent, Belgium

^{half dozen}Department of Emergency Medicine, Ghent Academy Hospital, Ghent, Kingdom of belgium

D. Vogelaers

¹Department of General Internal Medicine, Ghent University Infirmary, Ghent, Belgium

^twoDepartment of Internal Medicine, Ghent University Hospital, Ghent, Belgium

⁵Faculty of Medicine and Health Sciences, Ghent Academy Hospital, Ghent, Belgium

Received 2015 Feb 12; Accepted 2015 May 29.

Summary

Objectives

Effective and efficient advice is crucial in healthcare. Written communication remains the nearly prevalent form of advice between specialised and primary intendance. We aimed at reviewing the literature on the quality of written advice, the touch of communication inefficiencies and recommendations to better written advice in healthcare.

Design

Narrative literature review.

Methods

A search was carried out on the databases PubMed, Spider web of Scientific discipline and The Cochrane Library by means of the (MeSH)terms 'communication', 'primary health care', 'correspondence', 'patient condom', 'patient handoff' and 'continuity of patient care'. Reviewers screened 4609 records and 462 full texts were checked according following inclusion criteria: (1) publication between January 1985 and March 2014, (2) availability every bit full text in English language, (three) categorisation as original inquiry, reviews, meta‐analyses or letters to the editor.

Results

A total of 69 articles were included in this review. It was found that poor communication tin lead to diverse negative outcomes: discontinuity of intendance, compromise of patient safety, patient dissatisfaction and inefficient use of valuable resources, both in unnecessary investigations and medico worktime equally well as economic consequences.

Conclusion

There is room for improvement of both content and timeliness of written communication. The delineation of ownership of the communication process should exist articulate. Peer review, procedure indicators and follow‐upwardly tools are required to mensurate the touch on of quality improvement initiatives. Communication between caregivers should feature more prominently in graduate and postgraduate training, to become engraved as an essential skill and quality characteristic of each caregiver.

Review criteria

A search was carried out on the different databases by means of the (MeSH)terms 'communication', 'primary health care', 'correspondence', 'patient safety', 'patient handoff' and 'continuity of patient care'. Reviewers screened 4609 records and 462 total texts were checked according post-obit inclusion criteria: (i) publication betwixt January 1985 and March 2014, (two) availability as full text in English, (3) categorisation as original enquiry, reviews, meta‐analyses or messages to the editor.

Bulletin for the clinic

In that location is room for improvement of both content and timeliness of written communication. The depiction of ownership of the communication process should exist clear. Peer review, process indicators and follow‐up tools are required to measure the impact of quality improvement initiatives. Communication between caregivers should feature more prominently in graduate and postgraduate grooming, to become engraved as an essential skill and quality characteristic of each caregiver.

Introduction

In the evolution of medicine, an increasing number of patients, in particular with chronic affliction or illness, is requiring treatment by healthcare providers from different disciplines 1. Two major trends sally. First, diagnostic workups and treatments are increasingly organised on an outpatient ground, and, second, especially treatment and care is shifting towards primary intendance. Both trends increase the need for sharing information between specialists and general practitioners (GPs) to ensure continuity of care, in an integrated transmural model 2, 3, 4, 5. The practice and commitment of healthcare is argued to be fundamentally and critically dependent on effective and efficient communication 6. This is particularly true for countries such as the Britain, Kingdom of denmark and the netherlands, where GPs act as obligatory gatekeepers and the communication towards and from secondary care determines the smooth running of the healthcare organisation 7. However, countries or healthcare systems without this obligatory gatekeeper function may exist at college gamble for suboptimal communication between levels of care.

The aim of the nowadays paper is to review the existing literature on quality, efficacy and impact of written advice in healthcare equally well equally of recommendations for comeback.

Methods

The databases PubMed, Web of Science and The Cochrane Library were searched using the (MeSH)terms 'communication', 'primary wellness intendance', 'correspondence', 'patient rubber', 'patient handoff' and 'continuity of patient care'. The MeSH terms were internally validated by the coauthors. Articles in this review needed to be (one) published prior to March 2014 and after January 1985, (two) available as full text in English, (3) categorised as original research, reviews, meta‐analyses or letters to the editor. Database screening was closed 31 March 2014. Titles and abstracts were reviewed to verify these criteria. If all inclusion requirements were nowadays or if this remained unclear, the articles were fully read. In case the full text revealed that non all requirements were present, the newspaper was excluded. Additional literature was obtained through searching references in the manuscripts (snowball method).

A framework with four categories was predefined: modalities of communication, deficits in communication, economic bear upon of communication inefficiencies and recommendations. An individual newspaper could be categorised into different fields. The review was farther elaborated past addressing each category separately and rereading all manufactures that were relevant for that category.

Results

The results of the search process are summarised in Figure1. Out of a total of 5013 papers selected, 404 duplicates were removed. 4609 records were screened and 462 remained for full text screening. Finally, 69 manufactures were included in the review. The aim, setting, sample description, design, coverage of categories addressed inside the review and master findings of these individual studies are summarised in the online supplement.

Review stages based on PRISMA flow diagram eight

Modalities of communication

Although a review of the literature revealed that face‐to‐face communication is recommended, in practice, written communication remains the most usual ways of communication between healthcare professionals. Furthermore, at that place is a consensus about particular advantages of written communication over confront‐to‐face communication.

Face‐to‐face communication is essential to get the full conversation. In face‐to‐face advice, all involved parties tin can not only hear what is being said simply as well they can see the torso language and facial expressions that provide key information and so they can better empathize the meaning behind the words. In the past, this blazon of communication was only possible in person, merely as technology advances at that place are more ways to have these face‐to‐face conversations 9. Video conferencing is too a form of face up‐to‐face advice, even though it uses technology to connect the participants. These forms of direct advice may in fact have decreased in the electronic communication historic period, favoring indirect rather than direct communication x. Rapidly delivered e‐mail letters with a read confirmation may correspond a good proxy to telephone or face‐to‐face contacts and accept the advantage of traceability and consultation by third parties.

Written communication in the larger estimation remains the most usual, and sometimes the only, means of communication betwixt healthcare professionals three. The most frequently used forms of written communication are referral and belch messages. Referral letters tin exist subdivided into iii types: i.e. requests for a specific assessment or treatment, asking for a 2nd opinion and requests for mutual responsibleness for the care of a patient eleven. Discharge letters on the other paw generally refer to patients discharged from hospital. However, the term is also used for other settings such equally answer messages after a specialist outpatient visit without hospitalisation. This in itself poses a problem of semantics and definitions, equally the terminology of belch letters seems not to have followed the shift towards mainly outpatient intendance.

Written communication certainly has its advantages. For instance, information technology tin can be used for future reference purposes and information technology tin can be easily and simultaneously distributed to the required number of caregivers involved in the care process 12. They are not only a ways of communication but can also serve as a medico‐legal value 13. Moreover, in the current electronic environment, written advice has evolved towards a more firsthand medium and may therefore be preferred 14.

Letters too accept an educational goal. They tin can provide extra data that can increase the understanding of the problem, its implications, the issues, and options in management or the prognosis expected 15. Specialists 'teach' more in their letters than GPs vii and it was establish that 1 quarter of the specialists' letters had an educational value, as compared to 3% of GPs' letters 15.

Inefficiencies in written advice

In that location is a large trunk of literature on inefficiencies in written communication. Cross‐sectional studies, performed in different countries and settings, show a unequivocal concordance in both perceptions of the ideal content of written communication and its current inefficiencies. Reviews marshal with these findings. This overall agreement enables cartoon conclusions for clinical practice. In this department, on the one hand reports on subjective views of GPs and specialists setting out what they think letters should contain, and on the other hand reports with empirical data on the analysis of the content of bodily letters are included 16.

Mutual perceptions in the trialogue betwixt patient, physician and society

General practitioners and specialists disagree about the quality of their mutual communication. Specialists mention GPs' referral messages to lack data. Furthermore, they feel that GPs insufficiently follow their specialist communication. GPs in plough mention that many of their questions are insufficiently addressed by the specialists. The latter does not represent with specialist stance in a cross‐sectional study among a random sample of 550 GPs and 533 specialists selected from the Netherlands Medical Address Book 17 (Tableone). This written report showed that GPs phone accessibility is qualified as poor past specialists (32.viii% agrees with 'GP can be easily reached'), while GPs consider their telephone accessibility as good (85.3% agrees). Specialists call back poorly of the GPs' referral alphabetic character, as merely 29.one% of specialists charge per unit these letters as of good quality. But half of GPs feels their questions are addressed accordingly by the specialist, whereas specialists feel this number to exist considerably higher. According to specialists, GPs often do non follow the communication given. GPs rate their compliance much higher. Less than a quarter of GPs feel specialist letters get in on time, whereas specialists have a different perception. Both parties wish to receive feedback from each other, while in practice they hardly exercise so 17. Overall, less GPs' messages are judged as beingness of first-class quality than specialists' letters (39.five% vs. 78.half dozen%) seven. GP letters were found to have inaccurate medication lists (drugs or doses) in 42% of the cases xviii. In a study from a single general hospital in Kingdom of norway assessing referral and discharge letters, the Delphi technique was used by ii expert panels (each with one general hospital specialist, one GP and one public health nurse) using a standardised evaluation protocol with a visual analogue scale nineteen. The panels assessed the quality of the description of the patient'southward actual medical condition, erstwhile medical history, clinical signs, medication, activity of daily living (ADL), social network, demand of home intendance and the benefit of general infirmary care. This assay revealed low consensus betwixt health professionals at primary and secondary level and low quality of a majority of referral letters, considered every bit a health run a risk. Overall, twenty% of the discharge letters was missing vital medical information and less than half of the letters contained loftier‐quality information on ADL, social network or need for home care. However, it seems that some specialists (11%) and GPs (28%), are also dissatisfied about their ain letters mainly because of time constraints impacting on quality 10.

Tabular array 1

GPs' and specialists' perceptions on aspects of advice 17

	GPs agree	Specialists agree (%)	p‐value
GPs phone accessibility is skillful	85.3	32.viii	< 0.001
Referral letter of GP is of good quality	–	29.ane
Questions are addressed by the specialist	l.0	87.v	< 0.001
GPs follow the advice given past the specialist	92.2	49.5	< 0.001
Specialist letter of the alphabet is sent back in a timely manner	22.5	61.viii	< 0.001

Expectations on the modalities and content issues of communication may differ according to phases in particular diseases. This is indicated in an assessment on communication issues across the primary/secondary interface in ovarian cancer 20. GPs and specialists also have unlike expectations on the content of cancer patients' discharge letters, peculiarly on psychosocial items 21.

In the modern relational personalistic ethical perspective, the patient viewpoint and experience of the collaboration betwixt GP and specialists is at least equally of import every bit the perception of the healthcare professionals. To this purpose, a consumer quality index continuum of care has been validated for assessing patient's experiences across the interface betwixt chief and secondary care. This instrument consists of statements on GP approach, GP referral, specialist communication and collaboration between GP and specialists and was shown to be a useful instrument to appraise aspects of the collaboration betwixt GPs and specialists from patients' perspective i.

Relevance of communication items

Referral letters from GPs to specialists

More than 20 years ago, Newton et al. questioned GPs and specialists on which items they considered of import, revealing a high degree of consensus xvi. They also reported what the GP expects from the referral. These expectations are also described in Tattersall et al. 22, who, in dissimilarity, establish big differences between GPs and specialists concerning the data their messages should contain. A number of items are summarised in Tabletwo.

Table ii

Content of referral letters

Content of referral messages and information that specialists want in referral messages		Letters from specialists and data that referring doctors want in answer letters
Newton et al. (1992)	Tattersall et al. (2002)	Newton et al. (1992)	Tattersall et al. (2002)
Clinical content of general practitioner'due south alphabetic character:	Items of data:	Clinical content of consultant's respond:	Items of information:
Medical information Initial sentence stating reason for referral Outline of the history or argument of the problem Important medical history Findings on exam Findings on investigation Electric current medication Sociopsychological matters Known allergies	Medical information Reason for referral History of problem Medical history Clinical findings Findings on investigation/tests Current medication Sociopsychological matters Known allergies	Medical information Summary of the history Findings on examination Findings on investigation Appraisal of problem (including diagnosis where applicable) Management plan	Medical information Presenting history Medical history Drug history Social history Prognosis Side effects of proposed handling Benefits of treatment Diagnosis/staging of cancer Clinical findings Explanation of side effects Test results
Patient/Family involvement Whether or how the patient was involved in the referral decision What the patient or relative has been told What the patient or relative expects from the Referral	Patient/Family involvement Whether patient was involved in referral decision What patient/relative has been told What patient/relative expects from referral	Patient/Family unit involvement What the patient or relative has been told	Patient/Family interest What the patient or relative has been told Family unit problems relevant to management Advice given about when to contact infirmary
Clinician expectations What the full general practitioner expects from the referral Whether new referral or re‐referral	Clinician expectations What referring doctor expects from referral Whether new referral or re‐referral Previous therapy/interventions Provisional diagnosis Request for copy of consultation report Statement about expectation for render of patient	Clinician expectations Time to follow‐upwardly engagement Who saw the patient	Clinician expectations Farther tests washed or recommended Treatment/therapy recommended Follow‐upwards Whether patient expected to return to specialist Reason for referral addressed Who saw the patient Office of referring doctor and specialist
Administrative content of general practitioner's letter: Full general practitioner's proper name, address and telephone number Consultant's name, department and accost Patient'southward name, address, telephone number, mail code, date of birth, sex, NHS number Date on referral letter

Hartveit et al. aimed at identifying the recommended content of referral letters from GPs to specialised mental healthcare by means of word groups. Vii headings were proposed: personal and contact information, introductory information (e.g. is the patient suicidal?), example history and social state of affairs, present state and results, past and ongoing treatment and the professional person network involved, the patient'south cess, the reason for referral. More specifically, as compared with other referral letters, in mental healthcare a stronger emphasis on the planned integrated intendance, the specialist'south role and on the patient's involvement is recommended 23.

Jiwa et al. analysed 350 referral letters for upper gastro‐intestinal investigation from GPs and found that only few upper gastro‐intestinal symptoms were included 24. Furthermore, GP referral messages do not always include a specific question and when a question is formulated, it is not always addressed. This disables a real information exchange 25. McConnell et al. performed an data audit of referral and reply messages in cancer care. Oncologists wanted to take more information about the patient's medical status, the involvement of other doctors and any special considerations. GPs preferred more than information about the treatment plan, future management and expectations and psychosocial concerns. Referral letters about older patients were of low quality and only the actual medical state of affairs was well described. Belch messages did often not describe the performance of the patient and the demand for habitation intendance services, neither who was responsible for follow‐up 19.

Answer messages, including belch letters subsequently hospitalisation

A review by Kripalani et al. addressed which data GPs rate as most important in a discharge alphabetic character to provide adequate follow‐up: chief diagnosis (lacks in 13–17.five%), physical findings (ten.5–45.5%), results of investigations (38–65%), examination results pending at discharge (65–88%), discharge medication (21–25%) and the reason for any changes to previous medication, details of follow‐up arrangements (xiv–30%), information given to the patient and family (91–92%) 2. The latter was also identified in an earlier report, in which was institute that specialists just sporadically (< 20%) include such social information 26. Wrong diagnoses have also been found, likewise as discrepancies between the discharge summary and the have‐home prescription (39%) 27. Tattersall et al. compared the content of letters to the patients and messages to the referring physician. The latter were not well tailored to the referring physicians' needs and lacked information on recommended future tests, treatment options, side effects and prognosis 28.

Durbin et al. summarised fifteen audit studies on discharge or referral/consultation letters in mental healthcare 29. The items were grouped into four domains: authoritative details, patient details, clinical details and discharge/referral details. In discharge letters, clinical history, physical findings, examination results and follow‐upwards details were less reported. For referral letters, results were poorer: reason for referral was present in only 74% of the cases, 25% did non comprise present complaints, urgency and risk information were rarely reported, just 26% reported nigh the data given to the patient and clinical information and diagnosis were unsatisfactory in many cases 29.

The readability level of letters was some other consequence raised. Letters of specialists would exist too detailed and non enough structured (e.thousand. lacking headings, long paragraphs) xxx, 31.

Reasons for the poor content of written communication are also multifactorial: a lack of time to create notes 10, GPs maybe do not make a full cess of the issues 24, GPs and specialists may apply a different indicate of view 19, they may consider messages to have different goals (e.g. a tool for information transfer vs. archiving) 17, etc.

Timeliness

A considerable number of studies assessed timeliness of communication, either the subjective perception or real delays. Information technology is articulate that timeliness is a pregnant contributor to communication efficiency for all stakeholders.

Besides the unsatisfactory content of written communication, timeliness is some other oftentimes reported problem. Tardivity of specialists' letters has been identified as a major complaint of GPs 20, 32. Less than 1 quarter thinks the specialists' letters are delivered in time (as compared to 61.8% of the specialists) 17. 1 week after belch, 53% of the discharge letters reached the GP and approximately xi% never reached the GP 33. Hence, patients often contact or see their GP earlier he has received the letter (16–53%), which means that patients are so the get-go to inform the GP about their hospitalisation ii. This delay can have multiple causes and occurs at different stages of the reporting procedure: the specialist can wait too long to draw up the letter of the alphabet (whether dictated or extracted grade an electronic patient record); the administrative workup (due east.g. typing the letter) and verification (finalised by signature) can add significantly to the final delay xx. This could explain the perceptions of GPs and specialists virtually timeliness. For example, specialists written report to reply GPs within 7 days, whereas GPs report receiving an answer within 7 days only in 36% of the cases 10. Moreover, 4 weeks after the referral visit, 25% of the GPs had still not received an answer from the specialist 10.

Inefficient communication has several potentially negative consequences, for all involved in the healthcare process. Continuity of care, the connectedness of dissever and detached elements of care into a longitudinal process, suffers from inadequate communication. This applies peculiarly to advisory continuity, the reporting of adaptations in the chronic care process and their integration within a history of antecedents 34. It is evident that information on prior events can influence current decisions on the patient's intendance and that the lack or incompleteness of such data can lead to (potentially) preventable adverse events and subsequent patient harm. Likewise, poor communication often causes several types of delays, such every bit in consultation response or acceptance of a referral, in diagnoses and treatment 29, 35. Equally a upshot, patient safe may exist compromised when the right information is not available to the right person at the right time (east.g. translating into inconsistent treatment plans and inadequate follow‐up, medication errors and increasing polypharmacy) 29, 35, 36.

For healthcare providers, poor communication leads to additional workload equally information technology decreases confidence in decisions 29, 37. Last, patients tin can be confronted with having to repeat their stories, double tests, treatment delays and tin can receive conflicting information 29, which, in turn, may atomic number 82 to decreased patient confidence and satisfaction 35, 38. Several of these mechanisms additionally imply increased, unnecessary and avoidable costs, e.g. considering of unnecessary repeat investigations 35.

Economic bear upon of communication inefficiencies

Although healthcare providers spend a meaning amount of their time in advice, studies trying to quantify the economical impact of advice efficiencies are very scarce half-dozen. This lack in the literature is fifty-fifty more than surprising when keeping in mind that communication influences patient safe 39.

Literature provides numerous examples of outcomes of poor communication with an economic bear upon. First, it leads to avoidable hospital admissions 19 and readmissions 40, 41. Interventions to amend communication and coordination have been institute to reduce hospital admissions 42. Other avoidable healthcare expenditures can be seen in unnecessary testing, polypharmacy inappropriate referrals and repeated referrals for problems which were non fairly addressed during the first visit 10, 35, 43. Simply, and this comes on tiptop of the economic impact, patient safety suffers from poor communication 36. Residents considered communication difficulties as being the cause of the vast bulk of medical mishaps 39. Indeed, every bit x% of the exam results after belch crave action from the GP, merely if these do non accomplish the GP (in time), at that place may be propensity to medical error 44. The nigh hitting results come from Australia. The study found that communication problems were responsible for 11%, inadequate skill levels of practitioners for 6% and inadequate resources for 4% of the adverse outcomes respectively 45.

In cancer intendance, three types of costs because of poor communication accept been defined: the price of psychological distress, the cost of unnecessary handling and the toll of indirect system distress (e.thou. distress by healthcare providers) 46.

Agarwal et al. propose a conceptual model of communication outcomes, shown in Effigyii.

Conceptual model of communication outcomes in a hospital half-dozen

Hospital resource that should exist efficiently used include doctor and nurse time. A time–movement study reported that advice accounts for 24% of the work time of specialists 47. Communication inefficiencies in the infirmary setting for physicians are estimated to generate a waste matter of $800 one thousand thousand annually. Hendrich et al. reported a breakdown of nurse activities, in which approximately 20.6% of each nursing shift was classified as 'care coordination' (i.e. communication with team members or other departments) and 6.6% as 'wasted time' 48. The economic touch on of communication inefficiencies in nursing practices is estimated at well-nigh $4.ix billion per year. As a tertiary factor influencing resource utilisation, wasted costs because of poor advice leading hospital overstay, were estimated to be $half dozen.half dozen billion annually. The effectiveness of cadre operations is represented past the swiftness and safe of diagnostic and treatment processes, as ineffectiveness and errors will increase complication rates and lengths of stay. To this purpose, pathology adjusted length of stay and medication mistake rates are measurable process indicators. Quality of piece of work life is also affected past communication, as reflected in stress and job satisfaction measures. Fourth, since healthcare is a service business, hospitals are service organisations and should provide service quality. Poor communication (due east.thou. patients not existence timely informed virtually test results, delays in patient discharge, lack of information availability for the family of the patient…) bear on patient feel.

In this model, tangible as well every bit less tangible outcomes are combined. Tangible outcomes, such as length of stay and wasted physician and nurse fourth dimension, can be easily translated into monetary terms. Less tangible outcomes on the other hand, such as job satisfaction, accept an economic touch on through other processes. Job dissatisfaction leads to staff turnover as information technology represents an incentive to healthcare professionals for career moves. Therefore, increased costs are incurred for recruiting and training new employees with a learning curve, translating into less effectivity. Negative patient experiences with communication and service levels 49 volition predispose to hereafter choices for unlike hospitals and intendance organisations, turning abroad potential clients. Along the same line, referring physicians may switch specialists and hospitals because of poor advice 49. These trends are probable to be reinforced by the increasing demand for transparency regarding effectivity in specific diseases and the employ of social media.

In spite of this conceptualisation, reported data on economical touch on remain derived from and based on assumptions. In the USA, hospitals waste matter over $12.4 billion per year because of communication inefficiencies. More than than half of that amount (53%) is considering of an increase in length of stay, xl% is because of wasted nurse fourth dimension and 6.7% because of wasted physician time. For a 500‐bed hospital, annual losses because of communication inefficiencies are estimated to exist $4 1000000 6.

Recommendations to improve written communication

Structured letters

A well‐supported recommendation is the employ of structured referral and respond/discharge letters. Reply letters could, for example, contain a trouble listing, a management list and free text below. Structured letters take no longer to read and amend comprehension fifty. Using a template leads to college quality and reduced length of discharge letters 51. Structured messages are preferred by GPs, merely just few specialists write structured letters 52. GPs tin partly influence this by putting specific requests in their referral letter, which could and so exist repeated in the reply letter, followed past specific answers 25.

This strategy can be facilitated past the apply of wellness information technology, such as electronic patient records 53. However, this method tin still go more standardised and possibly too user‐friendly by the employ of structured instead of costless text fields 54. Effective health it could produce automatically structured computer‐generated letters thirty. These letters are preferred by GPs considering of higher scores on clarity and content 55.

Yet, standardisation and user‐friendliness often can be improved by the utilise of structured instead of free text fields.

At that place are withal some pitfalls associated with structured letters. A referral template was adult by the Irish Health Information and Quality Authority and the Irish Higher of GPs, but was plant to exist rarely used by specialists 56. They can result in extra workload for the physician because of long forms (to write and to read) 29. The inclusion of a tick box for urgent referrals should also be well considered: in that location is a risk for overuse 57 and patients are not seen earlier 15.

Curriculum – feedback

Another strategy is the use of different forms of feedback. First of all, specialists can provide feedback on the referral letters. This improves the quality of referral letters and tin brand referrals more focused 58. Of course, GPs tin besides provide feedback to specialists. Peer assessment is able to significantly ameliorate the quality of the written advice betwixt both parties 22, 59. To facilitate feedback or peer assessment, specific tools could be used iii.

Feedback tin also be introduced earlier, namely in the curriculum of medical students. Up till now, written communication is rarely addressed in communication courses 60. Training sessions have showed to heighten knowledge about written communication in healthcare, merely should not be restricted to 'knowing' and 'knowing how' but should equally focus on 'doing' threescore. Improvement strategies outlined above (feedback, peer assessment, tool) could also exist used during written communication courses.

Changing processes

A clear written advice between specialists and GPs is of great importance. Merely as Durbin et al. notice 'changing clinical practice is difficult' and therefore, multifaceted and broad interventions may exist more effective than interventions with a very specific impact. In their review of audit studies in mental healthcare, a combination of guidelines, preparation and a structured course is proposed 29. The use of computer‐generated letters could besides exist considered a change to the before process of dictated letters. This results in a college percentage of belch summaries completed at 4 weeks and moreover, reduces the amount of omitted, essential items 61, 62, 63, 64. For GPs too, computerised referral systems could reduce their administrative work and could probably requite the benefit to more than timely communication 10.

Such tools could as well contain a pharmaceutical decision‐support system which could reduce mistakes in medication lists 18. For dictated letters, a seemingly cocky‐evident recommendation is to always read and sign them when they are gear up, to avoid unintentional mistakes 65.

A suggestion to partly solve the timeliness trouble is to give the letter of the alphabet to the patient (or give him a copy). Every bit such, letters could sometimes sooner accomplish the addressee 2, 61, 66. Belch letters could for case be combined with a prescription grade for take‐domicile medication 67. Another possibility is to share medical notes with patients, which allows patients to review the notes (project 'Open Notes') 68. This change should, even so, not be implemented without any restriction because it may lead to specialists omitting information in the alphabetic character in order non to distress the patient 69.

With the availability of dissimilar advice channels, these could exist combined using respective advantages, such as direct phone calls for urgent and essential communications, conferences for on line multidisciplinary assessments, involving GPs, backed up with formal written or electronic messages. The latter may serve as validation and referral documents of the erstwhile. Electronic communication often needs, in the absence of the direct telephone communication, an alert arrangement, guaranteeing reception and rendering advisable activity by the receiver more than likely. Improving interaction volition lead to better results, such as better patient outcomes, better gatekeeping and standardisation of work processes, as evidenced in the meta‐analysis by Foy et al. 70.

A qualitative study in GPs confirms the above‐mentioned strategies: greater utilize of telephone, secretarial support, templates and delivery of the letters past the patient. In add-on, nurse‐led communications were proposed. They are likewise willing to reconsider electronic patient records and then that GPs, or even patients, could as well have access to it 20.

In contrast to other fields in medicine (such every bit in the treatment and prevention of blood stream infections 71 and other nosocomial infections, such as sepsis (Surviving Sepsis Campaign), there is no literature documenting the touch of a parcel arroyo assessing the specific touch on of a selected number of interventions with procedure and/or event indicators. It is clear that advice in whatsoever healthcare setting may be the subject of such a bundle approach that would ascertain priorities in an improvement program and render such an improvement initiative feasible in the field, against a jungle of recommendations.

Strengths and limitations of this review

This is a comprehensive review of the literature on written communication in healthcare, providing a multidimensional overview of this of import topic. During the search for this review has screened a vast amount of the literature (over 4500 manufactures) across a number of databases. Articulate and concrete ideas for improvement were proposed and explained.

Conclusion

In recent years, in many countries healthcare is experiencing a shift towards primary care, particularly driven by the growing number of chronically ill patients. At the same time, healthcare becomes more and more specialised and as such, communication betwixt specialised and primary intendance is of paramount importance.

Poor advice can indeed lead to various negative outcomes: discontinuity of care, compromise of patient prophylactic, inefficient use of valuable resource, dissatisfaction in patients and overworked physicians and economic consequences, oftentimes hidden. As written communication is however the most used class of communication between specialised and master intendance, this review can be a guidance for improvements in this field.

There is a articulate need for a structured approach, addressing both content (ensuring the required items, addressal of referral questions, diagnosis and management problems) and timeliness. This structured approach too includes articulate delineation of ownership of the communication process. Peer review is needed to assess quality indicators in this respect in each particular care process component. Process indicators and follow‐up tools are required to measure the touch on of quality improvement initiatives, according to the SMART (specific, measurable, achievable, realistic, fourth dimension related) principle 72. Finally, communication betwixt caregivers and the importance too as quality, should feature more prominently in both graduate and postgraduate preparation, to become engraved as an essential skill and quality characteristic of each caregiver.

Author contributions

All coauthors contributed to the report blueprint and reviewed drafts of the manuscript. The beginning author screened all the manufactures for inclusion in this review and appraised the study quality. Sophie Degroote screened a sample of these at title/abstract and total text. Dominique Vandijck scored the quality of a sample of the included articles. Peter Vermeir, Sophie Degroote, Dominique Vandijck and Dirk Vogelaers drafted the manuscript. All authors read and approved the final version of the manuscript.

Acknowledgements

The authors thank Ms. Marie Blankaert for providing administrative support.

Notes

Disclosures

There are no potential conflicts of interest to be reported.

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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4758389/