DDHA 9901 Week 2 Context Memo Example

Memorandum

To: Doctoral Project Faculty Reviewer

From: DHA Student

Date: October 21, 2026

Re: Organizational context for the discharge summary transmission problem

Purpose

This memo describes the organization in which the discharge summary problem sits, so that later arguments about cause, comparison and cost rest on a setting a reader can picture. The organization is described by category throughout and is identified nowhere; I refer to it as Larchmont Health, a composite name used in this course.

Governance

Larchmont is a nonprofit health system governed by a regional board of community members and physicians. It has two acute care hospitals, one of about 340 beds and one of about 120 beds, about 25 miles apart. It is not part of a larger national system. Its board approves the capital budget and the annual quality plan, and a system quality committee reports to the board quarterly. This matters because a nonprofit answering to a regional board tends to treat relationships with local independent physicians as strategic, which shapes how it responds to their complaints.

Services

Both hospitals provide emergency care, general medicine, general surgery, obstetrics and intensive care. The larger hospital also provides interventional cardiology and orthopedic surgery. Cardiac surgery, transplantation and most pediatric subspecialty care are referred to an academic center about 90 minutes away. The discharge summary problem concerns adult inpatients discharged home, mostly from general medicine. Patients transferred to the academic center are outside the problem, because their summaries are written elsewhere.

Workforce

Inpatient medical care at both hospitals is provided by an employed hospitalist group of about 34 full-time equivalents, including nocturnists. Hospitalists write and sign discharge summaries. Case managers, about 18 full-time equivalents, arrange follow-up appointments for some patients but not all. Health information management staff monitor record completion and send reminders to clinicians with overdue documents. No role is assigned to confirm that a summary reached an outside practice.

Information Systems

Both hospitals and the 14 primary care practices employed by Larchmont share one electronic health record, so a summary signed in the hospital is immediately visible to an employed primary care clinician who opens the chart. About 30 independent primary care practices refer patients to Larchmont. They use at least five other record systems. Summaries reach them in one of two ways: by secure electronic message through the system's health information service provider, for practices that have registered a secure address, or by fax from a central fax server, for practices that have not. The record system sends the summary automatically when the hospitalist signs it, but only if the patient's primary care clinician is correctly recorded in the patient's registration. A regional health information exchange operates in the area, and Larchmont contributes data to it, but few independent practices query it routinely. Adler-Milstein et al. (2021) describe health information exchange organizations still working through participation and governance, which matches local experience.

Patients and Payers

About 46% of Larchmont's inpatient days are covered by Medicare, including Medicare Advantage, 18% by Medicaid and most of the rest by commercial insurance. Larchmont participates in a Medicare accountable care organization with several of the independent practices, which gives both parties a financial interest in avoiding readmissions.

Incentives That Bear on the Problem

Three incentives shape behavior. Hospitalists are measured on record completion within the time allowed by the medical staff rules, which require summaries to be completed within the regulatory limit; they are not measured on whether summaries reach practices. Health information management is measured on the same completion rule. The accountable care organization's shared savings depend partly on readmissions, which gives leadership a reason to care about transitions but no direct measure of summary transmission. Kripalani et al. (2007) found that information transfer at discharge often fails at the hand-off between settings, a point where neither side is clearly accountable, which is the pattern these incentives produce here.

Known Weaknesses in the Information

Were et al. (2009) found that discharge summaries often failed to document the outpatient follow-up provider, among other omissions, and a similar weakness exists here: if the primary care clinician field in registration is blank or wrong, the record system has nowhere to send the summary. How often that field is wrong is not yet known and will be part of the evidence gathering.

Recent Changes

Two changes in the past two years bear on the problem. In 2024 Larchmont began offering secure electronic messaging to independent practices, and about half have registered an address; the rest still receive faxes. In the same year, information technology shortened the fax server's log retention to 90 days to save storage, which limits how far back any fax can be traced. Neither change was made with discharge summaries in mind, which is typical of how the conditions around this problem have formed.

What This Memo Leaves Out

The memo does not name the organization, its location or its staff, and its figures are rounded. It does not describe the system's finances beyond payer mix, which is all the problem requires.

References

Adler-Milstein, J., Garg, A., Zhao, W., & Patel, V. (2021). A survey of health information exchange organizations in advance of a nationwide connectivity framework. Health Affairs, 40(5), 736-744. https://doi.org/10.1377/hlthaff.2020.01497

Kripalani, S., LeFevre, F., Phillips, C. O., Williams, M. V., Basaviah, P., & Baker, D. W. (2007). Deficits in communication and information transfer between hospital-based and primary care physicians: Implications for patient safety and continuity of care. JAMA, 297(8), 831-841. https://doi.org/10.1001/jama.297.8.831

Were, M. C., Li, X., Kesterson, J., Cadwallader, J., Asirwa, C., Khan, B., & Rosenman, M. B. (2009). Adequacy of hospital discharge summaries in documenting tests with pending results and outpatient follow-up providers. Journal of General Internal Medicine, 24(9), 1002-1006. https://doi.org/10.1007/s11606-009-1057-y