Towards a Person-Centered After-Visit Summary to Facilitate Improved Heart Failure Care (HF-AVS): A Scoping Review and Call to Action.

Abstract

Person-centered care (PCC) has been advanced as an optimal model of chronic heart failure management in multiple guidelines. However, fulfilling the ideal of this model requires overcoming healthcare fragmentation via effective provider-to-patient communication. One potential communication tool is the after-visit summary (AVS), a core feature of modern electronic health records (EHR); however, little is known regarding its quality from a PCC lens and whether an optimal AVS for the heart failure (HF) population has been created previously. We evaluate the history of AVS use in U.S. healthcare as well as map the extent and type of evidence on its quality, stakeholder perspectives, and attempts to perform PCC-related modifications across various healthcare settings as well as in acute-on-chronic or chronic HF specifically, evaluating if a HF-specific AVS (HF-AVS) has been reported. A search of the peer-reviewed literature was conducted via MEDLINE (Pubmed) and SCOPUS. Select gray literature was included if cited by peer-reviewed articles. Articles were included if they were: 1) written in English, 2) discussed an EHR-generated documented intended for provider-to-patient communication, & 3) were situated within the U.S. healthcare system. Two authors screened relevant articles, with disagreements resolved by consensus. If a resolution was not found the senior author broke ties. Data were extracted by one abstractor and checked by at least one additional abstractor. This scoping review found that the AVS became a part of the modern electronic health record via legislative action. Incentives for continued use are still in place. While AVS use is widespread its quality is poor, without the necessary readability for PCC models. Patient, provider, and care partner perspectives suggest the need to reduce medical jargon reduction and streamlining workflows; however, barriers exist the level of EHR vendors, preventing large PCC modifications. In contrast, small "embeddable" interventions appear more likely to be successful. No HF-AVS was identified; however, the modification of an existing patient-oriented discharge summary for heart failure (PODS-HF) was present, warranting exploration of embedding the document into EHRs. One potential HF specific "embeddable" intervention is free text prompting patient initiation and up titration of guideline-directed medical therapy and routing to HF nursing and pharmacist teams. If pursued, teams should secure funding, collaborate with EHR vendors, and trial these interventions with objective medication and/or exercise adherence. Limitations to this scoping review are present including the lack of a pre-registered protocol. Future work is needed to increase the quality of the AVS evidence base.