Sandrine Couture, MDCM1, Dimitri Yang, BSc2, Sabrina Lessard, PhD3, Aigul Zaripova, MDCM4, Jennifer Tchervenkov, MD5, Carolyn Pavoni, MDCM1, Claire Godard-Sebillotte, MD, PhD1,2
1Division of Geriatric Medicine, Department of Medicine, McGill University, Montreal, QC;
2Research Institute of the McGill University Health Centre, Montreal, QC;
3Centre for Research and Expertise in Social Gerontology (CREGÉS), Integrated Health and Social Services University Network for West-Central Montreal, Côte Saint-Luc, QC;
4Department of Family Medicine, McGill University, Montreal, QC;
5Division of Geriatric Medicine, Centre intégré universitaire de l’Ouest-de-l’Île-de-Montréal, Montreal, QCDOI: https://doi.org/10.5770/cgj.28.830
ABSTRACT
Background
Geriatricians’ work provides holistic recommendations to improve the health of older adults, considering medical, social, psychological, and functional domains. Their implementation most often relies on primary care physicians. Extant evidence suggests benefit from systematized information transfer between hospital-based specialists and primary care physicians. Yet, direct communication between hospitals and primary care physicians is rare. We aimed to describe the information transfer practice of hospital-based geriatricians in Quebec, Canada.
Methods
We sent a survey to all (146) geriatricians and Geriatric Medicine residents of Quebec on their current practice and opinions on information transfer and obtained 64 responses. We then performed 20-minute semi-structured interviews with 13 participants to further explore knowledge on information transfer, barriers and facilitators, risks and benefits, and recommendations to improve transmission.
Results
While geriatricians believe that their recommendations should be transmitted to primary care physicians and that the absence of a systematic information transfer procedure has a negative impact on quality of care, only 1.6% report having such a procedure in place in their practice. They think that the absence of information transfer procedures disrupts the communications of key diagnoses and medication changes, and leads to duplicated interventions. Harnessing technology to facilitate information transfer is viewed as a solution.
Conclusion
Information transfer between hospital-based geriatricians and primary care physicians in Quebec is rare. The absence of a systematic information transfer procedure is seen by geriatricians as a hindrance to the provision of safe, high-quality care to older adults.
Key words: transitions of care, discharge summary, geriatric consultations, communication
Older adults with chronic diseases and frailty often require complex coordinated care between primary care and hospitals.(1) Hospital-based geriatricians provide holistic recommendations considering medical, social, psychological, and functional aspects and capabilities of older adults so as to optimize their health.(2) Evidence shows that these recommendations improve several health outcomes, including decreased mortality, increased likelihood of older adults being alive and in their own home at follow-up, decreased risk of institutionalization, and decreased risk of hospital readmission.(2,3) The implementation and monitoring geriatricians’ recommendations most often relies on primary care physicians (PCP) after discharge. Indeed, in-hospital consults include new diagnoses that require longitudinal follow-up, medication changes that are to be continued after discharge, tests to be scheduled as outpatient, and test results that are pending at discharge and need to be followed as outpatient. PCPs are the heart of continuity of care, which is described as “the connected and coordinated care that patients receive while between providers and the healthcare system”.(4) The receipt of discharge information by a patient’s PCP is associated with improved chronic disease management, fewer medication errors, and decreased readmissions.(5–8) On the contrary, breaches in the discharge process, which includes the discharge summary, discharge instruction, and continuity of care between inpatient and outpatient spheres, are associated with readmissions and ER visits.(9) Communication at the time of transitions of care is a World Health Organization (WHO) priority.(10) Older adults are considered particularly more vulnerable to adverse events following discharge from hospital.(11,12)
Nonetheless, direct communication between hospital physicians and primary care is rare. In a 2022 survey of primary care providers in eight large academic institutions in the US, 60% of responders reported that the discharge summary was their only source of communication with hospitalists, and 18% did not receive a summary by the time of their first posthospitalization visit.(13) Another US study demonstrated that only 31.1% of primary care physicians had access to a discharge summary >80% of the time.(14) A recent study from Ontario showed that, for patients with multiple emergency department (ED) visits, the rate of information transfer to primary care providers decreased from 58.2% to 45.7% between 2010 and 2015.(15) A 2020 Canadian Institute for Health Information report stated that 54% of PCPs received notification that there patient had been hospitalized, and 59% of PCPs received information from specialists about medications or care plan.(16) For both indicators, Quebec is the province that performed the worst, with 25% for notification of admission and 30% for information transmission from specialists.(16) In a 2018 survey, only 18% of Canadian specialists reported being able to exchange clinical summaries with doctors outside of their practice through their electronic medical record (EMR).(17)
An information transfer procedure can be defined as a set of steps that is the official, accepted way of performing this transfer. Having such a procedure to ensure continuity of care, rather than individual initiatives, is desirable as the patient safety literature demonstrates that a system approach is key in preventing human errors.(18,19)
There is no scientific literature addressing the current state of information transfer between hospital-based geriatricians and PCPs in Canada. The aim of this study was to describe the knowledge of geriatricians and their trainees regarding the transmission of their consultation notes and discharge summaries to primary care physicians, as well as barriers, facilitators, and best practices within the current Quebec health-care system regarding the transmission of notes pertaining to the older population. Quebec is one of the Canadian provinces with the most geriatricians whose practice and challenges might inform the growing number of geriatricians around the country.(20)
We conducted a sequential exploratory mixed methods study. The first phase was a quantitative study which consisted of one short survey sent to eligible physicians. In a second phase, we conducted semi-structured interviews of a sample of physicians and trainees recruited during the first phase. We then integrated the results of both phases. Qualitative description was deemed the most appropriate methodology for this study. Qualitative description focuses on gaining insights from informants on poorly understood phenomena and describing a phenomenon without developing theory.(21,22)
All geriatricians and Geriatric Medicine residents of the province of Quebec were approached to participate in the survey through the emailing list of the Association des Médecins Gériatres du Québec (AMGQ), the union representing all geriatricians, and a brief description of the study was provided to attendees at the annual scientific meeting of the AMGQ. Once a participant completed the survey, a last question was included to indicate interest in participating in an interview. We used a convenience sampling strategy, selecting all volunteers whom we felt had the most interest in the topic of our research. Volunteers were approached by email until saturation was achieved. Saturation occurs when new data becomes redundant of data previously collected.(23)
Development of individual questionnaire items was guided by standard methods of survey research,(24) published literature, and discussion within the research team. Initial questions explored the perception of a need for information transfer between Geriatricians and family physicians, and the presence/absence of a procedure in place. If respondents indicated that they did not have a procedure in place, further information was gathered about the impact of the absence of a transmission procedure and individual initiatives to counteract the absence of a systematic procedure. Questions were multiple-choice. The questionnaire was administered using Microsoft Forms. Invitations to complete the survey were sent out in May 2023 with two reminders over the next four months. Survey invitation explained to participants that the objective of this research was to improve communication to PCPs for frail older adults. Participants were excluded from survey results if they reported not doing inpatient consultations or admitting patients.
Semi-structured individual interviews were conducted by three researchers (DY, male medical student; SC, female Geriatric Medicine resident; and CP, female Geriatric Medicine resident; all trained in qualitative methods) using Microsoft Teams between August and November 2023. The interview guide was developed based on published literature and discussions within the research team (see Appendix A). Initial questions focused on the information transmission procedure in the participants’ practices. Participants were then asked to reflect on their past and current professional experience to explore barriers and facilitators to optimal information transmission, risks and benefits of transmission, and best practices for transmission. Lastly, participants were asked to make recommendations to improve information transmission in Quebec. Further questions were asked throughout the interviews for clarification and additional details.
Descriptive statistics were used to analyze survey results. Multiple-choice responses were reported as counts and proportions.
Interview recordings (audio and video) were transcribed verbatim by Microsoft Teams live transcription tool. Transcripts were de-identified and checked for accuracy by the researcher who performed the interview. Each participant was assigned a unique identifying code comprising of four-digit number to indicate the order in which they were interviewed.
Following a familiarization phase that involved listening to the interview recordings, reading and rereading the transcripts, each transcript was analyzed independently by two researchers (DY and SC, and SC and AZ; AZ is a medical student trained in qualitative research) using an inductive reflexive thematic analytical approach and then compared.(25) The researchers met on several occasions throughout the coding process to discuss their approach to analysis. Codes were organized into overarching themes. The themes were reviewed and discussed within the research team, during which further refinement was done and disagreements were resolved.
C G-S is a staff geriatrician and clinician investigator who works with several participating geriatricians and has supervised participating residents. SC, CP, and JT are Geriatric Medicine residents who have relationships with several participants as co-residents and have been supervised in their clinical duties by participating geriatricians. DY and AZ are medical students who had no prior relationship with any participant. SL is a qualitative researcher who had no prior relationship with any participant.
This study was approved by the McGill University Health Centre Research Ethics Board (2023-9021).
One hundred twenty-three geriatricians and 23 Geriatric Medicine residents were approached to complete our survey. We obtained 64 answers for a response rate of 44%. One geriatrician (2%) was excluded because they reported not doing consultations. Characteristics of survey responders and survey results are respectively presented in Tables 1 and 2. While 68.3% of geriatricians believed that their consults should be systematically sent to family physicians, only 1.6% had a procedure in place for information transmission in their practice. Furthermore, 93.6% of responders reported that the absence of such a procedure negatively impacted the care of older adults.
TABLE 1 Characteristics of survey responders (N=64)
Twenty geriatricians and Geriatric Medicine residents agreed to participate in an individual interview. Thirteen interviews were conducted. Data saturation was reached after the 12th interview and no further recruitment took place after the 13th interview. Interviews were, on average, 16 minutes in duration (range 10 to 25 minutes). Participant characteristics are shown in Table 3.
TABLE 3 Characteristics of interview participants (N=13)
Six overarching themes were generated from the data, detailed below.
Most geriatricians and geriatric medicine residents reported not being aware of a systematic process for information transmission between their practice hospital and family physicians. They noted that efforts for transmission were often the result of an individual initiative from the physician or an allied health team member: “So it was almost easier for me just to start to fax and mail everything myself.” (Participant 0003) And another participant said:
There is no systematic process that’s in place to transmit the discharge summaries or the consults at any of the centers I work with and a lot of the time it relies on having one very motivated and invested individual in the team. (Participant 0001)
Certain geriatricians benefited from administrative support from ward clerks and clinic administrative agents to assist with information transfer.
For every new consultation, the notice is sent to the family physician who requests, or any physician who requested the consult, and for some of the follow-ups, I ask the coordinator of the clinic to also send my note. (Participant 0006)
Several participants pointed out that the Quebec provincial standard discharge summary form contains a line to request transmission to the patient’s family physician. However, they were unsure if writing the contact information of the family physician was enough to trigger a transmission process.
On the discharge summary, however, there is a section where it’s clearly written “send a copy to this physician” or “send a copy to that physician”. And then you have to enter basically the information (…) Two years into my practice, something like that, I found out that archives doesn’t do that. (Participant 0003)
Reflecting on their current practice for information transfer led participants to express their ideals for optimal transmission.
Most participants agreed that having an EMR that would communicate between hospitals and primary care in the entire province was the optimal form of information transmission.
Participants, however, noted that a universal EMR represented a drastic change from current health information systems, and that an alternative could be to create dedicated administrative positions for information transmission. Moreover, some participants advocated for harnessing technology to assist in information transmission. Suggestions included developing new secure lines of communications between health-care providers, such as email and secure instant messaging: “If we had a secure SMS line, and the person could print and add to the chart, I think it would be simpler.” (Participant 0012)
Achieving these optimal modes for information transfers requires addressing the current barriers and facilitators in the process.
With regard to barriers to optimal transmission, participants noted that a lot of patients did not have a family physician to receive the information. When patients did have a family physician, participants reported having difficulty identifying this person and the right contact information. One participant exposed their concerns: “Just sometimes identifying who the primary care provider for a patient isn’t that obvious.” (Participant 0001)
The health-care system’s suboptimal information systems technology was also perceived by most geriatricians and geriatric medicine residents as a barrier to optimal transmission of information. Their primary concern was the fragmentation of information between different EMRs at each hospital and clinic. As a participant said: “There’s like more than 25 different EMRs that don’t speak to each other.” (Participant 0005)
Participants acknowledged that the province had an electronic platform, the Dossier Santé Québec (DSQ), accessible to physicians and residents, and containing the list of prescribed medications, as well as laboratory and imaging results. However, they felt that this technology was somewhat outdated.
If we were to have computers that were working, if the DSQ would stop crashing, if the DSQ would be faster also because you know, sometimes it takes like a good 2–3 minutes before you actually get to the information. (Participant 0003)
Lastly, due to the absence of a systematic information transfer process, participants noted that transmitting the information required individuals to carry out multiple steps, increasing the chances of human error. And a participant observed that: “We rely on the good will, competence, and memory of people to do it.” (Participant 0011)
In terms of facilitators to information transmission, a few participants who had access to an EMR with integrated external fax/messaging functions named technology.
I work at an outside clinic from the hospital where we have an EMR. And basically, (…) I also have the option of faxing or emailing, and it’s super, super easy because the way the system is set up. (Participant 0004)
There was consensus amongst participants that the primary risk of the absence of transmission was the loss of information and duplication of investigations and interventions. “It duplicated requests. Family physicians react on medications according to their evaluation, without considering what happened during the hospitalization.” (Participant 0012)
In parallel, improved continuity of care was largely viewed as the benefit of systematic transmission of information. A participant also reported that improving transmission of consultation notes in his practice had led to more open communication with family physicians and some productive exchanges: “Sometimes it happens that family physicians call me back after receiving my note because they want clarifications or have other questions. It also brings more discussions and more teamwork.” (Participant 0010)
In terms of risks of transmission, especially if systematic, participants were concerned about risks of breaches in confidentiality. This perceived risk was enhanced by the difficulty of identifying the proper contact information for family physicians and the uncertainty of whether they were sending the notes to the right person.
Given that there is no systematic way of identifying where, well, who was the physician that the notes should go to and what’s the most optimal address where this should be transmitted, it could present with the risk of a confidentiality breach. (Participant 0001)
Several participants also raised the possibility of overloading family physicians with information and administrative tasks. In the word of one of them: “It would be, I guess, more paperwork for the family physician to have to go through and read. I know they get a lot of like faxes and a lot of things they have to read through.” (Participant 0002)
No participant saw benefit to the absence of information transmission between geriatricians and family physicians.
Most participants admitted to having very limited knowledge of the legal framework surrounding information transfer between geriatricians and family physicians.
The overarching recommendation for improving information transfer in Quebec from most geriatricians and Geriatric Medicine residents was to develop a universal EMR for the province for both hospitals and outpatient primary care clinics.
Participants raised the possibility of improving the current provincial electronic platform, the DSQ, by including discharge summaries.
We have to take advantage of our informatic technology. And improve the system by integrating even all the informatic technology (…) which to me would include to create in the DSQ, which is the provincial health system charts, you know, a possibility to deposit in there these notes. (Participant 0006)
Finally, some participants emphasized the importance of geriatricians learning about the information transmission procedures in place—or the lack thereof—in their practice settings, and advocating for improved transmission given the complexity of their patient population. “I do want to state that it’s something that’s extremely important, right, as our patients are getting more complicated. There’s huge value in knowing what’s going on.” (Participant 0009)
This mixed-methods study explored geriatricians and Geriatric Medicine residents’ current information transfer practices and opinions regarding optimal transmission of hospital consultations and discharge summaries to primary care physicians. While most participants did not have a systematic procedure for information transfer to primary care physicians, they agreed that such a procedure should be implemented and would have benefits in terms of continuity of care and avoiding duplicated interventions. Technology was perceived as both a barrier when outdated or convoluted, and as a facilitator when harnessed to automatize information transmission. Participants cautioned that systematic information transfer could have potential adverse consequences including breaches in confidentiality and overloading primary care physicians with information.
Our study is the first study in Canada asking geriatricians about the issue of information transfer and, to our knowledge, worldwide. Previous studies have primarily focused on database and survey data, and were interested in the perspective of primary care providers and long term care physicians.(5,13,14,26)
The Quebec Code of Ethics of Physicians establishes the deontological obligations of physicians with regard to information transmission in the province. It states that a physician must promptly answer a consultation request in writing to the referring physician.(27) Furthermore, it states that the physician is responsible to ensure the medical follow-up required by the patient following his intervention.(27) Both code articles suggest that a specialist, such as a geriatrician, must share all the necessary information to patients’ primary care physicians to ensure proper follow-up. In March 2024, the Institut national d’excellence en santé et en services sociaux (INESSS) published a practical guide for best practices to improve the continuity of transition care for older adults with neurocognitive disorders. This guide emphasizes that all professionals should document all relevant information in the patient’s health record and share it with all involved professionals for continuity of care.(28) Thus, clear national recommendations exist to support systematic transmission of information, but, as demonstrated in our study, are not systematically followed in the care of older adults. Next steps in our research include a deliberative dialogue workshop with key stakeholders to develop evidence-based recommendations to improve information transfer in the province.
Leveraging technology to support information transfer was a common recommendation in our interviews. Previous quantitative studies support the effectiveness of information technology in the shared care of patients with chronic diseases. A 2017 systematic review showed that EMRs are associated with fewer readmissions, while electronic text-based communication applications lead to a positive effect on the number of PCPs contacting hospitals and on PCP confidence.(29)
Participants in our study suggested developing a common EMR in the province to facilitate information transfer. The government of Quebec announced in August 2023 the progressive implementation of a provincial EMR, Epic Systems, with a pilot project in two regions starting in 2025.(30) The government’s priorities in selecting this EMR are to improve access to patient medical information and fluidity of data-sharing across the health-care network.(30) This aligns with geriatricians’ aspiration of having a universal EMR for information sharing in the province. Epic Systems is the EMR that was selected across multiple health-care organizations across Ontario. With its Care Everywhere feature, the EMR has allowed data exchange and interoperability between organizations within and across cities.(31) Lessons can be learned from Ontario, which has an established EHR Connectivity Strategy to allow timely transmission of health-care information across organizations.(32) Its equivalent of the DSQ allows access to specialist consultations and discharge summaries from participating organizations. Alberta is currently the Canadian leader in connectivity, with its province-wide clinical information system, Connect Care, that not only is in place in hospitals, but also in community care, home care, public health services, and correctional facilities.(33)
While technology has the potential to revolutionize information transfer in health care, there are possible adverse effects associated with EMRs. A notable potential adverse effect is information overload, which can be associated with decreased efficiency and lead to medical errors.(34) EMRs should be well designed for people to be able to access the information in the time constraint of a primary care encounter with the notification that the patient has been to the ER or hospitalized.
Our study has several limitations. First, our study only recruited geriatricians and Geriatric Medicine residents from Quebec. Our results are therefore context-specific and not generalizable to other health-care systems and jurisdictions. Second, only one geriatrician who disagreed with the need for information transfer to primary care physicians was reached through the survey, and none participated in the interview process. It is possible that geriatricians who do not prioritize information transfer in their practice were less inclined to participate in the study, and we may have missed enriching insights from these dissenting opinions. In addition, social desirability bias may have affected answers to some questions of the survey and could explain why we only had one dissenting opinion. Lastly, our study included geriatricians whose insights only reflect one side of the information exchange with primary care. Primary care experiences are required to understand the full interaction.
Geriatricians and Geriatric Medicine residents in Quebec perceive systematic information transfer to primary care physicians as a key intervention for the provision of safe, high-quality care to older adults. Most of them, however, do not currently have such a procedure in place. Improving health-care technology and electronic medical records is viewed as an important step to facilitate information transfer.
We would like to thank the Association des Médecins Gériatres du Québec (AMGQ) for supporting this project. We would also like to thank Dr. Philippe Desmarais and Dr. Quoc Dinh Nguyen for their contributions to the elaboration of our survey.
We have read and understood the Canadian Geriatrics Journal’s policy on disclosing conflicts of interest and declare that we have none.
This research was supported by the Helen McCall Hutchison Award of the Foundation of the Montreal General Hospital and by the McGill Faculty of Medicine and Health Sciences Research Bursary Program. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
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Video Interview
Initial Questions
Role: geriatrician vs. geriatric resident vs. other role, please specify.
Primary practice location: Community vs. University or other, please specify.
Number of years of practice:
[For geriatricians and geriatric residents, members of the multidisciplinary team, administrative staff]
The following questions will be used depending on the situation.
[In the questionnaire, you answered that you think notes should not be sent.]
[For those familiar with the legislative framework governing the communication of hospital medical records to front-line teams: hospital legal service, Collège des Médecins du Québec, Canadian Physicians Protective Association]
Correspondence to: Claire Godard-Sebillotte, MD, PhD, Montreal General Hospital, 1650 Cedar Ave., Montreal, QC H3G 1A4, E-mail: claire.godard-sebillotte@mcgill.ca
COPYRIGHT
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial No-Derivative license (https://creativecommons.org/licenses/by-nc-nd/4.0/), which permits unrestricted non-commercial use and distribution, provided the original work is properly cited.
Canadian Geriatrics Journal, Vol. 28, No. 3, SEPTEMBER 2025