Information Technology Improves Emergency Department Patient Discharge Instructions Completeness and Performance on a National Quality MeasureA Quasi-Experimental Study
12 July 2013
accepted: 07 October 2013
19 December 2017 (online)
Objectives: To compare the completeness of Emergency Department (ED) discharge instructions before and after introduction of an electronic discharge instructions module by scoring compliance with the Centers for Medicare and Medicaid Services (CMS) Outpatient Measure 19 (OP-19).
Methods: We performed a quasi-experimental study examining the impact of an electronic discharge instructions module in an academic ED. Three hundred patients discharged home from the ED were randomly selected from two time intervals: 150 patients three months before and 150 patients three to five months after implementation of the new electronic module. The discharge instructions for each patient were reviewed, and compliance for each individual OP-19 element as well as overall OP-19 compliance was scored per CMS specifications. Compliance rates as well as risk ratios (RR) and risk differences (RD) with 95% confidence intervals (CI) comparing the overall OP-19 scores and individual OP-19 element scores of the electronic and paper-based discharge instructions were calculated.
Results: The electronic discharge instructions had 97.3% (146/150) overall OP-19 compliance, while the paper-based discharge instructions had overall compliance of 46.7% (70/150). Electronic discharge instructions were twice as likely to achieve overall OP-19 compliance compared to the paper-based format (RR: 2.09, 95% CI: 1.75 – 2.48). The largest improvement was in documentation of major procedures and tests performed: only 60% of the paper-based discharge instructions satisfied this criterion, compared to 100% of the electronic discharge instructions (RD: 40.0%, 95% CI: 32.2% – 47.8%). There was a modest difference in medication documentation with 92.7% for paper-based and 100% for electronic formats (RD: 7.3%, 95% CI: 3.2% – 11.5%). There were no statistically significant differences in documentation of patient care instructions and diagnosis between paper-based and electronic formats.
Conclusions: With careful design, information technology can improve the completeness of ED patient discharge instructions and performance on the OP-19 quality measure.
Citation: Bell EJ, Takhar SS, Beloff JR, Schuur JD, Landman AB. Information technology improves emergency department patient discharge instructions completeness and performance on a national quality measure: A quasi-experimental study. Appl Clin Inf 2013; 4: 499–514 http://dx.doi.org/10.4338/ACI-07-RA-0046
KeywordsComputerized medical records systems - emergency care information systems - patient discharge - quality improvement - health care reform
- 1 National Hospital Ambulatory Medical Care Survey: 2010 Emergency Department Summary Tables. Hyattsville, MD: National Center for Health Statistics; 2013: 29.
- 2 Yu KT, Green RA. Critical aspects of emergency department documentation and communication. Emergency medicine clinics of North America 2009; 27 (04) 641-654 ix. PubMed PMID: 19932398.
- 3 Taylor DM, Cameron PA. Emergency department discharge instructions: a wide variation in practice across Australasia. J Accid Emerg Med 2000; 17 (03) 192-195. PubMed PMID: 10819382. Pubmed Central PMCID: PMC1725372. eng.
- 4 Samuels-Kalow ME, Stack AM, Porter SC. Effective discharge communication in the emergency department. Ann Emerg Med 2012; 60 (02) 152-159. PubMed PMID: 22221840. eng.
- 5 Tsilimingras D, Bates DW. Addressing postdischarge adverse events: a neglected area. Jt Comm J Qual Patient Saf 2008; 34 (02) 85-97. PubMed PMID: 18351193. eng.
- 6 Were MC, Li X, Kesterson J, Cadwallader J, Asirwa C, Khan B. et al. Adequacy of hospital discharge summaries in documenting tests with pending results and outpatient follow-up providers. Journal of general internal medicine 2009; 24 (09) 1002-1006. PubMed PMID: 19575268. Pubmed Central PMCID: 2726888.
- 7 Coleman EA, Mahoney E, Parry C. Assessing the quality of preparation for posthospital care from the patient’s perspective: the care transitions measure. Medical care 2005; 43 (03) 246-255. PubMed PMID: 15725981. Epub 2005/02/24. eng.
- 8 Kripalani S, LeFevre F, Phillips CO, Williams MV, Basaviah P, Baker DW. Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care. JAMA: the journal of the American Medical Association 2007; 297 (08) 831-841. PubMed PMID: 17327525.
- 9 VanSuch M, Naessens JM, Stroebel RJ, Huddleston JM, Williams AR. Effect of discharge instructions on readmission of hospitalised patients with heart failure: do all of the Joint Commission on Accreditation of Healthcare Organizations heart failure core measures reflect better care?. Quality & safety in health care 2006; 15 (06) 414-417. PubMed PMID: 17142589. Pubmed Central PMCID: PMC2464879. Epub 2006/12/05. eng.
- 10 Forster AJ, Murff HJ, Peterson JF, Gandhi TK, Bates DW. The incidence and severity of adverse events affecting patients after discharge from the hospital. Ann Intern Med 2003; 138 (03) 161-167. PubMed PMID: 12558354. eng.
- 11 Coleman EA, Berenson RA. Lost in transition: challenges and opportunities for improving the quality of transitional care. Ann Intern Med 2004; 141 (07) 533-536. PubMed PMID: 15466770.
- 12 Roy CL, Poon EG, Karson AS, Ladak-Merchant Z, Johnson RE, Maviglia SM. et al. Patient safety concerns arising from test results that return after hospital discharge. Ann Intern Med 2005; 143 (02) 121-128. PubMed PMID: 16027454. eng.
- 13 Engel KG, Buckley BA, Forth VE, McCarthy DM, Ellison EP, Schmidt MJ. et al. Patient understanding of emergency department discharge instructions: where are knowledge deficits greatest?. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine 2012; 19 (09) E1035-E1044. PubMed PMID: 22978730. eng.
- 14 Walz SE, Smith M, Cox E, Sattin J, Kind AJ. Pending laboratory tests and the hospital discharge summary in patients discharged to sub-acute care. Journal of general internal medicine 2011; 26 (04) 393-398. PubMed PMID: 21116868. Pubmed Central PMCID: PMC3055980. Epub 2010/12/01. eng.
- 15 Kripalani S, Jackson AT, Schnipper JL, Coleman EA. Promoting effective transitions of care at hospital discharge: a review of key issues for hospitalists. J Hosp Med 2007; 2 (05) 314-323. PubMed PMID: 17935242.
- 16 McMillan TE, Allan W, Black PN. Accuracy of information on medicines in hospital discharge summaries. Internal medicine journal 2006; 36 (04) 221-225. PubMed PMID: 16640738. Epub 2006/04/28. eng.
- 17 Callen J, McIntosh J, Li J. Accuracy of medication documentation in hospital discharge summaries: A retrospective analysis of medication transcription errors in manual and electronic discharge summaries. International journal of medical informatics 2010; 79 (01) 58-64. PubMed PMID: 19800840.
- 18 Forster AJ, Murff HJ, Peterson JF, Gandhi TK, Bates DW. Adverse drug events occurring following hospital discharge. Journal of general internal medicine 2005; 20 (04) 317-323. PubMed PMID: 15857487. Pubmed Central PMCID: PMC1490089. eng.
- 19 Forster AJ, Clark HD, Menard A, Dupuis N, Chernish R, Chandok N. et al. Adverse events among medical patients after discharge from hospital. CMAJ 2004; 170 (03) 345-349. PubMed PMID: 14757670. Pubmed Central PMCID: PMC331384. eng.
- 20 Coleman EA, Smith JD, Raha D, Min SJ. Posthospital medication discrepancies: prevalence and contributing factors. Arch Intern Med 2005; 165 (016) 1842-1847. PubMed PMID: 16157827. eng.
- 21 Snow V, Beck D, Budnitz T, Miller DC, Potter J, Wears RL. et al. Transitions of Care Consensus policy statement: American College of Physicians, Society of General Internal Medicine, Society of Hospital Medicine, American Geriatrics Society, American College Of Emergency Physicians, and Society for Academic Emergency Medicine. J Hosp Med 2009; 4 (06) 364-370. PubMed PMID: 19479781. eng.
- 22 National Quality Measures C. Care transitions: percentage of patients, regardless of age, discharged from an emergency department (ED) to ambulatory care or home health care, or their caregiver(s), who received a transition record at the time of ED discharge including, at a minimum, all of specified elements Rockville MD: Agency for Healthcare Research and Quality (AHRQ); [5/20/2013]. Available from: http://www. qualitymeasures.ahrq.gov/content.aspx?id=28142.
- 23 Hospital Outpatient Quality Reporting Specifications Manual [Version 5.0a].. American Medical Association. 2011 p. 2-105.
- 24 O’Leary KJ, Liebovitz DM, Feinglass J, Liss DT, Evans DB, Kulkarni N. et al. Creating a better discharge summary: improvement in quality and timeliness using an electronic discharge summary. J Hosp Med 2009; 4 (04) 219-225. PubMed PMID: 19267397. Epub 2009/03/10. eng.
- 25 Frimpong JA, Jackson BE, Stewart LM, Singh KP, Rivers PA, Bae S. Health information technology capacity at federally qualified health centers: a mechanism for improving quality of care. BMC health services research 2013; 13: 35. PubMed PMID: 23363660. Pubmed Central PMCID: PMC3570359. Epub 2013/02/01. eng.
- 26 Temporary Suspension of Hospital Outpatient Quality Reporting Measure OP-19: Transition Record with Specified Elements Received by Discharged Patients.. Centers for Medicare & Medicaid Services. 2012
- 27 Gilbert EH, Lowenstein SR, Koziol-McLain J, Barta DC, Steiner J. Chart reviews in emergency medicine research: Where are the methods?. Ann Emerg Med 1996; 27 (03) 305-308. PubMed PMID: 8599488. eng.
- 28 Sinclair JC, Bracken MB. Clinically useful measures of effect in binary analyses of randomized trials. J Clin Epidemiol 1994; 47 (08) 881-889. PubMed PMID: 7730891. eng.
- 29 Schechtman E. Odds ratio, relative risk, absolute risk reduction, and the number needed to treat--which of these should we use?. Value Health 2002; 5 (05) 431-436. PubMed PMID: 12201860. eng.
- 30 Shrout PE. Measurement reliability and agreement in psychiatry. Statistical methods in medical research 1998; 7 (03) 301-317. PubMed PMID: 9803527.
- 31 Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics 1977; 33 (01) 159-714. PubMed PMID: 843571.
- 32 Boast P, Potts C. Connecting cost and quality through automated discharge instructions. Healthcare financial management: journal of the Healthcare Financial Management Association 2011; 65 (08) 114-118. PubMed PMID: 21866729.
- 33 Schabetsberger T, Ammenwerth E, Andreatta S, Gratl G, Haux R, Lechleitner G. et al. From a paper-based transmission of discharge summaries to electronic communication in health care regions. International journal of medical informatics 2006; 75 3–4 209-215. PubMed PMID: 16112892. Epub 2005/08/23. eng.
- 34 Callen JL, Alderton M, McIntosh J. Evaluation of electronic discharge summaries: a comparison of documentation in electronic and handwritten discharge summaries. International journal of medical informatics 2008; 77 (09) 613-620. PubMed PMID: 18294904.
- 35 Humphreys T, Shofer FS, Jacobson S, Coutifaris C, Stemhagen A. Preformatted charts improve documentation in the emergency department. Ann Emerg Med 1992; 21 (05) 534-540. PubMed PMID: 1570909.
- 36 D VN. Rajavelu P, Rajagopalan A. Pre-formatted written discharge summary-a step towards quality assurance in the emergency department. International journal of emergency medicine 2008; 1 (04) 321-325. PubMed PMID: 19384649. Pubmed Central PMCID: 2657266.
- 37 Isaacman DJ, Purvis K, Gyuro J, Anderson Y, Smith D. Standardized instructions: do they improve communication of discharge information from the emergency department?. Pediatrics 1992; 89 6 Pt 2 1204-1208. PubMed PMID: 1594378.
- 38 Hayrinen K, Saranto K, Nykanen P. Definition, structure, content, use and impacts of electronic health records: a review of the research literature. International journal of medical informatics 2008; 77 (05) 291-304. PubMed PMID: 17951106. Epub 2007/10/24. eng.
- 39 Health IT and Patient Safety: Building Safer Systems for Better Care. The National Academies Press: 2012