Background:
Poor communication between hospital caregivers and either patients or their primary care physicians accounts for almost 60% of preventable or ameliorable postdischarge adverse events. Clinicians at many hospitals have relied on dictation to create discharge documentation. However, dictation cannot ensure that key information is included or presented in a standardized way. As such, many hospitals have moved to electronic systems to support the discharge process, enabling cued reminders, mandatory fields, and autoimport of data to support the transmission of key information to patients and postdischarge providers. We sought to determine whether introduction of a Web‐based discharge module would improve the quality and timeliness of discharge documentation.
Methods:
A 10‐month observational before–after study was used to determine the impact of a Web‐based discharge module at our tertiary‐care hospital. Both the timeliness and quality of discharge documentation were assessed for approximately 50 randomly chosen cases per quarter. An explicit review process was used in which trained physicians reviewed the inpatient medical record as a “gold standard” and then rated discharge documentation for the presence of 8 predetermined data elements. Reviewers also provided a global assessment of discharge documentation quality. Discharge documentation was considered “defect free” if it contained adequate information for all 8 applicable data elements. Comparisons were analyzed using logistic regression for the presence of each element and for the defect‐free rate.
Results:
Following introduction of the discharge module, the defect‐free rate increased from 60% and 68%, 4 months and 1 month prior to implementation, respectively, to 84% and 93%, 2 and 6 months following implementation, respectively (P = 0.001). The greatest contributors to the overall improvement were marked improvement in inclusion of studies pending at discharge, which was made mandatory following review of data after the second month postimplementation demonstrated low compliance, and discharge medication instructions, facilitated by an automatic report generated by the module that clearly indicates differences between preadmission and discharge medication regimens. The global assessments found that the introduction of the discharge module reduced the frequency of any discrepant or redundant information in the discharge documentation from 92% to 57% (P = 0.0002). Timeliness of discharge documentation also improved, with 98% of discharge documents completed by 24 hours following discharge compared with 88% prior to implementation (P = 0.006).
Conclusions:
Electronic clinical systems can improve the quality and timeliness of documentation for patients being discharged from the hospital. The success of this module supports the adoption of electronic systems to aid at hospital discharge and could serve as a model as vendor electronic medical records continue to upgrade their products.