title: Do electronic discharge summaries contain more complete medication information? A retrospective analysis of paper versus electronic discharge summaries.
abstract: Complete, accurate and timely hospital discharge summaries are important for continuity of care. The aim of this study was to evaluate the effectiveness of an electronic discharge summary system in improving the medication information provided compared to the information in paper discharge summaries. We conducted a retrospective audit of 199 paper and 200 electronic discharge summaries from a 350-bed teaching hospital in Sydney, Australia. The completeness of medication information, and whether medication changes during the admission were explained, were assessed. Further, the likelihood of any incomplete information having an impact on continuity of care was assessed. There were 1352 and 1771 medication orders assessed in paper and electronic discharge summaries, respectively. Of these, 90.9% and 93.4% were complete in paper and electronic discharge summaries, respectively. The dose (OR 25.24, 95%CI: 3.41-186.9) and route (OR 8.65, 95%CI: 3.46-21.59) fields of medication orders, were more likely to be complete in electronic as compared with paper discharge summaries. There was no difference for drug frequency (OR 1.09, 95%CI: 0.77-1.55). There was no significant improvement in the proportion of incomplete medication orders rated as unclear and likely to impede continuity of care in paper compared with electronic discharge summaries (7.3% vs. 6.5%). Of changes to medication regimen, only medication additions were more likely to be explained in the electronic (n=253, 37.2%) compared to paper (n=104, 14.3%) discharge summaries (OR 3.14; 95%CI: 2.20-4.18). In summary, electronic discharge summaries offer some improvements over paper discharge summaries in terms of the quality of medication information documented. However, explanations of changes to medication regimens remained low, despite this being crucial information. Future efforts should focus on including the rationale for changes to medication regimens in discharge summaries.
authors.affiliation: The University of New South Wales UNSW Sydney NSW 2052 Australia.
authors.forename: Elin C
authors.initials: EC
authors.lastname: Ehnbom
authors.affiliation: Australian Institute of Health Innovation The University of New South Wales, Sydney NSW.
authors.forename: Magdalena Z
authors.initials: MZ
authors.lastname: Raban
authors.affiliation: Australian Institute of Health Innovation The University of New South Wales, Sydney NSW 2052.
authors.forename: Scott R
authors.initials: SR
authors.lastname: Walter
authors.affiliation: St Vincent's Health Australia (NSW) Rushcutters Bay NSW 2011.
authors.forename: Katrina
authors.initials: K
authors.lastname: Richardson
authors.affiliation: Centre for Health Systems and Safety Research Australian Institute of Health Innovation The University of New South Wales, Sydney NSW 2052.
authors.forename: Johanna I
authors.initials: JI
authors.lastname: Westbrook
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001315:Australia; D003266:Continuity of Patient Care; D057286:Electronic Health Records / Q000706:statistics & numerical data*; D005260:Female; D006784:Hospitals, Teaching; D006801:Humans; D016015:Logistic Models; D008297:Male; D008485:Medical Audit; D059065:Medication Reconciliation / Q000592:standards*; D054539:Medication Therapy Management / Q000706:statistics & numerical data*; D008875:Middle Aged; D010351:Patient Discharge / Q000706:statistics & numerical data*; D012189:Retrospective Studies