Information Technology Improves the Quality of the Emergency Department Patient Discharge Instructions: A Quasi-Experimental Study

Emergency department (ED) patient discharge instructions are an important component of high-quality emergency care. To promote high-quality ED discharge instructions, the Centers for Medicare & Medicaid Services (CMS) advanced Outpatient Measure 19 (OP-19), a national quality measure which requires 5 elements in all ED discharge instructions: diagnosis, major procedures or tests performed, patient instructions, follow-up instructions, and new or changed medications. Our ED transitioned from a paper-based, handwritten discharge instructions form to a custom-designed electronic discharge instructions module in May 2012. In this study, we compared the quality of ED discharge instructions, as measured by OP-19, before and after the introduction of the electronic discharge instructions module. We hypothesize that the electronic discharge instructions will be of higher quality than the handwritten instructions. We performed a quasi-experimental study examining the impact of an electronic discharge instructions module in an academic ED. We randomly selected a total of 300 patients discharged home from the ED from 2 specific time intervals: 150 patients in the 3 months before implementation and 150 patients in the 3 to 5 months after implementation of the new electronic module. The primary author retrospectively reviewed each patient's discharge instructions and scored compliance for each required OP-19 element, as well as the overall OP-19 compliance per CMS specifications. A second expert reviewer independently scored a random sample of 40 charts. We calculated compliance rates, as well as risk ratios (RR) and risk differences (RD) with 95% confidence intervals (CIs) comparing the overall OP-19 scores and individual OP-19 element scores of the electronic and handwritten discharge instructions. We calculated agreement and kappa statistics between the 2 reviewers. The electronic discharge instructions had 97.3% (146/150) overall OP-19 compliance, while the handwritten discharge instructions had a compliance of 46.7% (70/150). Electronic patient discharge instructions were twice as likely to have achieved overall OP-19 compliance compared to the handwritten format (RR: 2.09; 95% CI 1.75-2.48). The 4 electronic discharge instructions that did not achieve overall OP-19 compliance were all missing patient instructions. The largest improvement was in the documentation of major procedures or tests performed: only 60% of the handwritten discharge instructions satisfied this criterion, compared to 100% of the electronic discharge instructions (RD: 40%, 95% CI: 32%-48%). There was a modest difference in medication documentation with 92.7% for handwritten and 100% for electronic formats (RD: 7.3%, 95% CI: 3.2%-12%). There were no significant differences between the handwritten and electronic formats for patient instructions and diagnosis. There was 90% agreement between the 2 reviewers, with a kappa of 0.71. Electronic discharge instructions in our ED were of higher quality than handwritten discharge instructions and twice as likely to satisfy the OP-19 quality measure. With careful design, information technology can be successfully implemented to improve the quality of ED patient discharge instructions.