Journal of General Internal Medicine

, Volume 26, Issue 7, pp 718–723 | Cite as

Effect of Standardized Electronic Discharge Instructions on Post-Discharge Hospital Utilization

  • John W. ShowalterEmail author
  • Colleen M. Rafferty
  • Nicole A. Swallow
  • Kolapo O. DaSilva
  • Cynthia H. Chuang
Original Research



Several physician organizations and the Centers for Medicare and Medicaid Services (CMS) support compliance measures for written discharge instructions. CMS has identified clear discharge instructions with specific attention to medication management as a necessary intervention.


We tested the hypothesis that implementing a standardized electronic discharge instructions document with embedded computerized medication reconciliation would decrease post-discharge hospital utilization.


Retrospective pre- and post-implementation comparison cohort study.


Subjects were hospitalized patients age 18 and older discharged between November 1, 2005 and October 31, 2006 (n = 16,572) and between March 1, 2007 and February 28, 2008 (n = 17,516).


Implementation of a standardized, templated electronic discharge instructions document with embedded computerized medication reconciliation on December 18, 2006.


The primary outcome was a composite variable of readmission or Emergency Department (ED) visit within 30 days of discharge. Secondary outcomes were the individual variables of readmissions and ED visits within 30 days.


The implementation of standardized electronic discharge instructions with embedded computerized medication reconciliation was not associated with a change in the primary composite outcome (adjusted OR 1.04, 95% CI 0.98–1.10) or the secondary outcome of 30-day ED visits (adjusted OR 0.98, 95% CI 0.98–1.10). There was an unexpected small but statistically significant increase in 30-day readmissions (adjusted OR 1.08, 95% CI 1.01–1.16).


Implementation of standardized electronic discharge instructions was not associated with reduction in post-discharge hospital utilization. More studies are needed to determine the reasons for post-discharge hospital utilization and to examine outcomes associated with proposed process-related recommendations.


medical informatics hospital medicine performance measurement readmission health care utilization 



Cynthia Chuang MD, MSc, is funded, in part, by the Eunice Kennedy Shriver National Institute of Child Health and Human Development (K23 051634).

Conflict of Interest

None disclosed.


  1. 1.
    Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. 2009;360:1418–28.PubMedCrossRefGoogle Scholar
  2. 2.
    Makaryus AN, Friedman EA. Patients' understanding of their treatment plans and diagnosis at discharge. Mayo Clin Proc. 2005;80:991–4.PubMedCrossRefGoogle Scholar
  3. 3.
    Coleman EA, Smith JD, Raha D, Min SJ. Posthospital medication discrepancies: prevalence and contributing factors. Arch Intern Med. 2005;165:1842–7.PubMedCrossRefGoogle Scholar
  4. 4.
    Witherington EM, Pirzada OM, Avery AJ. Communication gaps and readmissions to hospital for patients aged 75 years and older: observational study. Qual Saf Health Care. 2008;17:71–5.PubMedCrossRefGoogle Scholar
  5. 5.
    Centers for Medicare and Medicaid Services. Application of incentives to reduce avoidable readmissions to hospitals. Fed Regist. 2008;73:23673–5.Google Scholar
  6. 6.
    Snow V, Beck D, Budnitz T, 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-Society of Academic Emergency Medicine. J Gen Intern Med. 2009;24:971–6.PubMedCrossRefGoogle Scholar
  7. 7.
    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? Qual Saf Health Care. 2006;15:414–7.PubMedCrossRefGoogle Scholar
  8. 8.
    Jha AK, Orav EJ, Epstein AM. Public reporting of discharge planning and rates of readmissions. N Engl J Med. 2009;361:2637–45.PubMedCrossRefGoogle Scholar
  9. 9.
    Balaban RB, Weissman JS, Samuel PA, Woolhandler S. Redefining and redesigning hospital discharge to enhance patient care: a randomized controlled study. J Gen Intern Med. 2008;23:1228–33.PubMedCrossRefGoogle Scholar
  10. 10.
    Coleman EA, Parry C, Chalmers S, Min SJ. The care transitions intervention: results of a randomized controlled trial. Arch Intern Med. 2006;166:1822–8.PubMedCrossRefGoogle Scholar
  11. 11.
    Jack BW, Chetty VK, Anthony D, et al. A reengineered hospital discharge program to decrease rehospitalization: a randomized trial. Ann Intern Med. 2009;150:178–87.PubMedGoogle Scholar
  12. 12.
    Nelson EA, Maruish ME, Axler JL. Effects of discharge planning and compliance with outpatient appointments on readmission rates. Psychiatr Serv. 2000;51:885–9.PubMedCrossRefGoogle Scholar
  13. 13.
    Friedman B, Jiang HJ, Elixhauser A. Costly hospital readmissions and complex chronic illness. Inquiry. 2008;45:408–21.PubMedGoogle Scholar
  14. 14.
    Hernandez C, Jansa M, Vidal M, et al. The burden of chronic disorders on hospital admissions prompts the need for new modalities of care: a cross-sectional analysis in a tertiary hospital. QJM. 2009;102:193–202.PubMedCrossRefGoogle Scholar
  15. 15.
    Grafft CA, McDonald FS, Ruud KL, Liesinger JT, Johnson MG, Naessens JM. Effect of hospital follow-up appointment on clinical event outcomes and mortality. Arch Intern Med. 2010;170:955–60.PubMedCrossRefGoogle Scholar
  16. 16.
    Ingarfield SL, Finn JC, Jacobs IG, et al. Use of emergency departments by older people from residential care: a population based study. Age Ageing. 2009;38:314–8.PubMedCrossRefGoogle Scholar
  17. 17.
    Graumlich JF, Novotny NL, Nace GS. Patient readmissions, emergency visits, and adverse events after software-assisted discharge from hospital: cluster randomized trial. J Hosp Med. 2009;4:E11–9.PubMedCrossRefGoogle Scholar

Copyright information

© Society of General Internal Medicine 2011

Authors and Affiliations

  • John W. Showalter
    • 1
    • 2
    Email author
  • Colleen M. Rafferty
    • 3
  • Nicole A. Swallow
    • 3
  • Kolapo O. DaSilva
    • 4
  • Cynthia H. Chuang
    • 3
    • 5
  1. 1.Department of Medicine,Penn State College of MedicineHersheyUSA
  2. 2.Department of Information Technology,Penn State College of MedicineHersheyUSA
  3. 3.Division of General Internal MedicinePenn State College of MedicineHersheyUSA
  4. 4.Penn State College of MedicineHersheyUSA
  5. 5.Department of Public Health Sciences,Penn State College of MedicineHersheyUSA

Personalised recommendations