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

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A review of the article by Showalter, "Effect of Standardized Electronic Discharge Instructions on Post-Discharge Hospital Utilization".


Readmissions to the hospital or the visits to the emergency department within 30 days of discharge are considered failed discharges. Jenck and colleagues, according to this article, estimated that these readmissions in 2004 alone cost the health care system $17.4 billion.Centers of Medicare and Medicaid Services (CMS) estimates that some of these readmissions can be prevented by clear and concise discharge instruction given to the patients at the time of discharge. Electronic Health Records (EHRs) has the potential benefit to reduce readmission and ED use post hospital discharge by standardizing and producing comprehensive discharge instructions. Though studies have shown that comprehensive post discharge interventions have beneficial effects but the effect of standardized discharge instructions created electronically is not clear.


Settings and Interventions

This study was conducted in Penn State Hershey Medical Center, which is a large academic medical center. Discharge instructions were typed in a word document template prior to the implementation of the study, however there were no mandatory fields that were required to be filled. Also medication reconciliation was done by hand. An electronic standardized discharge template was created that the CMS regulatory requirements. In this new form some data like admission and discharge date, medications were auto populated and other fields were typed but now were mandatory.


A pre-implementation cohort of patients aged 18 and over was compared with compared with a post-implementation cohort. Post implementation cohort was selected 3 months after the new discharge template was implemented.


Primary outcome of the study was either a readmission or an ED visit within 30 days of the index discharge.


In order to account for already known risk factors for readmissions, data was analyzed with multiple covariates. These variables were, age, sex, race, severity of illness, diagnoses, disposition home versus others. Also included were patients on dialysis.

Data Management and Statistical Analysis

Pre-implementation and post–implementation cohorts were compared for primary and secondary outcomes through multivariable logistic regression analysis done through SAS, Version 9.1 (SAS Institute, Cary, NC). Study had the power to estimate a difference of 1% in readmissions or ED use.


A total of about 34,000 patients were studied with slightly over half of these were in post-implementation group. The groups had small but statistically difference in race, discharge destination and severity of illness. Pre-implementation group had more whites and were sent home or to an acute rehabilitation place. In unadjusted analyses, small but statistically significant difference in readmission rates was seen in the post-implementation cohort for secondary outcomes. Age, severity of illness, and discharge diagnoses of COPD, CHF, Pneumonia and ESRD were associated with higher odds of readmissions.


Other studies have shown that discharge instructions with medication reconciliation alone may not be sufficient to reduce readmissions or use of the ED post-discharge. However the authors were unable to find a good explanation to why an electronic discharge instruction would be associated with a small but statistically increase in the readmission rate. This increase could be due to slight differences between the two cohorts with regard to age and having more patients with diagnoses with higher than average readmission rates. A more comprehensive study analyzing the factors leading to readmission or ED use may be needed.

My thoughts

This study fails to show any decreased utilization of hospital resources post implementation of standardized electronic discharge instructions. In my opinion this means that a more comprehensive approach is needed to reduce failed discharges, that includes a standard method of communication information to the patient and other healthcare workers like it was done in this study and improving the environment to which the patient is discharged to. We need to provide better mechanisms of getting the patients followed up with their physicians and also work on developing a better primary care system. It may be the case that the hypothesis that CMS maintains may be fundamentally incorrect, and there is no achievable benefit in regard to the quality of passive written discharge instructions. In this case efforts would be better spent on maximizing post-discharge patient engagement through more active methods. In a study use of templates to improve readability of discharge instructions authors Mueller et. al [1] showed that a well thought pre-developed discharge instructions templates help user readability of discharge instructions.

Related Articles

Readability of patient discharge instructions with and without the use of electronically available disease-specific templates


  1. Mueller, S. K., Giannelli, K., Boxer, R., & Schnipper, J. L. (07/01/2015). Journal of the american medical informatics association : JAMIA: Readability of patient discharge instructions with and without the use of electronically available disease-specific templates BMJ. doi:10.1093/jamia/ocv005 http://dx.doi.org.ezproxyhost.library.tmc.edu/10.1093/jamia/ocv005
  2. Showalter, J. W., Rafferty, C. M., Swallow, N. A., DaSilva, K. O., & Chuang, C. H. (2011). Effect of Standardized Electronic Discharge Instructions on Post-Discharge Hospital Utilization. Journal of General Internal Medicine, 26(7), 718–723. http://doi.org/10.1007/s11606-011-1712-y http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3138594/?tool=pmcentrez