We conducted a randomized controlled trial comparing traditional dictation with a novel web-based computer program, as methods of discharge summary generation. There was no difference in PCP overall satisfaction between these 2 methods. Patient satisfaction, completion of outpatient follow-up, and return to the hospital, were similarly unaffected. Housestaff appeared to prefer the EDS method overall.
Although an EDS program such as ours might seem intuitively to be superior to conventional dictation, existing evidence suggests otherwise. Electronic documentation systems can be overly inclusive, resulting in “information overload” and loss of focus on useful data.17
Copy and paste functions, used extensively in systems such as ours to transfer imaging and other reports, have been associated with inconsistent and outdated information.21
Electronic discharge summaries might also be deficient in information, compared to those produced by hand.16
Ours is the first randomized controlled trial to evaluate the use of a secure web-based computer program to generate individualized discharge summaries. In a previous study, discharges created from computer database information were compiled manually by 1 of the study authors.11
In our study, the medical housestaff used the EDS directly to prepare discharge summaries. Compared to similar previous studies, ours included more clinical endpoints (ED visits, hospital readmissions, completion of outpatient appointments and tests), as well as a previously validated, patient-centered measure of the adequacy of information communication during the transition out of hospital. Our PCP survey response rate was comparable to other similar studies.11,15
In contrast to previous studies of a similar design, our study assessed the quality of summaries in the immediate postdischarge period. By collecting data on community physician satisfaction earlier, our study provides a clinically relevant endpoint, and reduces the potential for recall bias.
The mean overall quality of dictated discharge summaries assessed in our study was higher than that reported for the summaries assessed by similar means in an earlier study.11
This high baseline quality of discharge summaries may have compromised our power to detect any difference from the use of the EDS. Nonetheless, the point estimates for the primary outcomes were similar. Though our results do not demonstrate a significant increase in discharge summary quality with the EDS system, they are reassuring in that no decrement was seen, and the confidence intervals do not include what we considered a clinically important difference. Moreover, the analysis of secondary endpoints suggests that EDS discharges are safe, user-friendly, and patient-centered.
The results of the housestaff survey suggest that the EDS method of preparing discharge summaries was slightly more time-consuming, but preferred overall. Our study was conducted within the first few months of the launch of the EDS, when it had yet to be incorporated into routine practice. We anticipate that the time required to complete discharge summaries by the EDS method (currently estimated at less than 30 minutes) will continue to decrease.
Three discharge summaries from the EDS arm were not posted on the HIS. Possible reasons include failure of the housestaff to generate the summary, and failure of the attending physician to finalize the report. This has been addressed by the addition of an email reminder function for attending physicians, which ensures that all discharge summaries are finalized as quickly and reliably as possible.
An electronic discharge summary program has several potential advantages compared to traditional dictation. First, the discharge summaries generated can be stored as a searchable database, providing a large repository of data that would otherwise be embedded in the paper record. Second, such a program can be modified to include reminders, forcing functions, and constraining functions, and to improve adherence to evidence-based therapies and screening tests for certain common conditions. Third, an electronic discharge summary program can be used to improve transitions during hospitalizations, such as when one resident signs over care of a patient to another at month end.
Further research in this area should focus on determining the effect of computer-assisted discharge summary generation on rates of medication errors after discharge. Qualitative data from focus groups of both PCPs and hospital-based physicians would assist in refining programs such as our EDS to make the discharge process more user-friendly, and to provide more meaningful information in a more efficient manner. A formal study of cost-effectiveness would be useful to inform decisions on the adoption of similar technological innovations.
Our study has a few weaknesses that must be considered. The study period was relatively short, with only 30 days of follow-up for patient outcomes. Only readmissions and ED visits at the study site were included. Our study did not include a run-in period to collect baseline values for PCP assessments of discharge summaries, and did not assess the accuracy of either of the discharge summary methods. Strict blinding of the PCPs to the method of discharge summary preparation may not have been achieved given the differences in output from each system. Nonetheless, we considered any bias from PCPs against or in favour of either method to be an outcome of interest, and therefore appropriately captured by the survey tool. We were not able to reach our prespecified number of discharges, and ultimately included only 45% of the original 209 eligible discharge summaries. This limited our ability to detect statistically significant differences. Finally, our single-center trial may not be fully generalizable to other settings.
We performed a randomized controlled trial of electronic vs. dictated discharge summary generation. The results of our study show that a web-based computer program can produce discharge summaries with overall quality not significantly different from those generated by the traditional method of dictation. Our program was well received by the medical housestaff, resulted in a low rate of summary nonreceipt, and had no discernable negative impact on clinical endpoints. As such, the EDS stands to play a key role in ongoing efforts to integrate computerized tools for patient care and enhance the quality of patient discharge.