Chapter 42. Information Transfer

Harvey J, Murff, M.D.
David W. Bates, M.D., M.Sc.
Harvard Medical School

Introduction

Patient safety can be compromised by discontinuities in care. Studies suggest that discontinuity results from poor information transfer¹ and faulty communication,² which in turn may cause avoidable adverse events.³

Improving information transfer and communications among healthcare providers is an important patient safety practice and has been strongly recommended as a means to improve patient care.^1,3-7 This chapter evaluates safety practices involving improvements of provider-to-provider information transfer. Practices for evaluation include transfer of information between inpatient and outpatient pharmacies (Subchapter 42.1), sign-out systems for medical housestaff (Subchapter 42.2), automatically generated electronic discharge summaries (Subchapter 42.3), and systems to improve patient notification of abnormal results (Subchapter 42.4).

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Subchapter 42.1. Information Transfer Between Inpatient and Outpatient Pharmacies

Background

Accurate and timely information transfer between community and acute care pharmacies is an important safety practice. Patients admitted to the hospital could benefit from the hospital's pharmacy obtaining better information concerning their medication allergies as well as prior therapeutic failures.⁸ Furthermore, when patients transition from acute care to outpatient care, changes in medications that occurred during hospitalization may cause confusion for both patients and providers. In one study surveying patients one week after hospital discharge, patients' knowledge of their drug indications were worse for medications introduced during their hospitalization than for those taken prior to hospitalization (OR 0.69, 95% CI: 0.53-0.89).⁹

Confusion and incomplete information may increase the risk of under- or overmedication, harmful drug interactions, and other problems. Existing literature suggests that pharmacist interventions may reduce potential adverse drug events and have a modest impact on patient morbidity and mortality.^10,11 However, these studies have used independent reviewers to judge the impact of the intervention and have not specifically measured adverse drug events or patient outcomes. Clinical pharmacists' consultations prior to discharge might also improve patient medication compliance (see Chapter 7).¹²

Uncontrolled studies report that information-exchange programs between hospital and community pharmacies are perceived as beneficial and may have a positive impact on patient outcomes.¹³ Although not the primary outcome measured in their small (n=127) observational study, Dvorak et al did note that using a pharmacy-to-pharmacy referral form was effective in preventing 2 medication errors. Thus, practices that improve information transfer between hospital and community pharmacies may improve patient safety.

Of the many potential methods for improving information transfer between hospitals and outpatient pharmacies, controlled trials have been reported in the literature for only 2: pharmaceutical care plans cards¹⁴ and patient information facsimiles between pharmacies.⁸ Although direct electronic communication of pharmacy data may be superior to these methods, no controlled studies are currently available regarding this practice and therefore it is not reviewed within this chapter.

Practice Description

In a study by Smith and colleagues, patients received a card prior to discharge listing their pharmaceutical care plan, which included medication doses, indications, schedules, side effects, information as to the importance of drug compliance, and how to obtain medication refills.¹⁴ Patients were instructed to give the card to their community pharmacist. In another study, the intervention consisted of pharmacy-to-pharmacy facsimile transmission at the time of admission and discharge from the hospital.⁸ In this study, when a patient was admitted to the hospital their community pharmacy transmitted patient demographic information, historical information concerning allergies and adverse drug reactions, current medications, refill history, pharmacist's monitoring notes, communications with patient and physician, and a detailed medication history to the admitting hospital. After discharge the hospital pharmacy transmitted to the community pharmacy a list of any potential medication problems identified by the hospital pharmacist on admission, the patient's daily monitoring log, the pharmacist's discharge summary, and a discharge medication table. The medical records department of the hospital also transmitted the patient's discharge summary and laboratory test results to the community pharmacy.

Prevalence and Severity of the Target Safety Problem

Medication problems can arise because patients are frequently discharged from the acute care hospital on medications different from their ambulatory regimen.¹⁵ Elderly patients in particular are at risk after discharge.¹⁶ In one study, hospital providers changed 53% of the drugs prescribed by the primary care providers.¹⁵

The extent to which these medication changes and lack of communication result in recently discharged patients failing to receive medications or appropriate monitoring for their drug therapy is unclear. In one study of elderly patients, 32% of medications prescribed at discharge were not being taken 2 days after discharge.¹⁷ Another study found that 51% of patients recently discharged from acute care hospitals had deviated from their prescribed regimen.¹⁸ Of those that had deviated from the prescribed drug regimen, 70% did not understand the medication regimen. In a Scottish study, recently discharged, elderly patients were issued a 5-day supply of their medication on discharge and visited in their homes after these 5 days had elapsed.¹⁶ Twenty-seven percent of the patients had not received a new prescription ordered on discharge. Of the patients with new prescriptions issued, 19% received inaccurately labeled medications. Medications were considered mis-labeled when non-specific container labels, such as "take as directed" replaced the more specific labels given on discharge. Some authors have suggested that improving communication about medications prior to and just after hospital discharge might reduce these medication errors.^18,19

Poor communication is not the only problem.¹⁶ Patient factors influence whether a medication is ultimately picked up and taken as directed. Deviations from prescribed drug regimens are multifactorial and improving pharmacy-to-pharmacy communication is only one aspect of the overall problem.

Opportunities for Impact

Data from primary care providers reveal that 96% of the respondents would like information concerning hospital drug changes.²⁰ Ninety-four percent of community pharmacists surveyed also wished to be provided with information concerning hospital drug changes.²⁰ We were unable to identify data regarding what percentage of hospital pharmacies routinely transfer information on patients' medication regimens when they are admitted to and discharged from acute care.

Study Design and Outcomes

Two controlled studies were identified in the literature (Table 42.1.1). Both were randomized trials but neither was blinded. In Smith et al, patients received a written pharmacy care plan at discharge. Home visits were made 7 to 10 days later to assess compliance and discrepancies in the medication that patients were taking versus those ordered at discharge (Level 2).¹⁴ In the study by Kuehl et al,⁸ patients were randomly assigned to either usual care or to a bi-directional exchange of pharmacy information by facsimile between the ambulatory pharmacy and the admitting hospital, upon admission and discharge (Level 1). The outcomes were pharmacist interventions, such as changing medication doses or making allergy recommendations (Level 2).⁸

Evidence for Effectiveness of the Practice

Smith et al's small study (n=53) of a pharmacy care plan card found that in both groups patients were taking different medications than those ordered at discharge. The authors found that compliance with post-discharge medications was significantly better in the group that had received the information card (p<0.01). Unintentional changes to the medication were found in 14/28 (50%) of the study patients and 17/25 (68%) of the control patients during the follow-up visits (Pearson's chi-square p=0.18)

In the study by Kuehl et al, significantly more experimental group patients than control group patients had at least one in-hospital pharmacist intervention documented (47% vs. 14%, p<0.001). The mean number of in-hospital pharmacist interventions per patient was also significantly higher in the experimental group (1.0 vs. 0.2, p<0.0001). The types of interventions made by hospital pharmacists included addition of a medication the patient was taking as an outpatient that was not originally ordered on admission, dosage changes, and changes related to drug allergy. Interventions by ambulatory care pharmacists were also more frequent in experimental group patients compared with control group patients. Community pharmacists who received hospital pharmacy records performed interventions on one or more patients 42% of the time, while no interventions were performed in the control group (p=0.001). Specific community pharmacist interventions included monitoring of therapy (13/57), taking actions related to drug allergy problems (13/57), requesting documentation of an indication for a particular medication (9/57), and making a dosage change (8/57).

Although the data abstractor was blinded with regard to study group, the nature of the intervention did not permit blinding of participating pharmacists (i.e., they received faxed information for some patients but not others). Also, the pharmacists were not explicitly blinded to the study's objectives. It is unclear how this knowledge might have affected the results. It could have resulted in more careful scrutiny of any potential drug problem (bias away from the null) or less scrutiny of these orders (bias towards the null). Kuehl et al note that although the results suggest discriminatory documentation did not play a major role, the possibility cannot be ruled out.

Another potential limitation of this study was the completeness of follow-up. Of the eligible patients from ambulatory care pharmacies, only 50% returned to their pharmacy during the study period. There were no comparisons presented between the ambulatory pharmacy visit group and the loss to follow-up group. This large loss to follow-up could have significantly altered their findings.

Potential for Harm

None of the studies evaluating different hospital-community pharmacy communication processes detailed any adverse events. However, the degree of added workload and effects on current workflow must be taken into account.

Costs and Implementation

The 2 reviewed interventions for improving hospital to community pharmacy information transfer seemed simple and relatively inexpensive.^8,8,13,14,14 Although no formal cost analysis was performed, Dvorak et al described their method (use of a pharmacy-to-pharmacy referral form) as being "labor-intensive." No records were kept of the time necessary to provide the referrals but the authors estimated the time commitment per patient to be 30 minutes.¹³ It is also important to note that complete information transfers occurred for 75% of the subjects in Kuehl's study, indicating that there is still room for improving the process. With improvements in information transfer technology, automated transfer of information from hospital to community pharmacy could have important patient safety benefits without excessively increasing providers' workloads.

Comment

Providing patients with data forms to convey transfer of information between hospital and ambulatory pharmacies has potential for reducing discontinuities resulting from inadequate medication information. Few studies have evaluated the effect of these interventions on patient outcomes, although any improvement in the transfer of this information would likely be well received by ambulatory providers. Future studies are necessary to determine if and how improved pharmacy-to-pharmacy communications reduce preventable adverse drug events and improve patient outcomes. Identifying the most effective and least disruptive forms of inter-pharmacy communication remains an area for further investigation.

Table 42.1.1. Practices to improve transfer of medication information

Study	Study Setting	Intervention	Study Design, Outcomes	Results
Smith, 199714	53 patients (>65 yrs old) discharged to home who were likely to experience difficulties with their medications	Copies of medication doses, indications, side effects, importance of compliance and refill information given to patients at discharge	Level 1, Level 2	Patients taking medication not prescribed at discharge: information card 75%, control 96% (p<0.01)
Kuehl, 19988	156 patients admitted to small mid-western community hospital	Pharmacy-to-pharmacy facsimile transmission of medication regimen at time of admission and discharge from hospital	Level 1, Level 2	Patients with 1 pharmacist interventions in hospital: faxed-summary 47%, control 14% (p<0.001) Patients with 1 pharmacist interventions in community: faxed summary 42%, control 0% (p<0.05)

References

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14. Smith L, McGowan L, Moss-Barclay C, Wheater J, Knass D, Chrystyn H. An investigation of hospital generated pharmaceutical care when patients are discharged home from hospital. Br J Clin Pharmacol 1997;44:163-165.

15. Himmel W, Tabache M, Kochen MM. What happens to long-term medication when general practice patients are referred to hospital? Eur J Clin Pharmacol 1996;50:253-257.

16. Burns JM, Sneddon I, Lovell M, McLean A, Martin BJ. Elderly patients and their medication: a post-discharge follow-up study. Age Ageing 1992;21:178-181.

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18. Parkin D, Henney C, Quirk J, Crooks J. Deviations from prescribed drug treatment after discharge from the hospital. BMJ 1976;2:686-688.

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20. Munday A, Kelly B, Forrester JW, Timoney A, McGovern E. Do general practitioners and community pharmacists want information on the reasons for drug therapy changes implemented by secondary care? Br J Gen Pract 1997;47:563-566.

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