Do electronic discharge summaries contain more complete ...

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http://dx.doi.org/10.12826/18333575.2014.0009.Lehnbom http://dx.doi.org/10.12826/18333575.2014.0009.Lehnbom

Do electronic discharge summaries contain more complete medication information? A retrospective analysis of paper versus electronic discharge summaries

Elin C Lehnbom, Magdalena Z Raban, Scott R Walter, Katrina Richardson and Johanna I Westbrook

AbstractComplete, accurate and timely hospital discharge summaries are important for continuity of care. The aim of this study was to evaluate the effectiveness of an electronic discharge summary system in improving the medication information provided compared to the information in paper discharge summaries. We conducted a retrospective audit of 199 paper and 200 electronic discharge summaries from a 350-bed teaching hospital in Sydney, Australia. The completeness of medication information, and whether medication changes during the admission were explained, were assessed. Further, the likelihood of any incomplete information having an impact on continuity of care was assessed. There were 1352 and 1771 medication orders assessed in paper and electronic discharge summaries, respectively. Of these, 90.9% and 93.4% were complete in paper and electronic discharge summaries, respectively. The dose (OR 25.24, 95%CI: 3.41-186.9) and route (OR 8.65, 95%CI: 3.46-21.59) fields of medication orders, were more likely to be complete in electronic as compared with paper discharge summaries. There was no difference for drug frequency (OR 1.09, 95%CI: 0.77-1.55). There was no significant improvement in the proportion of incomplete medication orders rated as unclear and likely to impede continuity of care in paper compared with electronic discharge summaries (7.3% vs. 6.5%). Of changes to medication regimen, only medication additions were more likely to be explained in the electronic (n=253, 37.2%) compared to paper (n=104, 14.3%) discharge summaries (OR 3.14; 95%CI: 2.20-4.18). In summary, electronic discharge summaries offer some improvements over paper discharge summaries in terms of the quality of medication information documented. However, explanations of changes to medication regimens remained low, despite this being crucial information. Future efforts should focus on including the rationale for changes to medication regimens in discharge summaries.

Keywords (MeSH): Patient Discharge Summaries; Electronic Health Records; Medication Reconciliation; Medication Therapy Management; Patient Care Management; Continuity of Patient Care

IntroductionTransitions from one care setting to another are risk points for medication management (Forster et al. 2003; Forster et al. 2005; Tam et al. 2005; Vira, Colquhoun & Etchells 2006; Easton, Morgan & Williamson 2009). Discharge summaries are used to communicate important information about events during care in hospital. However, discharge summaries are often incomplete, lacking information such as main diagnosis (van Walraven & Weinberg 1995; Bolton et al. 1998; Adhiyama et al. 2000; van Walraven & Demers 2001; Wilson et al. 2001), discharge medica-tions (van Walraven & Weinberg 1995; Bolton et al. 1998; Wilson et al. 2001) and follow-up plans (van Walraven & Weinberg 1995; Wilson et al. 2001; Raval, Marchiori & Arnold 2003), which may negatively affect continuity of care and contribute to adverse events (Kripalani et al. 2007; Witherington, Pirzada & Avery 2008). Adverse events are common among patients

recently discharged from hospital (Forster et al. 2003; Forster et al. 2004) and suboptimal medication management during or immediately after hospitalisa-tion has been identified as a contributing factor in 28% of potentially avoidable readmissions within 30 days after discharge (Feigenbaum et al. 2012).

Doctors in primary health care settings, as well as those working in hospitals, rated comprehensive medication information as the third most important component in a discharge summary, after discharge and admission diagnosis in a Canadian study (van Walraven & Rokosh 1999). Comprehensive medication information, including explanations of any medica-tion changes during hospitalisation, are important to communicate to general practitioners (GPs) to facilitate their counselling of patients and to prevent medication errors after discharge (Karapinar et al. 2010). Despite the importance of an accurate list of medications at discharge, several studies have shown

4 HEALTH INFORMATION MANAGEMENT JOURNAL Vol 43 No 3 2014 ISSN 1833-3583 (PRINT) ISSN 1833-3575 (ONLINE)

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that medication lists in discharge summaries are often incomplete, inaccurate or inadequate (Wilson et al. 2001; McMillan, Allan & Black 2006; Glintborg, Andersen & Black 2007; Perren et al. 2009; Viktil et al. 2012). Many hospitals have introduced electronic systems to improve the information communicated in discharge summaries. A pre-post evaluation of electronic discharge summaries by O’Leary and colleagues (O’Leary et al. 2009) found a significant overall improvement in electronic versus dictated discharge summaries due to better documenta-tion of issues to follow-up, pending test results and information provided to patients and family. However, there was no significant improvement in documentation of discharge medications (O’Leary et al. 2009). Evaluation studies of electronic discharge summaries conducted in Australia have shown mixed results (Alderton & Callen 2007; Callen, Alderton & McIntosh 2008; Callen, McIntosh & Li 2010). One study found that up to 93% of GPs found electronic discharge summaries were an overall improvement on the paper discharge summary in terms of quality of information and its timeliness (Alderton & Callen 2007). However, neither of the studies comparing paper and electronic discharge summaries found a significant difference in the quality of medica-tion documentation (Callen, Alderton & McIntosh 2008; Callen, McIntosh & Li 2010).

This study aimed to assess and compare the quality of medication information in paper and electronic discharge summaries in terms of completeness of information, the potential impact of incomplete information on continuity of care, and whether changes in medication regimens during the admission were adequately explained.

MethodsDischarge summary processesThe study took place in a 350-bed teaching hospital in Sydney, Australia. On admission to hospital, patients’ medications-on-admission (MOA) (Figure 1) are recorded in the hospital’s electronic medication management system (eMMS) by a hospital pharmacist. An eMMS has been implemented across all inpatient wards except the emergency department (ED), and is used to record medication prescriptions and administrations during a patient’s hospital stay. The implementation of eMMS started in 2005 and the roll-out was completed in 2010 (except ED).

Figure 1: A list of medications-on-admission (MOA)

Figure 2: A paper discharge summary

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Figure 3: A current medications at discharge list as displayed in the electronic medication management system (eMMS)

Figure 4: The comparison view of discharge medication and medications on admission

Figure 5: A medication list in an electronic discharge summary

Prior to January 2012, discharge summaries were paper based and produced manually by doctors. Upon discharging a patient, doctors would handwrite discharge summaries using a standardised form with a specific section for medications (Figure 2). As part of the discharge process the eMMS was used to generate a current medications at discharge list (Figure 3) to be taken home by the patient and to be used for medicines supply by the hospital pharmacy. This is undertaken within the eMMS by selecting the current medica-tions prescribed as an inpatient that are to continue at discharge, reviewing the MOA list and re-commencing any relevant medi-cations withheld at admission. Rather than writing discharge medications by hand onto the paper discharge summary, doctors would frequently print out the current medications at discharge list from the eMMS and attach it to the paper discharge summary.

A new ‘medical (electronic) discharge summary and discharge medications protocol’ was developed and it was introduced in January 2012, requiring all discharge summaries to be created electronically instead of by hand. The implementation was timed to coincide with the arrival of new medical officers (interns and registrars) who were taught the discharge process during their orienta-tion. In addition, demonstration sessions were held for residents and registrars. The new discharge process involves the doctor accessing the electronic discharge summary within the electronic medical record and typing information into sections on clinical activity, results, risks and assessments and follow-up. To complete the medicines section, the current medications at discharge list is imported from the eMMS to populate the discharge medicines section of the electronic discharge summary (Figure 4). A final prompt of the comparison view of the discharge medications and MOA (Figure 5) is provided. Any changes required to a medi-cation in the electronic discharge summary can only be made by editing the current medications at discharge list in the eMMS and re-populating the discharge summary. If there have been any changes to a patient’s medication regimen during the admission, these changes should be explained in the


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free text ‘Details of Medication Change’ field in the electronic discharge summary (Figure 5) to facilitate continuity of care. Information such as start date for antibiotics, intended length of treatment, warfarin doses and follow-up requirements should be docu-mented either in the free text field or in the notes about current medications at discharge. The elec-tronic discharge summary is retained in the hospital’s electronic medical record, uploaded to a patient’s personally controlled electronic health record (if they have opted-in) and sent electronically to the patient’s general practitioner if they have the infrastructure to receive and send electronic communication. Discharge summaries are printed-out and faxed or posted to all other general practitioners. The new discharge summary policy adheres to the Australian Commission on Safety and Quality in HealthCare National Safety and Quality Health Service Standard for continuity of medication management (Standard 4.12) (Salemi & Singleton 2007).

Study design and sampleWe conducted a retrospective audit of discharge summaries at the hospital to determine whether the implementation of the new electronic discharge summary improved medication information.

Discharge summaries of patients discharged in February 2011 (paper discharge summaries completed by hand, frequently with an eMMS printout of current medications at discharge list) and in February 2012 (electronic discharge summaries with discharge medications populated from the current medications at discharge list within the eMMS) were reviewed. We determined the sample size required to detect a 10% difference in completeness or adequacy (assuming 80% completeness for paper discharge summaries) with 80% power, and significance at 5%, a sample size of 200 paper and 200 electronic discharge summaries was required. Patients discharged alive and for whom a MOA list was available were eligible for inclusion.

Data collectionTo assess completeness of discharge medication orders and whether changes in medication regimens during the admission were adequately explained in discharge summaries, research pharmacists extracted medica-tion information including the medication name, dose, route and frequency (including length of treatment for anti-infectives), from the MOA list and discharge summary.

Medication orders in the discharge summaries were examined to assess whether medication dose, route and frequency was recorded. If any of these fields were missing, the medication order was considered incom-

plete. Each medication order could have more than one incomplete field. Orders for anti-infectives (e.g. antibiotics, antifungals, antivirals) were required to explicitly state the length of treatment, including the length of treatment remaining; otherwise the medica-tion order was considered incomplete.

For each medication order with one or more incom-plete fields, the impact of missing information was evaluated based on the extent to which it may impede the GP from ensuring continuity of care. In other words, would the GP be able to interpret the order and continue treatment, or would the missing information prohibit the GP from understanding what was required to continue treatment requiring them to seek further information.

Changes to a patient’s medication regimen during the hospital stay were recorded by comparing the MOA list to the medication list in the discharge summary. Changes to the medication were recorded either as: i) additions when medication was in the discharge medication list, but not the MOA list; ii) discontinu-ations when medications were in the MOA list, but not the discharge summary medication list; iii) dose changes when the total daily dose of a medicine was changed, or; iv) frequency changes when the dose frequency changed irrespective of whether the total daily dose changed. For each recorded change, the discharge summary was assessed to establish whether the reason for the change had been documented. This was done by examining the recorded notes on medica-tions in the discharge summary. If it was stated in the discharge summary that a medication, for example had been ceased, we considered this ‘explained’ as the GP would know that the medication had been ceased intentionally and not unintentionally omitted from the discharge summary.

The study was approved by the study hospital’s Human Research Ethics Committee.

Statistical analysisCharacteristics of sampled patients and records were compared between the paper and electronic discharge summaries to assess the potential for confounding in the main analysis. The distributions of age between the samples from paper and electronic discharge summaries were compared with a Kolmogorov-Smirnov test. This test was also used to compare length of stay (LOS) and number of medication orders per discharge summary. The difference between the proportion of females, in paper and electronic discharge summaries was assessed by a chi-square test.

Changes in the completeness of dose, frequency (including length of treatment, if applicable) and route of medication between the two periods were assessed


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by calculating odds ratios (ORs). Since there were generally multiple medications per record, the ORs were calculated with logistic regression using a generalised estimating equations (GEE) approach to account for correlation between records belonging to the same patient. Changes in the number of incomplete fields between paper and electronic discharge summaries were assessed with multinomial logistic regression where the outcome was categorised as all fields complete, one field incomplete or two or more fields incomplete.

The two categories related to importance meant that changes in importance could be assessed by the GEE logistic regression approach described above among discharge summaries with at least one incomplete field. Where medi-cations were discontinued, added or changed, differences in the provision of an explana-tion between paper and electronic discharge summaries was also assessed by same GEE logistic approach for each type of medication modification.

ResultsA total of 199 patient records were reviewed to assess the quality of paper discharge summaries. Of these, 37 were excluded from further analysis due to missing information (n=36) or the medical record not being available (n=1). A total of 200 patient records were reviewed to assess the quality of electronic discharge summaries. Of these, 23 were excluded due to missing informa-tion. Of the sampled patients, 36 (18.1%) and 23 (11.5%), had no paper or electronic discharge summaries available, respectively.

The final sample included 162 paper and 177 electronic discharge summaries. As shown in Table 1 there were no significant differences in patients’ age, sex and length of stay for patients with paper and electronic discharge summaries, respectively. Patients who were discharged with an electronic discharge summary had signifi-cantly more medications on admission as well as on discharge compared to patients discharged with paper discharge summaries. When adjusted for the number of medications on arrival, the number at discharge was not significantly different between paper and electronic discharge summaries (p=0.81).

Table 1: Characteristics of sampled patients and discharge summaries

PAPER ELECTRONIC TEST DISCHARGE DISCHARGE FOR CHARACTERISTIC SUMMARIES SUMMARIES DIFFERENCEPatient characteristicsTotal sample 162 177 -Age, median year (IQR) 72.2 (57.5-81.4) 69.3 (57.8-82.4) p=0.651

Female, n (%) 79 (49) 83 (47) p=1.002

Length of stay,

median days (IQR) 8.0 (5.0-17.0) 7.0 (5.0-13.0) p=0.151

Discharge summary characteristicsTotal medication orders, n 1352 1771 -Medication orders per discharge summary, mean 8.7 10.1 0.041

Regular medications, n (%) 1590 (91.3) 1235 (89.8) 0.142

1 Two-sample Kolmogorov-Smirnov test2 Chi-square test

Completeness of medication ordersMedication orders were assessed with regard to the dose, route and frequency field being complete. For anti-infec-tives, the length of treatment had to be documented for the frequency field to be considered complete. There were 1352 medication orders assessed for completeness in paper discharge summaries. Of these, 1229 (90.9%) medication orders had all fields completed, 104 (7.7%) medication orders had one incomplete field and the remaining 19 (1.4%) had more than one incomplete field. A total of 1771 medication orders in electronic discharge summaries were assessed, of which 1654 (93.4%) had all fields completed whereas 111 (6.3%) medication orders had one incomplete field. All but one medication order with one incomplete field were anti-infectives lacking information about the intended length of treatment. The remaining six (0.3%) medication orders in electronic discharge summaries had more than one incomplete field. This was due to an error in the electronic discharge summary program that was not identified in testing but was discovered early after roll-out and corrected immediately.

The odds of medication orders in electronic discharge summaries having one field incomplete was approximately 77% lower than in paper discharge summaries (OR 0.23, 95% CI: 0.09-0.59) while the odds of two or more incom-plete fields was 21% lower (OR 0.79, 95% CI: 0.60-1.05). Table 2 shows the proportion of medication orders with the dose, route or frequency field complete in paper and electronic discharge summaries respectively, and the results of the logistic regression models that assessed this improve-ment. The odds of dose and route being complete increased significantly in electronic compared to paper discharge summaries.


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Table 2: Results of logistic regression comparing change in completeness of the dose, route and frequency fields in paper and electronic discharge summaries

COMPLETE RECORDS n (%) ELECTRONIC vs. PAPER

COMPLETENESSPAPER n=1352

ELECTRONIC n=1771 ODDS RATIO* 95%CI p-VALUE

Dose 1333 (98.6) 1770 (99.9) 25.24 3.41, 186.9 0.002

Frequency 1253 (92.7) 1655 (93.5) 1.09 0.77, 1.55 0.64

Route 1310 (96.9) 1764 (99.6) 8.65 3.46, 21.59 <.0001

Overall~ 1229 (90.9) 1654 (93.4) 1.38 0.96, 1.98 0.08

* OR for electronic discharge summaries compared to reference category of paper discharge summaries ~ Complete vs. any incomplete field (dose, frequency or route)

Table 3: Results of logistic regression comparing the proportion of medication discontinuations, additions, dose changes and frequency changes explained in paper and electronic discharge summaries

TYPE OF MEDICATION CHANGE

DISCHARGE SUMMARY

NUMBER OF CHANGES EXPLAINED

(% OF TOTAL)ODDS OF BEING

EXPLAINED (95% CI) p-VALUE

Discontinuation Paper 38 (12.4) 1.000.82

Electronic 43 (14.9) 1.07 (0.58-1.99)

Addition Paper 104 (14.3) 1.00<.0001

Electronic 253 (37.2) 3.14 (2.20-4.48)

Dose change Paper 27 (19.9) 1.000.14

Electronic 48 (28.1) 1.58 (0.87-2.88)

Frequency change Paper 10 (14.7) 1.000.89

Electronic 12 (13.6) 1.08 (0.39-3.00)

Documented reasons for medication changesThere was a total of 1236 medication changes iden-tified in paper discharge summaries. Of these, 306 (24.8%) were discontinuations, 726 (58.7%) were additions, 136 (11.0%) were dose changes and 68 (5.5%) were frequency changes. In electronic discharge summaries, a total of 1237 medication changes were identified. These included 288 (23.3%) discontinuations, 690 (55.8%) additions, 171 (13.8%) dose changes and 88 (7.1%) frequency changes.

The proportion of medication changes that were explained in the discharge summary are presented in Table 3, which also shows the results of the logistic regression models assessing any differences. From these results, medications added during the hospital stay were three times more likely to be explained in the electronic discharge summaries compared with new medications added during admission on the paper discharge summaries. Medication discontinu-ations, dose changes, or frequency changes were no more likely to be explained on electronic discharge summaries than on paper summaries.

Potential impact of missing information on continuity of careThere were 123 (9.1%) and 117 (6.6%) medication orders with at least one incomplete field in paper and electronic discharge summaries, respectively. Of the incomplete medication orders, 99 (80.5%) in the paper and 116 (99.1%) in the electronic discharge summaries were rated as ‘unclear’, indicating that the missing information would prohibit the GP from understanding what was required to continue treatment requiring them to seek further information. The majority of unclear orders were for anti-infectives (77.8% in paper and 94.8% in electronic discharge summaries, respectively) as doctors did not document the length of treatment. A significantly higher propor-tion of anti-infective orders in electronic discharge summaries had the length of treatment documented (e.g. five days) compared to paper discharge summaries (43.6% vs. 13.0%, p<0.001), but failed to mention whether this was the total length of treatment or the remaining days of treatment, making it unclear when anti-infective treatment should cease.


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DiscussionElectronic discharge summaries were found to have significant improvements in the documentation of dose and route information, as well as the explanations for medications added to medication regimens compared with paper discharge summaries. However, other changes to patients’ medication regimens, such as dose changes, frequency changes, or cessation of a medica-tion, were not explained more frequently on electronic discharge summaries. Furthermore, we found no significant difference in the proportion of discharge summaries with missing information likely to impact on continuity of care.

Previous research has shown no significant improvements in the quality of medication informa-tion in electronic compared with paper discharge summaries (van Walraven et al. 1999; Callen, Alderton & McIntosh 2008; Callen, McIntosh & Li 2010). However, in those studies, doctors had to manually type in all discharge medications in the electronic discharge summary. At our study site, the discharge medications were populated from the current medica-tion at discharge list in the eMMS. Even prior to the implementation of the electronic discharge summary, doctors would frequently print a copy of current medications at discharge from the eMMS and attach it to the discharge summary, rather than manually transcribe this information. This would explain why over 90% of all medication orders in paper discharge summaries were complete. This also suggests that beyond the paper-based or electronic format of discharge summaries, the specific nature of individual systems has a substantial influence on completeness and accuracy of information.

A high number of medication changes were iden-tified, with over 1200 changes in both paper and electronic discharge summaries. This is similar to what has previously been reported (Himmel et al. 2004; Grimmsmann, Schwabe & Himmel 2007; Viktil et al. 2012; Harris et al. 2013). When the electronic discharge summary system was designed, a free-text box was included in the electronic discharge summary to facilitate the inclusion of explanations for medica-tion changes, to improve communication to GPs and to ensure continued appropriate medication manage-ment post-discharge (Ng et al. 2013). However, our results suggest that this strategy has only been partially successful, as less than 40% of medica-tion changes are explained in electronic discharge summaries. Documenting explanations of medication changes in discharge summaries is important and the New South Wales (NSW) Therapeutic Advisory Group’s (TAG) has included this as an indicator for the quality use of medicines in hospitals (NSW

Therapeutic Advisory Group 2007). At baseline of a NSW TAG quality improvement project including 16 hospitals in NSW and the Australian Capital Territory, 39.4% of discharge summaries requiring a docu-mented explanation for medication changes had an explanation (Oliver & Campbell 2011). Following a multi-faceted intervention consisting of education to junior medical doctors (JMOs), workshops for JMOs and the provision of ‘top-tips’ lanyard cards, the proportion of discharge summaries with documented changes increased to 54.4%. It would appear that this improvement has not been sustained over time as we found that less than 40% of medication changes were explained in both paper and electronic discharge summaries. This low level of documented explanations can jeopardise continuity of care when patients transi-tion from hospital as GPs will not know whether the change was intentional (clinically justified changes) or unintentional (unexplained change without clinical justification). Unintentional changes to medication regimes are common, affecting 22% to 72% of patients at admission and 25% to 71% of patients at discharge (Lehnbom et al. 2012).

It is known that GPs are concerned about the lack of explicitly stated rationale for changing MOA in discharge summaries (Karapinar et al. 2010), and that poor communication can contribute to prevent-able adverse events and hospital readmissions (Witherington, Pirzada et al. 2008). A retrospective analysis of discharge summaries for 108 patients aged 75 years and over in a UK teaching hospital who were readmitted within 28 days of discharge found that 67 (62%) patients had no discharge summary available and that 41 (38%) patients were readmitted due to medication-related problems, of which 25 (61%) were considered to be preventable (Witherington, Pirzada & Avery 2008).

Doctors at our study hospital are required to specify the brand of warfarin, type of insulin and length of treatment for anti-infectives in electronic discharge summaries, just as they were in paper discharge summaries. This is recorded in free-text fields. The overwhelming majority of unclear medication orders, requiring GPs to seek clarification, were for anti-infectives. Although a significantly higher proportion of doctors included the number of days of treatment in electronic discharge summaries, they failed to mention whether this was the total number of days that treatment was required (and when the treatment had started) or whether this was the remaining days of anti-infective treatment. Appropriate use of anti-infec-tives is necessary to prevent antimicrobial resistance and the length of antibiotic treatment should be clearly communicated to GPs. A system re-design might be


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needed where the length of treatment for anti-infec-tives is a mandatory field, to remind doctors to include this pertinent information in discharge summaries.

There were limitations to this study. First, we treated the MOA list as the gold standard and did not assess the appropriateness of medication therapy in relation to current chronic and acute conditions. However, it is possible that the MOAs on occasion were incorrect and that ‘changes’ in the medication regimen were in fact not a change and should therefore not be ‘explained’ in the discharge summary. It has been well demonstrated that pharmacists take more accurate medication histories than doctors and it is unlikely that a significant number of MOAs would be incorrect (Gleason et al. 2004; Cornish et al. 2005; Lessard, DeYoung & Vazzana 2006; Vira, Colquhoun & Etchells 2006; Kwan et al. 2007; Pippins, Gandhi et al. 2008; Gleason et al. 2010; Steurbaut et al. 2010; Knez et al. 2011). Second, we assessed the quality of medica-tion orders in the electronic discharge summaries one month after the new system had been implemented, allowing little time for new doctors to become familiar with the process. Current doctors, including registrars and residents, were given demonstrations of the new process. However, it is almost always the interns who create the electronic discharge summaries and they had only been in their job for less than a month.

Conclusion In summary, our data show that electronic discharge summaries offer some improvements over paper discharge summaries in terms of the quality of medica-tion information documented. However, information missing in discharge summaries remains a problem. To further improve the quality of electronic discharge summaries, future efforts should be directed at improving continuity of care by recording the length of treatment for anti-infectives and documenting the rationale for changing medications during hospitali-sation. Continuous education of doctors about why documenting explanations for changes are important, as well as incorporation of electronic medication reconciliation functionality in the eMMS, may improve the quality of medication information in electronic discharge summaries further. An electronically recon-ciled list of discharge medications should include each medications status at discharge; that is, continued, new, changed or ceased, to facilitate continuity of care.

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Elin C Lehnbom, BPharmSc, MPharmSc, MClinPharm, PhDPostdoctoral Research FellowCentre for Health Systems and Safety ResearchAustralian Institute of Health InnovationUNSW MedicineLevel 1, AGSM Building (G27)The University of New South WalesUNSW Sydney NSW 2052 AustraliaTelephone: +61 2 9385 1465Fax: +61 2 9385 8280email: [email protected]

Magdalena Z Raban, BPharm, MIPH (Honours)Postdoctoral Research FellowCentre for Health Systems and Safety ResearchAustralian Institute of Health InnovationThe University of New South Wales, Sydney NSW 2052email: [email protected]

Scott R Walter, BA, GradDipEd, MBiostatBiostatisticianCentre for Health Systems and Safety ResearchAustralian Institute of Health InnovationThe University of New South Wales, Sydney NSW 2052email: [email protected]

Katrina Richardson, BPharm, DipHospPharmPharmacist – eMedicines ManagementIT Service Centre, St Vincent’s Health Australia (NSW)Rushcutters Bay NSW 2011email: [email protected]

Johanna I Westbrook, BAppSc, GradDipAppEpid, MHA, PhDProfessor and DirectorCentre for Health Systems and Safety ResearchAustralian Institute of Health InnovationThe University of New South Wales, Sydney NSW 2052 email: [email protected]


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