Standardized Documentation of Drug Recommendations in Discharge Letters

P. Knaup; J. Pilz; J. Kaltschmidt; S. Ludt; J. Szecsenyi; W. E. Haefeli

doi:10.1055/s-0038-1634084

Methods of Information in Medicine, Table of Contents

Methods Inf Med 2006; 45(04): 336-342
DOI: 10.1055/s-0038-1634084

Original Article

Schattauer GmbH

Standardized Documentation of Drug Recommendations in Discharge Letters

A Contribution to Quality Management in Cooperative Care

P. Knaup

¹Institute for Medical Biometry and Informatics, Department of Medical Informatics, University of Heidelberg, Heidelberg, Germany

,

J. Pilz

²Center for Information Technology and Biomedical Engineering, Heidelberg University Hospital, Heidelberg, Germany

,

J. Kaltschmidt

³Department of Internal Medicine VI, Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Heidelberg, Germany

,

S. Ludt

⁴Department of General Practice and Health Services Research, Heidelberg University Hospital, Heidelberg, Germany

,

J. Szecsenyi

⁴Department of General Practice and Health Services Research, Heidelberg University Hospital, Heidelberg, Germany

,

W. E. Haefeli

³Department of Internal Medicine VI, Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Heidelberg, Germany

› Author Affiliations

Abstract

Summary

Objectives: To analyze the necessity and potential usefulness of a computerized physician order entry (CPOE) system in supporting the writing of pharmacotherapeutic recommendations in discharge letters.

Methods: Systematic analysis of drug recommendations in discharge letters of a hospital providing tertiary care, structured interviews with in-hospital prescribers, and focus groups with general practitioners who admit patients to this hospital.

Results: We analyzed 1800 randomly selected discharge letters, 1205 of which contained pharmaco-therapeutic recommendations. The frequencies, structure, and quality of these recommendations varied considerably between departments. Nearly 16% of the recommendations contained both proprietary (brand) and non-proprietary names (active ingredient). Interviewed clinicians expressed interest in CPOE systems that check for contraindications and interactions between drugs, suggest cheaper products, and automatically insert active ingredients when omitted. The focus group sessions confirmed that the pharmacotherapeutic recommendations in current discharge letters do not effectively support daily clinical practice.

Conclusions: Documenting active ingredients as well as brand names in drug therapy recommendations is currently not part of clinical practice. Computerized decision support can help to optimise the structure and communication of therapeutic information across interfaces and can be a quality factor with considerable influence on process quality, outcome quality, and costs of cooperative patient care.

Keywords

Medical informatics - decision support - drug information services - computerized medical records systems - discharge letters

Full Text

References

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