The transition between acute care and community care represents one of the most vulnerable periods in health care delivery, particularly as the complexity of inpatient populations increases. The vulnerability of this period has been attributed to three main factors. First, changes to patients’ medication regimens during hospitalization are numerous, yet failure to reconcile discrepancies between admission and discharge is frequent . Second, the patient/family is required to take over care responsibilities at discharge and must often personally relay important information to the primary care physician
. This can be particularly challenging if the TOC information is poorly communicated, presented too rapidly, if instructions are verbal only, or if the patient struggles with health literacy
[1–3]. Finally, crucial information is often not transferred between acute care physicians and community physicians .
Information about the hospitalization (such as medication changes, patient diagnoses, interventions, diagnostic findings, and necessary follow-up) is commonly transferred to the community care physician through a summary of the patient’s acute care stay that is faxed or mailed. Deficits with respect to timeliness and/or complete failure to transmit are widespread
[1, 4]. At the first post-discharge appointment, this summary is unavailable to the community care physicians up to 75% of the time
[1, 5–7]. This negatively impacts the continuity of care provided to many patients
[1, 7]. When summaries are received, inconsistent content and inaccuracies are common
[1, 4]. Acute care physicians, whether medical or surgical, often neglect to include diagnostic findings, treatment/hospital course, discharge medications, pending tests results, and whether the patient and family received counseling
Computer-enabled TOC communications have potential to avert such problems. These communication tools, operating on electronic health record or web-based platforms can provide an immediate link between acute care and primary care physicians, and interfaces can be designed to ensure consistent information transfer. In addition, physicians in both settings have expressed preference for electronic discharge documents over hand written/dictated summaries with respect to clarity, comprehensiveness, and positive impacts on continuity of care
Kripalani and collegues
 published a systematic review examining the prevalence of discharge communication deficits and looked broadly at all types of interventions that target those deficits. Very few of the interventions reviewed by Kripilani et al. involved significant contributions from electronic medical record data to construct the discharge summary, and none used the internet to transmit information. However, the publications years considered spanned 1977 to 2005.
In recent years, original studies
[9–20] have emerged assessing the efficacy of computer enabled TOC communication compared to traditional summaries. In the context of a rapidly growing literature on electronic medical records and telehealth interventions, our team systematically reviewed the literature and identified 12 controlled studies assessing the efficacy of computer-enabled TOC communication tools
. The findings in the literature globally indicate that compared to traditional TOC summaries, computer-enabled TOC communications of various types appear promising, particularly with respect to improving timeliness of discharge summary delivery, and satisfaction among physicians and patients/families. There are also some positive impacts on overall patient management and continuity of care. However, only four of these studies reported the effects of such tools on the notable clinical endpoints of hospital readmission, post-discharge mortality, and adverse events
, and in doing so, none had sufficient statistical power to assess these endpoints. As a result, only one study
 in our review demonstrated a reduction in readmission to hospital within 12 months due to the implementation of a web-based TOC communication platform. Our published systematic review identified a need for a well-designed, sufficiently powered study evaluating relevant clinical outcomes associated with an electronically based TOC tool. Given the growing demand and monetary investments associated with these tools, such a study would have implications on a global scale.
The Ward of the 21st century (W21C) initiative at the University of Calgary, in Alberta, Canada is an interdisciplinary research and innovation program focused on health system safety and quality (see
http://www.w21c.org). The W21C team, working collaboratively with Alberta Health Services, the provincial health authority, undertook iterative consultation with multiple clinical stakeholders as well as patients and family, and developed an electronic communication TOC tool. The tool was built off of the already functioning electronic platform called Sunrise Clinical Manager (SCM) that physicians use to manage inpatient orders and to access patient medical records, diagnostic imaging and laboratory results. An initial pilot test of the tool involving 100 actual patient transfers of care summaries from an adult internal medicine ward to the community was performed on the Medical Teaching Unit (MTU) affiliated with the W21C. This pilot study involved detailed assessments of usability issues, provider and patient satisfaction, completeness and timeliness of the discharge summaries. The information generated from this pilot led to the refinement of the tool to the extent that it satisfied the needs of acute care physicians, primary care physicians, and patients. The refined tool will be made available for use by physicians and medical students on the MTU and used for this study.
On this backdrop of iterative tool development and pilot work, a protocol for a randomized controlled trial to more definitely test the efficacy of the TOC communication tool was developed. With funding from the Canadian Institutes of Health Research, the RCT will assess the efficacy of the TOC communication tool for reducing the endpoint of death or hospital readmission at 3 months. Secondary objectives are: i) to assess the impact of the tool on the occurrence of post-discharge adverse events and adverse drug events; ii) to evaluate the cost-effectiveness of the tool.