Impact of an Electronic Medical Record System on Emergency Department Discharge Instructions for Patients With Hypertension

BACKGROUND: Uncontrolled hypertension is associated with significant patient morbidity and health care costs. Many patients evaluated in the emergency department (ED) do not regularly consult health care providers and have socioeconomic barriers to receiving primary care. Hypertension screening and counseling has been advocated as a routine part of ED care. Previous work has shown poor referral rates and education for ED patients presenting with elevated blood pressure (BP). We sought to determine whether implementation of an electronic medical record (EMR) would improve these rates. METHODS: We performed a retrospective study conducted in 2 urban academic EDs, comparing pre-EMR (handwritten discharge) to post-EMR discharge instructions for patient referral for BP management and education on lifestyle modification. Medical records of patients aged ≥ 18 years with a systolic BP rate ≥ 140 or diastolic BP rate ≥ 90 mm Hg were included. Patient data included demographics, BP rate, presenting symptoms, and administration of antihypertensive medication while in the ED. Discharge instructions were reviewed for a directed referral for outpatient BP management, prescriptions for antihypertensive medication, and lifestyle modifications. RESULTS: Of the 1000 medical records reviewed, 500 were pre- and 500 were post-EMR, including a total of 389 patients who had persistently elevated BP on reassessment. At discharge, acknowledgment of elevated BP occurred in 45% of patients in the pre-EMR phase and only 26% in the post-EMR phase (P < 0.0001). Provision of all 5 lifestyle modifications occurred in none of the pre-EMR patients and in 15% of the post-EMR patients (P < 0.0001). Factors associated with a directed referral for the patient included increasing BP rate, pharmacologic treatment of hypertension in the ED, or provision of a prescription for an antihypertensive medication at discharge. The post-EMR phase was negatively associated with a directed referral for outpatient BP management. CONCLUSION: Overall, the initiation of EMR led to a decrease in outpatient referrals and acknowledgment of elevated BP rates in discharge instructions. The provision of more complete lifestyle modifications improved in the post-EMR phase.