2024 Volume 144 Issue 7 Pages 741-748
In 2020, the Japan Community Healthcare Organization (JCHO) Hoshigaoka Medical Center started providing information to community pharmacies about patients admitted to the acute care ward using discharge medication summaries (the summaries). We conducted an online self-recording survey of 149 pharmacies belonging to the Hirakata City Pharmacists Association to clarify the usability of the summaries, any related issues, and to further discuss future collaboration between hospitals and pharmacies. 46 pharmacies have received the summaries in the past, of which 44 pharmacies answered that they have utilized the summaries with patient instruction and prescription queries of doctors. However, two pharmacies responded they did not utilize the summaries, and the reasons were (a) the information was not timely and (b) patients whom the discharge medical summary was sent for did not come to the pharmacy. There were some requests regarding the summaries such as, “I would like to know what kind of information hospital pharmacists want from community pharmacists.” Preference for sharing information other than the summaries (e.g., online tools) with hospital pharmacists was related to whether the pharmacy was providing home pharmaceutical visit services. The survey revealed that, in addition to the usability of the summaries, there are also events that prevent them from being utilized. Some of the challenges include the timing of sending the summaries, the accurate identification of the family pharmacy and the communication of follow-up after discharge from hospital. Collaborating with pharmacies providing home pharmaceutical visit services would be beneficial in creating new system of bidirectional information sharing.
Patients admitted to acute care hospitals are started on medication for new treatment and to prevent recurrences of diseases. Medications administered prior to hospitalization are also reviewed.
Most of these patients need continuous medication after they are discharged from the acute care hospitals to ensure seamless treatment even if they change their medical care providers, such as if they transition to outpatient clinics at another clinic.
In 2015, Ministry of Health, Labour and Welfare (MHLW) published the “Pharmacy Vision for Patients,” which indicated “Strengthen cooperation with medical institutions such as home doctors” as one of the functions of the family pharmacies.1)
With regard to collaboration between hospitals and pharmacies, “The Tracing report (Medication Information Forms)” is in operation, in which the community pharmacists provide feedback to the hospital’s physicians and pharmacists on information obtained from the patient, such as adherences and changes in the patient’s physical condition, including side effects, during taking the medication, and is allowed to calculate the fee for providing medication information in the dispensing fees. Furthermore, in 2020, an “additional fee for drug information linkage at time of discharge” was introduced to support pharmacies performing continuous pharmaceutical management and evaluate the information provided by medical institutes to community pharmacies. This fee is calculated in addition to traditional medication information provision fees at discharge in case hospital pharmacists provide written patient information during hospitalization when prescriptions are changed or discontinued.
Based on this background, in 2020, JCHO Hoshigaoka Medical Center started providing information to family pharmacies about patients admitted to the acute care ward and whose prescriptions were changed or discontinued compared to before admission using “the discharge summaries about medication (the summaries).” We formatted the summary based on “Medication Management Summary (Revised edition)” published by the Japanese Society of Hospital Pharmacists. A feature of our summary is that it is designed to provide a detailed overview of prescription changes, with the aim that “medication reconciliation” carried out during hospitalization is continuously managed by the family pharmacies after discharge (Fig. 1). Since then, there have been several reports on patient information summaries provided by hospital pharmacists to community pharmacists upon patient discharge. These reports assessed the usability of the summaries as their receipt triggered prescription inquiries by the community pharmacies, which led to a change in prescribing, increased efficiency in obtaining patient information, and improved medication instructions.2,3) Ishihara et al. reported the usability of patients’ information, which included drug changes and the reason for the changes.3) While these reports indicated cases in which the summaries were used effectively, they did not report cases wherein they were not utilized and the reasons for it. The current situation is that the format of the summary form differs from facility to facility, and the method of providing it varies from facility to facility, such as “hand-delivered to the patient” or “sent by fax.4)” Therefore, the utilization of and problems associated with the summary statements may differ depending on the method of operation. In these backgrounds, it is essential to research the utilization of the summaries in own institution and to find out the issues of them from the reasons why it was not utilized and the requests from community pharmacists in order to achieve seamless medication therapy for patients.
For the hospital pharmacists to know whether the “medication reconciliation” performed during the hospitalization was appropriate and provided the necessary information, the community pharmacists are required to provide information to the hospital pharmacists about the patient’s condition and instruction after discharge. The use of return of the summaries as a method of feedback from community pharmacists has been reported, but the low rate of returns has also been noted.4,5) In the future, it is necessary to know what systems are feasible to deepen the collaboration between hospital and community pharmacists.
This study aimed to clarify the usability and the background of events in cases for which the discharge medication summaries were not utilized in community pharmacies and to explore further the collaboration between community and hospital pharmacies.
The format of the summary is shown in Fig. 1. “Summary of changes in prescriptions and other details” on the summary includes a field for describing the name of the drug that led to the change or discontinuation, the reason for the change or discontinuation, and the condition of the patient after the change. “Reasons for change or discontinuation” included five items (i.e., (1) Duplication of the same component drug, (2) Duplication of drugs with the same effect, (3) Drugs are not reviewed according to symptoms and medical tests, (4) Contains potentially inappropriate drugs, (5) To improve adherence, and (6) Additional prescriptions for disease on admission) to make it easier to understand why medication reconciliations was made. When considered necessary by the pharmacists in charge of in-patient care, each item includes details such as clinical laboratory test results.
After the hospital pharmacist prepares the summaries on the electronic medical record containing patient information up to the date of discharge, the summary is faxed to the family pharmacies from the Community Relations Office the day after the discharge date.
Self-recorded Survey on the Summaries to Community Pharmacists
We compared the relation between the “characteristics of each pharmacy” and “willingness to share patient information with hospital pharmacists.” Based on the responses to Q16, pharmacies were classified as “willing” and “unwilling” to share patient information with hospital pharmacists. Those who responded, “I would like to” were considered “willing,” while those who responded “I cannot say” or “I do not want to” were considered “unwilling.” We analyzed the relationship between these groups and the characteristics of each pharmacy (Q3 “Providing home pharmaceutical visit services or not,” Q4 “Having family pharmacists or not,” and Q5 “Performing health support function or not”) by using Fisher’s direct probability test.
This study was approved by the JCHO Hoshigaoka Medical Center Clinical Research Review Committee (approval number 2237).
The response rate for the questionnaire was 33.6% (50 /149 pharmacists).
Characteristics of Each Pharmacy (Q2–Q5)The median number of full-time pharmacists in these pharmacies that responded to the survey was 2 [range: 2–3]. While 43 pharmacies (86%) conducted home pharmaceutical visit services, 41 facilities (82%) had family pharmacists, and 5 facilities (10%) were health support pharmacies.
Whether Summaries Were Received in the Past (Q6)Forty-six pharmacies (92%) responded they had received summaries in the past.
Utilization of the Summaries at Daily Work (Q7–Q9)Forty-four pharmacies responded they had utilized the summaries, with “patient instruction” being the most common use (31 including 2 free answer). (Table 1). Two pharmacies responded they did not utilize the summaries, and the reasons were (a) the information was not timely and (b) patients whom the discharge medical summary was sent for did not come to the pharmacy.
| 1. Patient instruction | 29 |
| 2. Prescription queries | 5 |
| 3. Safety evaluation of prescription | 3 |
| 4. Other (Free Answer) | |
| Understanding prescription changes before and after hospitalization | 1 |
| Comparing with the prescription before hospitalization | 1 |
| Patient instruction and Confirming drugs during administration | 1 |
| Providing information to physicians | 1 |
| Sharing information with physicians and Patient instruction | 1 |
| Collaboration with home-visiting nurses | 1 |
| 5. Non-response | 1 |
To the question, “Have you stored the summaries after they were sent to you?” 39 pharmacies responded “Yes,” and five responded “No.” Of the 39 pharmacies that stored the summaries, 28 used paper-based storage methods, and 11 posted or downloaded the summaries to the patient records.
Usability of the Summaries and the Reasons (Q12, Q13)Forty-six pharmacies that had received the summaries in the past in Q6 responded to regarding the usefulness of the summaries. While 29 found them useful, 17 found them rather useful. None of the pharmacies responded that the summaries were useless. The 41 responses related to the reasons why they were useful (Q13-1) were organized into seven categories, and most of them were about information on patients during hospitalization. While 23 selected the category “I could recognize medication therapy during hospitalization,” 19 chose “I could know the background of hospitalization (disease name, etc.)” (Table 2).
| 1. I could follow the therapy (medication) during hospitalization. | 23 |
| 2. I could know the background of hospitalization (disease name, etc.). | 19 |
| 3. The discharge medication summaries led to improved quality of drug administration guidance. | 10 |
| 4. I could compare the discharge and outpatient prescriptions. | 8 |
| 5. I could get accurate information about treatment during hospitalization. | 6 |
| 6. The discharge medication summaries were useful for sharing patient information with home- visiting nurses. | 1 |
| 7. I could secure a stock of the newly started drugs. | 1 |
The numbers indicate the number of comments that fit into the category.
Based on the responses, the most useful information (Q13-2) was “Drugs started during hospitalization and reasons for this” (n=25), followed by “Drugs discontinued during hospitalization and reasons for this” (n=13), “the disease that led to hospitalization (n=5), adherence to medication” (n=2), and “Drug changes during hospitalization (Other, free description)” (n=1) (Fig. 3).
The pie chart shows the responses to Q13-2. The other included one case of drug changes during hospitalization.
Summary requests asked for information related to the disease that led to hospitalization, changes in Activities of Daily Living (ADL) during hospitalization, clinical test data, dispensing methods, securing inventory of newly started drugs, and the status of nursing care certification. Additionally, there were some requests such as, “I would like to know what kind of information hospital pharmacists want from community pharmacists.” and “It would be helpful if you could send them as soon as possible” (Table 3).
| · I would like to know what kind of information hospital pharmacists want from community pharmacists. |
| · I would like to know the name of the disease that led to hospitalization, the flow of drug change, and the reason for drug change. |
| · If the diagnosis and the reason for hospitalization are in the discharge medication summaries, appropriate use of drugs would be possible, and briefing the patient about the medications becomes easy. |
| · Including the changes in ADL and laboratory results during hospitalization would help in providing instructions to the patient after discharge. |
| · Dispensing tips such as one dose packing and drawing colored lines on dispensing paper. |
| · If there are drugs that have been started during hospitalization and are likely to be prescribed at the next outpatient visit, and if there are drugs that should be prepared at the pharmacy, the shortage and out-of-stock cases would be somewhat reduced if the hospital pharmacist would confirm whether or not the patient wants the original drugs or their generic versions and write down the discharge medication summaries. |
| · It would be helpful if you could send them as soon as possible (Last time, the discharge medication summaries were sent at night when the patient came to my pharmacy). |
| · Sharing information such as disease names, medication (ex, chemotherapy), laboratory results, and the status of nursing care certification. |
To the question, “(Ｑ16) In addition to the discharge medication summaries, would you like to share patient information with the hospital pharmacist by phone or online tools?,” while 22 pharmacists responded, “I would like to,” 24 responded, “I cannot say,” and four responded “I do not want to” (Fig. 4).
The pie chart shows the responses to Q16. In the figure, “Yes” for “I would like to,” “Neither” for “2. I cannot say” and “No” for “3. I do not want to.”
Based on the pharmacy characteristics, those that provided home pharmaceutical visit services were more willing to share information with hospital pharmacists than those who did not provide home visit services (p=0.014) (Table 4). The other pharmacy characteristics (“Having family pharmacists or not,” and “Performing health support function or not”) showed no association with wanting to share patient information.
| Q16. In addition to the discharge medication summaries, would you like to share patient information with the hospital pharmacist by phone or online tools? | ||||
|---|---|---|---|---|
| Willing | Unwilling | p-Value | ||
| Q3. Providing home pharmaceutical visit services | Yes | 22 (51.2%) | 21 (48.8%) | 0.014 |
| No | 0 | 7 (100%) | ||
This study differs from previous reports in that it also focuses on the lack of effective use of summaries, which was not clear in the past.
And, as in previous reports, pharmacies that received the summaries and utilized them confirmed that they were utilized in post-discharge pharmaceutical management, including patient instruction and prescription queries of doctors in this study. All pharmacies that received summaries in the past confirmed the usability of the summaries for (1) sharing accurate information and (2) ensuring and improving safety.
1) Sharing Accurate InformationBefore summaries were introduced, information about progress during hospitalization and reasons for prescription changes were obtained through interviews with the patients or their families. However, most information obtained orally from patients was usually ambiguous, and the pharmacists had no choice but to provide medication instructions without proper understanding of the reasons for the prescription change. On the other hand, since the summaries were written by the hospital pharmacists who were in charge of patients, they provided accurate information regarding the medications during hospitalization. Hence, the summaries are useful because they help community pharmacists not only with patient instruction but also in providing correct information to multiple professionals during home visit services. In this survey, we also obtained opinions on the difficulties in collecting information from patients and the usability of the summaries as a means of sharing correct information.
2) Ensuring and Improving SafetyPatients who are discharged from acute care hospitals visit an outpatient department at their hospital or another clinic. Shinmori pointed out that changing medical care providers due to shifting in where health care is provided can have adverse effects on the patient’s outcomes.4) For example, if there are any errors in the medication information on the referral documents exchanged between doctors, the patients might not get the necessary drugs at the clinic they visit after being discharged.
In this survey, several opinions were received, such as “We are comparing discharge prescriptions and outpatient prescriptions because prescription errors often occur when patients transfer to the outpatient department of another hospital after discharge.” Thus, using the summaries may avoid undesirable outcomes for patients due to changing healthcare providers and contribute to seamless medical care.
Therefore, summaries are helpful for pharmaceutical care and multi-disciplinary collaborations in community pharmacists’ daily work.
On the other hand, in the previous reports, the actual situation regarding the cases wherein the summaries were not utilized was unknown, as the utilization of them was researched in pharmacies that received them and conducted pharmaceutical management for patients. New findings from the study, based on the responses to the questionnaire “Q9 Reasons why the summaries were not utilized” and “Q15 Summary requests,” clearly indicate that there were events that were not utilized due to “the information was not timely” and “patients whom the discharge medical summary was sent for did not come to the pharmacy,” “they were sometimes sent after the patient had come to the pharmacy.”
From these results, the issues faced by hospitals that “use faxes” include timing of sending the summaries and confirming the “family pharmacies.” The summaries should be sent as early as possible. It is also a challenge to minimize the time lag between the sending of them and the review of them by the receiving pharmacy. Suzuki et al. reported that the most common timing for community pharmacists to receive them, as requested by the community pharmacists, was at the time of discharge, followed by the first outpatient visit after discharge.7) To be utilized, the summaries should be received at the patients’ family pharmacies by the time the patients arrive there. For this, the hospital pharmacists should know when the patients visit their hospitals after discharge. About confirming the “family pharmacies” where the summaries are to be sent, the response “a patient for whom the summary was sent didn’t come to the pharmacy” points to cases where patients went to pharmacies different from the ones the hospital pharmacists sent the summaries to. Although previously reported facilities ‘hand-deliver’ them to the patient, Kamata et al. describe the possibility of patients not submitting them the pharmacy.2,8) “Hand delivery to patients” or ‘use of faxes’, whichever method of operation is adopted, hospital pharmacists need to clearly explain the purpose of the summaries to the patients and their families when trying to obtain consent to send the summaries.
According to the results of the responses to “Q15 Summary requests,” it is necessary to create a format that communicates complete information about changes in the patient’s condition such as the disease that led to hospitalization, laboratory results, changes in ADL, and dispensing tips.
In Q13-2 “the most useful information” in this survey, only five pharmacies selected “Disease that led to hospitalization” and none selected “Laboratory data during hospitalization.” Our summaries do not have a section for admission disease and laboratory data, and the pharmacists in charge of in-patient care use their judgement to include the circumstances of admission and the progress made during the hospitalization as the reason for the change in prescriptions. This study did not investigate the status of these descriptions, so it is unclear whether “names of hospital admissions and laboratory data are listed but usability by community pharmacists is low” or whether they are “undervalued due to low description rates.”
In facilities where the name of the disease on admission is not set as an item on the summary, as in our hospital, the name of the diagnosis and the purpose of admission were mentioned by community pharmacists as requests for additional items on the information form.3) For laboratory data, where there is the section on the form, hospital pharmacists have a high rate of description and community pharmacists have a high rate of usability.3) Considering the addition of items such as hospital admission disease names and laboratory data could prevent hospital pharmacists from failing to include them, and could also make it easier for the community pharmacists receiving the information to communicate this information, thus increasing their evaluation of the usability of the information. Suzuki et al. reported that community pharmacists felt that clinical tests results (e.g., PT-INR, HbA1C) were necessary as indicators of renal and liver function and for pharmaceutical management.7) The summary could be made even more useful by using a format that allows these items to be included in the clinical tests result section.
As the other requests for the summary included “change in ADL” and “the status of nursing care certification,” a result not found in other reports. Forty-three (86%) of the facilities in this study included those that provide home pharmaceutical visit services. It is suspected that for these pharmacies, information on changing patient conditions can be a source of information on what services are needed for patients after discharge from hospital.
We also found an issue with the way information is shared between hospital pharmacists and community pharmacists. Currently, summaries communicate patient information in only one direction, i.e., from the hospital to the pharmacy, and no system provides feedback to the hospital pharmacists after discharge. In this survey, a request, “I would like to know what information hospital pharmacists want from community pharmacists,” was received. It is anticipated that hospital pharmacists will have more opportunities to receive feedback from community pharmacists by communicating to them specifically what kind of follow-up they would like after discharge from hospital. If bidirectional communication were possible between a hospital and pharmacy, the hospital pharmacists would be able to share information on patient progress after discharge so they would be better able to respond to inquiries from community pharmacists.
Among the pharmacies that want bidirectional communication using telephone or online tools, a higher proportion are those that provide home pharmaceutical visit services. Thus, we believe that collaborating with pharmacies providing home visit services would be beneficial when creating a new system of sharing information.
This study has some limitations. First, the survey had a low (33.6%) response rate. This was because we did not consider if the pharmacies included in the study had received summaries from our hospital in the past. Moreover, all pharmacies included in this survey belonged to the Hirakata City Pharmacists Association. After this survey, we researched the pharmacies belonging to the Hirakata City Pharmacists Association, where summaries were sent from our hospital, and found 117 of them (from 1st April 2020 to 30th September 2022), of which 42 pharmacies responded to this survey. This survey includes the opinions of 35.9% of the pharmacies that received the summaries from our hospital.
When evaluating pharmacy characteristics, we found that more than 80% of the pharmacies that responded to the survey were “pharmacies with family pharmacists” or “pharmacies that conducted home pharmaceutical visit services.” Hence, the status of pharmacies that did not have these characteristics was not reflected in our results. The characteristics of pharmacies that did not respond to the survey were unknown.
The summaries provide accurate patient information from hospitalization to discharge. These documents help community pharmacists in providing continuous pharmaceutical care.
However, this survey revealed that there were some events in which the summaries were not utilized, and the background to these events. For the summaries to be utilized for ongoing pharmaceutical management after discharge from hospital, some of the challenges include timely provision of them and accurate identification of the family pharmacy. In addition, it is necessary to devise a way to communicate the necessary follow-up after discharge so that the community pharmacist knows what information to feed back to the hospital pharmacist after discharge.
Collaboration with pharmacies that provide home pharmaceutical visit services may be useful in creating new bidirectional information sharing.
We would like to express our sincere gratitude to the pharmacies belonging to the Hirakata City Pharmacists Association for their cooperation in this survey.
The authors declare no conflict of interest.
