The Joint Commission Journal on Quality and Patient Safety Volume 41 Number 3 March 2015 126 The Joint Commission Journal on Quality and Patient Safety P atient discharge is a critical transition point in the cycle of care during which avoidable medical errors such as miscom- munication or incomplete transfer of information can lead to adverse postdischarge patient outcomes, particularly readmis- sions. 1–7 As a result, the development of best-practice discharge checklists to standardize the discharge process and promote safe discharge has been proposed. 8,9 Checklists have already been implemented in various hospital settings, such as the operating room and the ICU. 10,11 However, the efectiveness of checklists is highly variable, given the inconsistency in physicians’ compliance to checklists and practical implementation limitations. 10–12 Common reasons for poor compliance include perceived increased workload by phy- sicians, lack of integration with physicians’ clinical work fow, and lack of support or perceived beneft by physicians. 13–15 Checklists have traditionally been implemented on paper, and barriers to checklist use may be dependent on checklist mo- dality. 15 Te recent adoption and increasing use of electronic health records (EHRs) provides an opportunity to explore EHR technology as a novel and more efcient vehicle for checklist de- livery. 15–17 Unlike a paper checklist, an EHR checklist is secure, 18 can ft into physicians work fow seamlessly, 19 and can be instant- ly shared with other team members and collaboratively updated, resulting in potentially more team-based, coordinated care. 18,20,21 In this article, we describe the design, development, and evaluation of an EHR discharge checklist at an academic med- ical center. Methods SETTING Tis study was conducted at Stanford University Medical Cen- ter (Stanford, California), an academic medical center with more than 25,000 inpatient admissions per year and approxi- mately 2,100 medical staf and 700 interns and residents. Our Institutional Review Board considered the study as quality im- provement and therefore “exempt.” Methods, Tools, and Strategies Development and Evaluation of an Electronic Health Record– Based Best-Practice Discharge Checklist for Hospital Patients Article-at-a-Glance Background: Checklists may help reduce discharge errors; however, current paper checklists have limited functionality. In 2013 a best-practice discharge checklist using the elec- tronic health record (EHR) was developed and evaluated at Stanford University Medical Center (Stanford, California) in a cluster randomized trial to evaluate its usage, user satisfac- tion, and impact on physicians’ work fow. Methods: Te study was divided into four phases. Results: In Phase I, on the survey (N = 76), most of the participants (54.0%) reported using memory to remember discharge tasks. On a 0–100 scale, perception of checklists as being useful was strong (mean, 66.4; standard deviation [SD], 21.2), as was interest in EHR checklists (64.5, 26.6). In Phase II, the checklist consisted of 15 tasks categorized by admission, hospitalization, and discharge-planning. In Phase III, the checklist was implemented as an EHR “smart-phrase” allowing for automatic insertion. In Phase IV, in a trial with 60 participating physicians, 23 EHR checklist users reported higher usage than 12 paper users (28.5 versus 7.67, p = .019), as well as higher checklist integration with work fow (22.6 versus 1.67, p = .014), usefulness of checklist (33.7 versus. 8.92, p = .041), discharge confdence (30.8 versus 5.00, p = .029), and discharge efciency (25.5 versus 6.67, p = .056). Increasing EHR checklist use was correlated with usefulness (r = .85, p < .001), confdence (r = .81, p < .001), and efciency (r = .87, p < .001). Conclusions: Te EHR checklist reminded physicians to complete discharge tasks, improved confdence, and in- creased process efciency. Tis is the frst study to show that medicine residents use “memory” as the most common method for remembering discharge tasks. Tese data rein- force the need for a formalized tool, such as a checklist, that residents can rely on to complete important discharge tasks. Trit Garg, BA; Jonathan Y. Lee, MD, MBA; Kambria H. Evans, MEd; Jonathan Chen, MD, PhD; Lisa Shieh, MD, PhD Copyright 2015 The Joint Commission