The Electronic Discharge Summary - a Local Solution Succeeds (2003)

Objective: To design an electronic discharge summary which also contained the right information for clinical audit and monitoring of quality. Background: Governments, hospital staff, community providers and general practitioners (GPs) recognise that quality and timely communication when the patient is leaving hospital, is the key to ensuring continuity of care, better health outcomes and a reduced re-admission rate.i,ii Effective communication between hospitals and GPs is essential for continuity of patient care, including medication regimes.iii,iv Australian literature contains examples of poor hospital - GP communication - such as inaccurate or illegible discharge summaries - that led to the patient receiving incorrect medication and poor continuity of care.v The flow of information between hospitals and GPs may be inconsistent, unpredictable, illegible and not sufficiently informative.vi,vii Further, GPs may receive information when it is too late to be useful.viii,ix Hospitals often give discharge summaries to patients to deliver to their GP, yet studies have shown that over 70 per cent of summaries never reach the intended destination.x,xi For effective management of post-hospitalised patients, it is 'imperative that full information about patient treatment and care is conveyed' to the GP before the patient's post-hospital review.xii Discharge summaries are normally delegated to the most junior member of the medical staff, are often handwritten, and the information contained therein is usually both illegible and irretrievable. If not given to the patient at the time of discharge the GP may not receive the summary before the first post-discharge review. Methods: A well-constructed discharge summary contains the essential information for quality monitoring of medical care in hospital. In August 1999, the General Practice Divisions Victoria developed a minimum data set for hospitals to provide to GPs when their patients are admitted to, or leave hospital; this information set was used in the construction of the summary. Electronic creation enables the document to be legible and transmitted by email or fax in a timely manner. Formulating the discharge summary as a database enables the information to be searched, retrieved and analysed by computer rather than by hand. Funding was received through the Effective Discharge Strategy project via the Department of Human Services, Victoria. Design of Database: Medical clinicians were consulted and senior medical clinical leadership drove this particular project. Essential fields included patient demographics (Name, Address, Contact Numbers, GP, Record Number, Date of birth, Consultant in charge), type of admission (public or private, emergency or elective) and clinical fields. The important clinical fields agreed were principal diagnosis, admission problem/presentation, comorbidities, investigations performed and results (selected relevant ones), operations or procedures, complications and progress, followup and outcome. For quality monitoring and improvement the discharge summary database includes the opportunity to record sentinel and adverse events and near misses. Patients who die should have a mortality version of the discharge summary completed (often forgotten when a death occurs). Results: The electronic discharge summary was introduced to all units in the Geelong Hospital in 2001 after a pilot project in Surgery in 2001. Implementation stretched computer access by junior doctors and 75 new computers had to be provided. Within a few weeks of introduction those units which showed senior clinical interest achieved a 100 per cent completion rate. A survey of General Practitioners showed positive feedback on the quality, legibility, usefulness and timeliness of the discharge summaries. One year after introduction clinicians were amazed at the clinical audit information which could be generated by the system. Data entry was also helped by the discharge database receiving patient demographic and identifier information from PiMs. All in-patients (now over 150,000 records) are in the system. 80% of summaries are sent to General Practitioners within 10 minutes, electronically by facsimile and/or email. The system is used by all units both acute and sub acute and across two hospital sites. Issues and obstacles that arose and were managed during the project included: confidentiality, consent, access to hardware, computer skill base, meeting user group expectation, impact of other IT systems within the organization, rapid intern and other staff turnovers, team expansion, engaging the support of the information technology staff, resource availability, affect of electronic documentation on other work processes. Learnings from the project included communication, planning, redirecting out of scope issues, balancing achieve-ables with actualities. Conclusion: A database was successfully introduced to generate electronic discharge summaries. Positive feedback was received from the referring general practitioners and the program gained senior clinical support during its introduction. Clinical audit data was retrieved and able to be presented in summary, aggregated form at the request of unit heads. Clinicians utilise the monthly quality reports to discuss the trends in patient outcomes. The projects success is attributed to strong managerial support, consistent clinical championship. All stakeholders involved in the discharge summaries and clinical information systems within the organization participated in the improvement effort. Clinicians convinced other professional groups that change was required, and encouraged their willingness to alter their roles and responsibilities to align with that change. Further, internal stakeholders were involved in the change process and informed the implementation strategy. Staff then were informed and educated about the system.