Evaluation of electronic discharge summaries: A comparison of documentation in electronic and handwritten discharge summaries
Introduction
The hospital discharge summary is an essential document for communicating with general practitioners (GPs) as it provides clinical and administrative information necessary for the continuity of care of patients discharged from hospital [1], [2], [3]. A prerequisite for the delivery of quality ongoing care is the provision of an adequate summary of the patient's hospital stay and details of any aftercare required. Data cited as being of prime importance include: admission and discharge diagnosis [4], [5], [6]; additional diagnoses [7]; physical examination findings and laboratory results [5], [6]; investigations [4]; procedures [4], [6], [7]; complications [6]; management and outcomes [4], [7]; hospital treatments [1]; drug allergies [5]; discharge medications [1], [4], [5], [6]; medical problems at discharge [6]; instructions for ongoing management [7], [8], [9]; follow-up details [1], [5], [6], [7]; and admission and discharge dates [4].
Traditionally, the hospital discharge summary has been created manually, either handwritten or dictated. Over time there have been numerous reports of errors and omissions in manually-created summaries [3], [5], [9], [10], [11], [12], [13], [14]. In the attempt to improve quality, structured formats were introduced more than two decades ago as an alternative to the narrative format [15]. GPs appear to prefer a structured format [16], [17]. In a further endeavour to improve quality, computer-generated (electronic) summaries have been developed [4], [10], [15], [18], [19], [20], [21]. Over the years, in creating electronic summaries, data entry has been carried out in different ways; these include the entering of data into the computer during hospitalisation and at discharge by medical staff [7], [10], [20] or the copying of data into the computer by non-medical staff from summaries written by doctors at discharge [4], [12], [15]. Recent advances in technology have enabled integration of administrative and clinical hospital information systems, to provide patient data for the electronic discharge summary [21], [22]. Comparisons of handwritten/dictated and electronic summaries in relation to completeness have been reported on [10], [15], and GPs have been canvassed as to their preference of type of summary [4], [5], [8], [18]. GPs have tended to favour electronic summaries in respect of comprehensiveness and clarity [18] and information on continuity of care [4], [8], [18]. However, as with handwritten/dictated summaries, electronic summaries may also contain serious errors and omissions [7].
The two comparisons of handwritten/dictated and electronic summaries regarding completeness [10], [15] were made several years ago, during earlier stages in the development of electronic discharge summary systems. The doctors creating the summaries were aware their work was being observed. No research comparing discharge summary methods has been published in recent years.
In the present study the discharge summaries of a population of recent inpatients was examined. The summaries had been either handwritten or created electronically. The aim of the study was to test whether, today, the electronic discharge summaries are superior to handwritten summaries regarding information on continuity of care, as GPs felt to be the case years ago. This was done by comparing electronic with handwritten summaries for the completeness of a number of items of information necessary to assist GPs deliver quality ongoing care. This research was carried out retrospectively, and the doctors who created the summaries were unaware their work was to be studied.
Section snippets
Study design and sample
The study sample consisted of the discharge summaries (handwritten or electronic) of patients hospitalised for at least two days between 1 April and 30 June 2005 in a 78-bed public hospital in Sydney, Australia. This hospital was an acute care facility for elderly patients and disabled patients of any age and a rehabilitation facility for patients of any age. All patients had been discharged to their place of residence into the care of a GP. The study was conducted by one investigator (MA)
Results
During the study period, 272 patients were discharged whose discharge summaries were eligible for audit. Of the 272 patients, 27 (10%) were inpatients at time of audit or had been transferred to another hospital with their records during the interval between the index discharge and the audit. Thus, 245 summaries were available for study. Of these, 177 (72.2%) had been created for medical patients and 68 (27.8%) for rehabilitation patients; 151 of the 245 summaries (62%) were electronic and 94
Discussion
The findings of this study show that an appreciable number of discharge summaries contained omissions and errors, but that these were more commonly present in the electronic than in the handwritten summaries. The value of reviewing discharge summaries has been demonstrated in this study, this research having shown that critical errors and omissions continue in the communication of clinical information from the hospital to the GP, despite advances in computerisation of the discharge summary. The
Conclusion
The results of our study show it is not necessarily the case that electronic discharge summaries are of higher quality as regards accuracy and completeness than handwritten ones, and electronic summaries may be more deficient in the early stages of electronic implementation. However, free text items such as summary of the patient's progress may more likely be documented in electronic summaries.
It is unknown what factors contributed to incompleteness in creating the electronic discharge
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