Discharge Summary: Transcription vs Electronic

1. Discharge Summary: Transcription vs Electronic Grace Paterson (grace.paterson@dal.ca), David Zitner (david.zitner@dal.ca) & Steven Soroka (steven.soroka@cdha.nshealth.ca) Medical Informatics & Nephrology, Dalhousie University Medical Residents� Education 2006/08/24

2. Patient Documentation Function of hospital: To improve health Documentation needed for Chronic Disease Management and other processes Electronic Discharge Summary Clinical communication shifting from paper world to electronic world Electronic Template Helps resident understand what is important Helps informaticians build better systems

3. Current Way of Doing Discharge Summaries Review the chart Dictate a discharge summary Handwritten interim report given to patient Dictation transcribed and faxed to Family Physician and copied to others Permanent part of patient�s hospital record Hospital abstracts information for statistics

4. Chronic Kidney Disease (CKD) Electronic Discharge Summary Usage determines what should be included Follow up care by Family Physician When/if patient returns to hospital Chronic disease management Diagnoses/Procedures/Consults for Canadian Institute for Health Information (CIHI) Discharge Abstract

5. What To Include & Why What are the key elements of a discharge summary? Why is knowing this important? Too much information clogs up the system with superfluous data What uses are made of the information?

6. What Improvement is Needed Improve the quality of the discharge summary By prompting people for information By pulling needed information from people By not passively expecting people to put in information that they deemed necessary

7. Why is Improvement Important If we got information in an electronic form we could move it around and make it usable for more than one group of people Family doctors General communication Patients Other care providers Disease management

8. Transcription vs Template Study Study question: Does use of the HL7 Template for Chronic Kidney Disease Discharge Summary lead to discharge summaries that are more complete and contain more of the essential data elements than those completed using the Dictation and Transcription System?

9. Electronic Discharge Summary Template designed to guide data entry �Pull� information via template Linked to Nova Scotia Drug Formulary Linked to World Health Organization ICD10 Online Database for Diagnosis codes Feedback �Push� concept descriptions for coded entries CIHI Discharge Abstract ICD10 diagnoses Map Clinical Narrative to Codes � narrative is more informative and more efficient for clinician

12. Clinical Pragmatics Ensure Intended Action=Actual Action Problem of Practical Data Entry Coding concurrent with data entry Lab results Diagnoses Medications Document Structure � pertinent information readily found

14. (New Topic) � Coding behind the scenes Two nosology systems recommended for Electronic Health Records SNOMED CT (note: Primary Renal Diagnosis codes are a subset) ICD (International Classification of Disease) Analytico-synthetic structure SNOMED Analyze domain into terms Synthesize into concept descriptions Logical definitions support inference Single hierarchical structure in ICD that categorizes diseases by organ system

18. CHAMP & Discharge Summaries: C - Clinicians The discharge summary provides a complete story is told in a way that encompasses the working behaviour and models of practice of the practitioners generating it. Clinical care of a patient is shared across health professions Document-based approach is used to provide the information needed by the next caregivers

19. CHAMP & Discharge Summaries:H � Health Informaticians Improving a patient�s health status is a guiding principle for clinical care and health informatics. Outcomes are the change in health status Economic impact (CIHI Discharge Abstracts look at resource intensity weights by ICD10 diagnosis) Clinical markers Humanistic (improve comfort, increase function and reduce likelihood of dying). Capture information for reuse by other communities of practice Medical Educators, Administrators, Patients

20. CHAMP & Discharge Summaries:A - Administration Our hospitals spend in excess of ~$2 million coding health records after patients are discharged from patient and Day Surgery hospital stays. A boundary infostructure supports health service administration program planning quality assurance.

21. CHAMP & Discharge Summaries: M � Medical Educators A case base is valuable for medical education training. It makes visible the complexities of the clinical action-related decision-making process in the different communities of practice associated with patient care. It supports lifelong learning based on real cases which form case memories that ultimately lead to tacit knowledge.

22. CHAMP & Discharge Summaries:P - Patient Personalized health care information can be based on patient data stored in the Clinical Document Architecture. Patient education leads to empowerment -- the enhanced ability of patients to actively understand and influence their health status.

23. You Can Help Sign up for our study with Grace Paterson grace.paterson@dal.ca 494-1764, Room 2L5 Tupper Building with Dr. Steven Soroka steven.soroka@cdha.nshealth.ca 473-3614 Room 5099 Dickson Building With Dr. Kevork Peltekian kevork.peltekian@cdha.nshealth.ca 473-7898 Room 203, 6 South, Victoria Building, VG Site, QEII HSC Provide feedback on how to improve template

24. In Conclusion Thank you for your time Any questions?