Computerised updating of clinical summaries: new opportunities for clinical practice and research?

Abstract

A new type of clinical summary, produced by copying standard descriptions of diseases on to a computer screen and editing them to match a patient's findings and diagnoses, was updated and reprinted as the patient's condition changed in the ward or as an outpatient. When this method was used to produce typed medical discharge summaries over a three month period, 73 out of 91 (80%) were sent out within a week after discharge compared with five out of 56 (9%) conventionally typed summaries received in a single general practice. Even completely new computerised summaries are quicker for the secretary to produce than conventional summaries, and the computerised summaries are designed to be scanned rapidly for relevant information. They can also be used to collect data automatically for research, clinical audit, and resource management.

Omission of Dysphagia Therapies in Hospital Discharge Communications

“…However, nursing hand-offs do not result in written documentation as universally present or as widely disseminated as the discharge summary [27]. Additionally, system factors, including poor in-hospital communication [55-57], high work-loads [58, 59], and cumbersome discharge summary and medical record systems [60-63], likely contribute to dysphagia omissions.…”

Electronic Versus Dictated Hospital Discharge Summaries: a Randomized Controlled Trial

“…10 Earlier work suggests that compared to conventional discharge summaries, electronically created discharge summaries have a greater likelihood of being generated, are more accurate, are delivered faster than dictated summaries, and are preferred by community physicians. [11][12][13][14][15] In contrast, a recent study reveals that electronic discharge summaries often lack crucial information. 16 There is also growing evidence that computer-generated clinical documentation as a whole is rated poorly by end users.…”

Challenges to implementing NPfIT: Computerised medical history is key to connecting health

“…It can be created initially from prepared guidelines by pasting them into the structured medical history, which is quick and allows the clinical management to be checked for errors 2. It can also be produced automatically in Microsoft Word from general practice computer systems by designing the appropriate database report forms.…”

“…A full evidence based computerised medical history outlines the particular diagnostic evidence for a particular patient, followed by an outline of the management, with dates and times 2 3. The particular evidence in the patient's electronic patient record and the general scientific evidence in the literature could be accessed from the history or its prepared guidelines by using hypertext or other links provided by Connecting for Health.…”

“…The history can be given to patients and used to explain diagnoses and decisions in a transparent and reassuring way,3 empowering those who wish to become expert patients. It can reduce the amount of paperwork for doctors and secretaries,2 and it would be a useful source of information for audit databases and hospital coders. Updating it on the ward reduces the length of inpatient stay,3 and the evidence based history can also be used to teach diagnostic problem solving 4…”