Discharge Summary: Transcription vs Electronic

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Discharge Summary Transcription vs Electronic

• Grace Paterson (grace.paterson_at_dal.ca), David
  Zitner (david.zitner_at_dal.ca) Steven Soroka
  (steven.soroka_at_cdha.nshealth.ca)
• Medical Informatics Nephrology, Dalhousie
  University
• Medical Residents Education 2006/08/24

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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

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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 patients hospital record
• Hospital abstracts information for statistics

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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

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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?

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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

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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

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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?

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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

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Select Patients Sex
Calculates Disease Severity Stage at Time
of Data Entry
Enter Patients Age
Enter Patients Creatinine
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Captures Diagnosis and Risk Factor History
for Information Reuse (Canadian
Organ Replacement Register Form)
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Clinical Pragmatics

• Ensure Intended ActionActual Action
• Problem of Practical Data Entry
• Coding concurrent with data entry
• Lab results
• Diagnoses
• Medications
• Document Structure pertinent information
  readily found

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(No Transcript)
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(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

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Nosology systematic classification of diseases
and the naming of clinical concepts characterized
by a disease.
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Concept Definition
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Learning Occurs at the boundary
between Communities of practice
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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

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CHAMP Discharge SummariesH Health
Informaticians

• Improving a patients 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

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CHAMP Discharge SummariesA - 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.

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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.

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CHAMP Discharge SummariesP - 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.

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You Can Help

• Sign up for our study
• with Grace Paterson grace.paterson_at_dal.ca
  494-1764,
• Room 2L5 Tupper Building
• with Dr. Steven Soroka steven.soroka_at_cdha.nshealth
  .ca 473-3614 Room 5099 Dickson Building
• With Dr. Kevork Peltekian
• kevork.peltekian_at_cdha.nshealth.ca 473-7898
  Room 203, 6 South, Victoria Building, VG Site,
  QEII HSC
• Provide feedback on how to improve template

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In Conclusion

• Thank you for your time
• Any questions?