230 likes | 695 Views
Patient Documentation. Function of hospital: To improve health Documentation needed for Chronic Disease Management and other processesElectronic Discharge SummaryClinical communication shifting from paper world to electronic worldElectronic TemplateHelps resident understand what is importantHelps informaticians build better systems.
E N D
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?