Vebjørn Mack Remen1, Anders Grimsmo. 1. The Norwegian Electronic Patient Record Research Center, Norwegian University of Technology and Science, Trondheim, Norway. vebjornmackremen@mac.com
Abstract
BACKGROUND: Information deficits contribute to medical errors. Hence several efforts to develop electronic communication systems to facilitate a flow of information between health care providers have been attempted, including initiatives to develop regional or national electronic patient summaries. OBJECTIVES: To study information access and information needs in inpatient emergency departments, and how clinicians in these departments handle deficits in available information. METHODS: We conducted an observational study of consecutive unplanned inpatient admissions using a structured form to register a set of predefined parameters and free-text notes, including a post-examination interview with the examining emergency department doctors and nurses. RESULTS: We observed 177 patient admissions, excluding any patients under 18 years of age and planned admissions. One in four patients arrived without any referral. Nearly all referrals described the presenting complaint with a tentative diagnosis. One third of the referrals lacked medication record and medical history. Only one in ten referrals contained information about contraindications. If the patient had previously been admitted to the hospital, the emergency department doctors used the existing electronic patient record and seemed to favor previous discharge letters as an information source. Information on current medications was often copied from earlier admissions. In half of the cases the patients also provided supplementary information in other ways not available, though one in five patients was not in a cognitive state to be properly interviewed. The examining doctors reported a lack of crucial information in 10% of the observed referrals. CONCLUSION: Overall, information about medications and previous history was described in most referrals, but was still the information most frequently inquired or searched for. Qualitative assessments revealed that insufficient information put a significant stress on both patients and staff, and in turn caused additional workload and risky work-arounds. In our assessment, these information deficits could be effectively mitigated by an up to date easy-access patient summary.
BACKGROUND: Information deficits contribute to medical errors. Hence several efforts to develop electronic communication systems to facilitate a flow of information between health care providers have been attempted, including initiatives to develop regional or national electronic patient summaries. OBJECTIVES: To study information access and information needs in inpatient emergency departments, and how clinicians in these departments handle deficits in available information. METHODS: We conducted an observational study of consecutive unplanned inpatient admissions using a structured form to register a set of predefined parameters and free-text notes, including a post-examination interview with the examining emergency department doctors and nurses. RESULTS: We observed 177 patient admissions, excluding any patients under 18 years of age and planned admissions. One in four patients arrived without any referral. Nearly all referrals described the presenting complaint with a tentative diagnosis. One third of the referrals lacked medication record and medical history. Only one in ten referrals contained information about contraindications. If the patient had previously been admitted to the hospital, the emergency department doctors used the existing electronic patient record and seemed to favor previous discharge letters as an information source. Information on current medications was often copied from earlier admissions. In half of the cases the patients also provided supplementary information in other ways not available, though one in five patients was not in a cognitive state to be properly interviewed. The examining doctors reported a lack of crucial information in 10% of the observed referrals. CONCLUSION: Overall, information about medications and previous history was described in most referrals, but was still the information most frequently inquired or searched for. Qualitative assessments revealed that insufficient information put a significant stress on both patients and staff, and in turn caused additional workload and risky work-arounds. In our assessment, these information deficits could be effectively mitigated by an up to date easy-access patient summary.