National guidelines for the on-screen presentation of discharge summaries Siobhan McFadden Project manager NIA Conference 6 August, 2017
Why have national guidelines? • Information in the discharge summary varies between settings and is not displayed in a consistent order. • Terminology between the hospital discharge summaries and the general practitioner software view is sometimes inconsistent. • The format of medications information across discharge summaries varies which can lead to medication errors.
Scope • Literature review and environmental scan • NEHTA style guide and discharge summary clinical document architecture specification • NEHTA EDS core components • Desktop reviews: ▪ of current processes for creating discharge summaries ▪ presentation of discharge summaries in clinical information systems, GP software and the My Health Record • Project consultation across multiple clinical settings both public and private - up to 70 stakeholders • Prototype development • Workshops and heuristic testing - eye tracking testing • Develop and finalise guidelines
Methodology
Findings and outcomes from phase one - current state assessment
Eye-tracking - initial fixations Analysing the data from the first eye-tracking sessions indicated that healthcare providers were confused about where to look first when reviewing the discharge summary.
Eye tracking – distribution of gaze
Recommendations and outcomes • Stakeholder review Workshops x 3 - reviewed and updated multiple prototypes over an iterative process • Eye tracking testing x 3 - reinforced the findings and changes adapted from the workshops Section one Section two Section three P ATIENT AND HOSPITAL A LLERGIES AND ADVERSE R ECOMMENDATIONS DETAILS REACTIONS Recipients and authors M EDICINES ON F OLLOW - UP DISCHARGE APPOINTMENTS P RESENTATION DETAILS C EASED MEDICINES I NFORMATION PROVIDED TO THE PATIENT P ROBLEMS AND A LERTS R ECIPIENTS DIAGNOSES P ROCEDURES S ELECTED I NVESTIGATIONS RESULTS C LINICAL S UMMARY
Recommended presentation Section 1
Section 2
Section 3
Summary • Standardised and consistent presentation of clinical information promotes safety and improves patient care • Presenting elements in a consistent and sequential manner allows the receiver of a discharge summary navigate more efficiently • Heuristic analysis and consumer testing contributed to the on-screen presentation of discharge summaries • Platform for health services procuring clinical information systems
Published in February 2017 https://www.safetyandquality.gov.au/wp-content/uploads/2017/02/Guidelines- on-screen-presentation-of-discharge-summaries.pdf
Questions?
Contact details: siobhan.mcfadden@safetyandquality.gov.au Siobhan McFadden
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