The DS is a crucial document within the patient chart, and its absence can have detriments on the level of completion of the EHR. Consequently, patient outcomes [8, 9], interprofessional collaboration [7], and administrative data quality [4, 5] are all impacted by an incomplete EMR. Our objective was to assess for the presence of a DS in inpatient charts, as well as variables associated with missing discharge summaries. Alberta Health Services’ current EMR system has been in use for over a decade. It is one of the most validated electronic systems in Canada, and has great utility for interprofessional collaboration and secondary research purposes [10]. Despite its utility and the evidence supporting a fully electronic EMR system, our findings demonstrated that EMR incompleteness was associated with patient baseline and setting characteristics. Interestingly, physicians were relying on paper charting or simply not creating discharge summaries when patients are middle-aged, surgical and have fewer comorbidities. To our knowledge, this is a novel finding. No previous studies have found associations between the aforementioned patient characteristics and the absence of electronic discharge summaries. The findings of our study will caution researchers when using EMR data pertaining to these 3 patient characteristics. This discussion delineates possible explanations for these associations.
Upon further assessment of the 85-chart sample, 70% were from outpatient surgical procedures, specifically urological and orthopedic procedures. The one urology clinic and two orthopedic clinics in Calgary were contacted for further information on DS practices. Across all clinics, staff reported limited need for a DS post-procedure, as the surgeon performing the procedure is often the surgeon that will see the patient in follow-up at the clinic. Additionally, given the simple nature of many of these procedures, there is no perceived need for a copy to be made to the family physician. A DS paper template is provided for surgeons at one orthopedic surgery site, albeit not used. Discharge instructions are thus the only document created, with the sole purpose of informing the patient with post-procedure care. However, both orthopedic and urological clinics reported creating a DS in the context of a complex case, wherein a nurse practitioner creates the DS, not the surgeon performing the procedure. Although we were unable to look further into whether or not those surgical cases with a DS were indeed more complex, we can speculate that it is physician preference that dictates whether or not a DS will be created, unless there is a complex case.
The reported incentive in surgical departments to create a DS for complex cases can explain the association found in this study’s larger cohort between lower CCI scores and a missing DS. A lower CCI score indicates fewer or less severe comorbidities, which can simplify the procedure. A simple procedure would thus not qualify as “complex” and would not be considered for a DS. Outside of the surgical realm, one study focusing on general medicine found that patients being discharged with a lower CCI score had nearly double the time to dictation from point of discharge (measured in days), compared to those with a higher CCI score, despite low CCI patients having significantly shorter lengths of stay. This apparent lack of urgency to create a DS could be reflected throughout healthcare provider practices for patients with fewer or less severe comorbidities, leading to the absence of a DS in this cohort of patients. Interestingly, the length of the DS (words used) in patients with lower CCI scores did not differ from that of patients with higher CCI scores, which could represent the intrinsic need for communication between inpatient and outpatient physicians [16], regardless of the complexity of the case. Additionally, the associated risks for readmission increase for every 3 days gone without a DS once a patient is discharged [17]. Therefore, for patients where no DS is ever created, the posed health risks could be detrimental.
With regards to the positive association between those aged 45-64 and the absence of a DS, there is a lack of literature to support this discovery. However, it could be related to the decreased complexity of these patients, and consequent non-urgency for creation of a DS. Compared to those aged 65 and greater, disease prevalence for many of the Charlson comorbidities, as well as the most commonly reported diseases (e.g. hypertension, type 2 diabetes, coronary artery disease), is far less frequent. Therefore, the perceived urgency in reporting on a patient undergoing a simple procedure with few comorbidities could be less compared to the urgency for reporting on a complex patient. This could result in an absence of a DS.
Our finding of missing EMR discharge summaries in surgical departments aligns with existing literature, though our study is the first to report on complete absence of the electronic DS [12]. Most studies report on the illegibility or scarcity of information within the surgical DS, while we found the document to be missing all together [13]. The lack of standardization in the creation of a DS by the surgeon performing the procedure calls for further investigation into departmental- or unit-culture norms. Possibly, there have been no voiced concerns within the healthcare system to incentivize surgeons to create a DS. However, this is dubious, given the extensive national and international literature on both general practitioner and patient dissatisfaction with post-procedure information and outcomes [12,13,14]. There is a dearth in literature regarding surgeon perspectives on the necessity of a DS. When broadened to perspectives from other specialties, one study found physicians often do not feel sufficiently informed on the patient’s health history to create a DS. Additionally, avoidance of redundancy of patient information within the EMR is a primary deterrent for the creation of a DS [15]. More investigation is needed on the surgeon’s perceived nonnecessity of a DS, as a means to understand why surgical cases are often missing a DS within the EMR and paper record.
In addition to having negative consequences on patient health outcomes, the absence of a DS can also affect the use of EMR data for secondary purposes [18]. In the process of transforming patient data into a data repository, a coder’s data abstraction and the resulting data quality can be hindered with an absent DS. Within coding practices, the DS is treated as a gold-standard document for coders to abstract, verify, and validate their coding. When the DS is missing, coders must use additional physician documentation (e.g. the History and Physical) to abstract their necessary codes. However, without the DS, if there is inconsistent information across different documents, coders cannot verify their codes against their gold-standard and are forced to omit codes. Therefore, the rigor with which the they can confidently code is consequently. This can lead to missing data within the database the codes are entered in, which decreases the quality of data. This data quality is crucial given its use for national statistics on population diseases and morbidity. Advances in medicine and research will be hindered if the missing DS phenomenon and subsequent poor data quality continues.
Limitations
Since some of the documents for charts within Calgary medical facilities are still in paper format, this study cannot fully report on the quality of the EMR; rather, it reports on the completeness of the patient medical record. Nonetheless, regardless of paper or electronic documentation, there was still a significant number of records missing a DS entirely.
Within the 893 charts, there is a possibility that charts were captured in the missing DS cohort, when there was actually a paper DS present. Nonetheless, the lack of an electronic DS within the electronic medical record is still relevant. Given the predominantly electronic form of communication between hospitals and general practitioners in Alberta, the inconsistency in availability of documentation in one single location can delay processes for practitioners searching for important health information. Additionally, the delay in receiving a paper document versus quickly accessing the electronic document from a general practitioners office can hinder health delivery services.
Lastly, due to inadequate resources, our sample size for assessing the presence of paper DS was 10%. While we recognize this is a small sample size, the purpose of this sample was to confirm our finding that the majority of patient charts in surgical departments are lacking a discharge summary. All of our analyses were performed on the 893 charts, and we believe the study’s power was not affected by this small sample size.