Get ready to discharge

There is a subtle change that happens as hospitals move from using targets to using quality improvement as a driver for change. It is one that is exemplified by a shift in the demands being made on systems that can generate electronic discharge summaries.

A year ago, says Dr Adam Towler, managing director of Bluewire Technologies, NHS trusts were looking to meet targets for getting discharge summaries to GPs within 48 hours and then 24 hours of their patients being discharged. Many were developing in-house solutions, based on existing systems, to meet these targets.

Now, though, the focus has shifted to preventing hospital readmission, reducing length of stay and improving the patient experience; for example by making sure that relevant information is at hand should the patient come back into hospital.

Dr Towler argues that electronic discharge summaries that pull in more clinical information – particularly about medicines – and that are highly automated can actively assist hospitals deliver on these quality measures. “And in this scenario the limitations of the home grown solutions are becoming apparent,” he claims.

Starting discharge earlier

Take reducing length of stay. “The ability to start producing the discharge summary earlier in the stay is one way of making sure discharge is not delayed – but it is certainly a challenge,” says Dr Towler.

It’s a challenge because of the way junior doctors traditionally work – it is usually the last job to which they attend – and because the information needed may not be readily available to an electronic document management solution.

SRC, Bluewire Technologies’ partner, has developed a system at West Suffolk Hospital that captures information from doctors’ handover lists – which include diagnosis and test results as well as prescribed medicines – to get the summary started.

It works in the background so there is no change in working patterns for junior doctors and, anecdotally, is helping to reduce length of stay.

Now SRC and Bluewire Technolgies are looking at capturing data not just from doctors’ handover lists but from nurses’ notes too, since these may also hold crucial information about discharge planning that could be useful to social care and community care.

Adding in business intelligence

Richard Strong, healthcare director at Dell, is convinced that EDS will become an increasingly useful tool in helping NHS trusts to meet quality outcomes.

He says: “We are expecting to see more and more coded content, more and more clinical content that will be distributed not just to GPs but also to social care and other areas. We expect people to start using electronic discharge summaries in combination with business intelligence to monitor patient populations for quality outcomes.”

For example, electronic discharge summaries combined with business intelligence could alert clinicians and managers to patients who have a longer than expected length of stay or who have not been prescribed drugs associated with a given diagnosis.

Dell does not provide software solutions but is looking to work with trusts and other suppliers to help them deliver on this agenda. “We have capabilities and knowledge of implementing solutions here and throughout the world,” says Strong. “This is a big topic and regardless of the outcome of the listening exercise [the government’s current pause in the passage of the Health and Social Care Bill] this is going to become more and more important.”

Data warehouses and alternatives

Gathering the data for such comprehensive and timely e-discharge summaries is a complex process. Charles Lilly, managing director at Health Systems Group, a consulting partner for Hitachi Data Systems, advocates an approach that builds on a data repository, such as Hitachi’s Clinical Repository, which launched globally in March 2011.

“Originally, the business case for document management systems was administrative – scanning documents would save time and reduce storage,” he says. “But the real benefits are clinical if you can start to draw in information that was previously in silos.”

A clinical repository brings electronic documents, test results, images and prescribing data together, allowing legacy systems to carry on in the background while all the data needed by the discharging physician is easily accessible in one place.

Mark Clark, director of e-health and life sciences for Hitachi Data Systems, says: “The data is cleansed, it is ring fenced for security and information governance requirements and, driven by a [Microsoft] FAST search engine, it is easily searchable and retrievable.” And it should be an ideal platform from which to build e-discharge summaries.

Other trusts have moved to web-based systems. For instance, Addenbrooke’s Hospital in Cambridge is now producing 800 discharge summaries a week using an e-discharge system built by Beacon Computer Technologies on a Microsoft platform.

The system has made producing discharge summaries quicker, safer and easier and has opened them up to GPs, outpatients and other community providers. They also form part of the electronic patient record.

Progress is real, but patchy

While some trusts are clearly doing good work, the past few months have seen some players drop out of the EDS solution market due to lack of interest – for example, Stalis. And others argue that the targets still loom largest in managers’ minds.

Dominic Dunn, sales and marketing manager for Sunquest Information Systems in Europe, says: “In the trusts we work with the 24 hour target is still very much the driver – and not all trusts have a solution that allows them to meet that by any stretch of the imagination.”

He says flexibility is the key to developing systems. Ideally, he says, a hospital will use templates to create discharge summaries in an HL7 format that can be easily transmitted to a GP system that is able to integrate an HL7 message into the GP record.

In the real world, individual departments produce their own documents in Word and as PDF files, while GP systems vary widely in their ability to integrate messages into their systems.

The first part can be handled reasonably well, says Dunn, by using Sunquest’s ICE Desktop to create an HL7 message from documents generated by different systems, whether that is the bed management system or the A&E system.

But variation in GP systems and their document management solutions is a real challenge. “There is a real variation in the GP systems’ ability to accommodate messages and what we need ideally is for NHS Connecting for Health and GP Systems of Choice to mandate some standards.”