Evaluation of electronic discharge summaries: A comparison of documentation in electronic and handwritten discharge summaries

Background: Hospital discharge summaries have traditionally been paper-based (handwritten or dictated), and deficiencies have often been reported. On the increase is the utilisation of electronic summaries, which are considered of higher quality than paper-based summaries. However, comparisons between electronic and paper-based summaries regarding documentation deficiencies have rarely been made and there have been none in recent years. Objectives: (1) To study the hospital discharge summaries, which were either handwritten or electronic, of a population of inpatients, with regard to documentation of information required for ongoing care; and (2) to compare the electronic with the handwritten summaries concerning documentation of this information. Methods: The discharge summaries of 245 inpatients were examined for documentation of the items: discharge date; additional diagnoses; summary of the patient's progress in hospital; investigations; discharge medications; and follow-up (instructions to the patient's general practitioner). One hundred and fifty-one (62%) discharge summaries were electronically created and 94 (38%) were handwritten. Odds ratios (ORs) with their confidence intervals (CI) were estimated to show strength of association between the electronic summary and documentation of individual study items. Results: Across all items studied, the electronic summaries contained a higher number of errors and/or omissions than the handwritten ones (OR 1.74, 95% CI 1.26-2.39, p < 0.05). Electronic summaries more commonly documented a summary of the patient's progress in hospital (OR 18.3, 95% CI 3.33-100, p < 0.05) and less commonly recorded date of discharge and additional diagnoses (respective ORs 0.17 (95% CI 0.09-0.31, p < 0.05) and 0.33 (95% CI 0.15-0.89, p < 0.05). Conclusion: It is not necessarily the case that electronic discharge summaries are of higher quality than handwritten ones, but free text items such as summary of the patient's progress may less likely be omitted in electronic summaries. It is unknown what factors contributed to incompleteness in creating the electronic discharge summaries investigated in this study. Possible causes for deficiencies include: insufficient training; insufficient education of, and thus realisation by, doctors regarding the importance of accurate, complete discharge summaries; inadequate computer literacy; inadequate user interaction design, and insufficient integration into routine work processes. Research into these factors is recommended. This study suggests that not enough care is taken by doctors when creating discharge summaries, and that this is independent of the type of method used. The importance of the discharge summary as a chief means of transferring patient information from the hospital to the primary care provider needs to be strongly emphasised. Crown Copyright (C) 2008 Published by Elsevier Ireland Ltd. All rights reserved.