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The standardized and rapid communication of patient care details between healthcare institutions andreferring providers is central to the improvement of healthcare delivery.

Challenges for HIT vendors are universal: a highly competitive market, software functionality issues, unrealistic visions and customer dissatisfaction. At the 11th annual Oacis Users’ Group Conference, I discovered some impressive customer success stories. One in particular describes how success can be achieved incrementally. The story is told by Oacis users from South Australia and it revolves around the deployment of an EHR system to eight hospitals and associated clinics in the state of South Australia. Though originally slated for the renal service only, the benefits realized were so immediate that the department of health decided to expand functionality and continue the implementation to include hospitals and clinics throughout the state (see Figure 1).

One of the most impressive achievements is the separation or discharge summary, a brief snapshot of the health of a patient at a particular point in time. By achieving standardized and rapid communication of patient care details between healthcare institutions and referring providers, the South Australia experience is an exemplar both on that continent and for North America as interoperability standards become central to the improvement of healthcare delivery. In fact, South Australia’s discharge summary is well-aligned with the continuity of care record standard being published by ASTM International, one of the largest voluntary standards development organizations in the world. It allows a primary care provider timely access to useful and potentially life-saving information from the patient’s previous episode of care, so that care can continue uninterrupted when the primary provider resumes responsibility. In the United States today, patient information remains locked in silos available only to providers practicing in the same facility; referring and community providers typically do not have ready access to information about their patients’ care in those facilities.

In South Australia, the facilities across metropolitan Adelaide may have different clinical care systems (laboratory, radiology, therapies, etc.) but because of the robustness of the EHR’s data repository, information captured in those systems is immediately available to all providers in each facility. This means the data is also instantly available for automating the compilation of intelligent discharge summaries. This benefits the referring or primary provider because pertinent patient data is available in hours rather than days. As a physician, I see a vast improvement in this model since I could have potentially life saving information in my hands prior to the next patient encounter — rather than having to hunt down that information when the patient appears in my office.

Typically the discharge summary is a document that a physician writes post-discharge that captures a variety of data intended to inform the primary or referring provider of the highlights of the patient care episode. This information could be but is not limited to patient allergies, current medications, consultations, procedures, test results, operative report, admitting and discharge diagnoses and description of the course of the patient’s hospital stay or encounter. Having been the recipient of many discharge summaries, I have concluded that the differences between a good summary and a bad one are profoundly important. A good summary provides concise and accurate information and helps ensure continuity of care of the patient. A haphazard summary is an unnecessary obstacle and may even be dangerous. A bad or incomplete summary forces the reader to take the time to go through the body of the chart to glean the information that is not readily available in the summary — assuming the reader even has access to the patient chart. The discharge summary implemented in South Australia leverages the power of the EHR’s data repository to automatically update and pull forward information on the patient throughout the encounter or hospitalization, thereby ensuring consistency and completeness in the final summary report.

A high degree of physician acceptance of the South Australian discharge summary is reported, perhaps because a wide range of information is automatically populated into the draft summary for the physician to consider. The specific information presented can be customized by each facility or provider, and is typically organized into logical sections:

• Patient demographics;
• Allergies;
• Current medications;
• Problem list or diagnosis;
• Procedures or surgeries;
• Clinical synopsis;
• Test results;
• Discharge plan;
• Hospital details;
• Nurse and ancillary notes;
• Encounter included in summary; and
• Future appointments.

In addition to automatically populating fields with online data from the current episode, the discharge summary can be integrated with voice recognition software to speed completion of comment fields.

The practical patient safety benefits of a timely and well-written discharge summary can be illustrated by a simple example. Assume Susan arrives at the emergency room with an acute case of appendicitis. Thankfully she is already in the facility’s EHR system, and the ER staff note her allergy to penicillin. Susan is taken to surgery and prepped with Betadine, which leads to a severe skin reaction and wound infection that delays her discharge. Upon completing the discharge summary, the care team includes the updated allergy information on the summary and transmits it via secure email to Susan’s primary care provider. Susan’s doctor is now immediately informed of this important new information and can monitor her condition carefully in follow-up care. Timely access to such critical data for the provider can also translate into appropriate patient education in the primary care setting, since Susan may not have remembered the Betadine allergy in the confusion of the ER admission. This example is mirrored in the South Australian model, where allergies and medications are updated and carried forward from the Oacis EHR to the discharge summary automatically.

In my clinical practice, I would see a patient in my office for routine follow-up after the patient had previously been seen by clinicians at another facility. My staff would spend at least an hour questioning the patient and telephoning other facilities to determine the most recent test results, current medications and recent therapies performed. Access to a current discharge summary would save my staff, me and the patient a significant amount of time. Since I practiced in a rural environment, I often referred patients for care to a larger facility 100 miles away. My patients often had diagnostic tests performed and new medications initiated, then presented to me for care before I ever received correspondence from the consultant detailing the patient’s care. Given the application used in South Australia, I would have had immediate access to all pertinent patient information without being an attending physician associated with the testing facility.

What about the cost savings to the patient? The cost benefit would be evident if a patient went to a consulting physician who decided to start the patient on a new medication that required liver function tests. On her next visit to her primary care physician, she reports the new medication but does not recall that liver function tests were performed. If her primary physician has a timely and thorough discharge summary, the patient avoids the costs of duplicate testing and also the discomfort and inconvenience associated with another trip to the lab — especially important for patients living in rural areas. Potentially this could improve patient compliance since redundancy could be virtually eliminated. Physicians do not want to order duplicate tests, and if the patient is unaware of tests that were previously performed and there is no record available for the physician to view, this can easily occur, and quite often does. The South Australia EHR helps eliminate duplicate testing in just this way, where benefits accrue both to the patient and the state health system. Deployed in the U.S., fewer unnecessary testing equates to less claims processing and review for insurers and health care professionals and ultimately reduction in patient anxiety.

Even a cursory review of the literature reveals compelling data regarding the importance of timely discharge summaries. One article written by Dr. van Walraven showed that discharge summaries were available only 15 percent of the time and that 27 percent of patients discharged from a hospital were urgently readmitted. Another article discussed the trend toward decreased readmission if the primary provider had access to a discharge summary but concluded that further study was needed to quantify that trend. As a physician, I do not need further study to acknowledge that access to a good discharge summary would help prevent the readmission of any one of my congestive heart failure patients. An accurate discharge summary available at the first follow-up visit is worth more than words can express to the patient and the provider.

Supporting Technology

At the core of the South Australia clinical information system is the Oacis EHR, a comprehensive, longitudinal, patient-centered repository that delivers real-time clinical information whenever and wherever it is needed. The South Australian Oacis repository contains approximately 260 million service records, over 12,500 trained clinical users from over 400 clinical units, and nearly 50 HL7 interfaces into the repository. The system is run in a highavailability environment and currently stores 1.2 terabytes of data, growing at the rate of approximately 1 gigabyte per week and processing an average of 80,000 transactions per day.

Relevance to Interoperability Movement in the U.S.

I enjoyed reading the statement from HIMSS in June 2005 about interoperability.We seem to find different buzzwords every few months without having a solid understanding of how it pertains to HIT until a few months later, when another word is found and the cycle starts again. The six key characteristics of interoperability made in this statement were: uniform movement of data, uniform presentation of data, uniform user controls, uniform safeguarding data security and integrity, uniform protection of patient confidentiality, and uniform assurance of a common degree of system service quality. Upon reviewing the South Australians’ discharge summary implementation, I found consistent parallels regarding this statement and the system used by our friends in Australia. The uniform movement of data was easily seen in the discharge summary distribution (via email, fax or postal service). Security and patient confidentiality is addressed at each facility and within the system itself. Uniform presentation of data was seen on each of the discharge summaries but allowed for each facility to decide what information was to be included on a patient-by-patient basis.

The South Australia Oacis EHR delivers both out-of-the-box functionality and a toolset that allows the end user to tailor the system in support of their workflow. I think that this end user functionality leads to increased end user support and satisfaction. Each facility was able to include in its discharge summary those important pieces of data that they deemed necessary for a complete document. Further increasing end user satisfaction is the ability for users to decide what particular vital signs and laboratory or radiology reports are needed to make this a complete and succinct document; and retrieving all that information automatically from the EHR reduces the time required for clinicians to complete the summary.

In summary, the South Australia state government set out to “improve the quality and safety of services, to strengthen and reorient services toward prevention and primary healthcare, to develop service integration and cooperation. …” This paper has discussed the coordinated efforts of the hospitals and clinics in South Australia based on their deployment of a patient-centric interoperable EHR.

The discharge summary is key to continuity of care for the patient and for the primary care provider. The discharge summary can alleviate the need for the patient to repeat allergies and medications to every facility and clinician providing patient care. The automated version implemented in South Australia can augment the process of dissemination of these important discharge summaries to the primary care provider or to another facility or physician who might treat this patient.

A system that automatically adds data to the discharge summary and updates it can decrease the amount of time a provider has to document, while making it easier for the provider to complete that final piece of critical patient information.

Those in the U.S. who are extolling the virtues of interoperability and RHIOs should take a closer look at what Australia has accomplished as a model to incorporate into our vision of the future.