Re: Discharge summaries

The editorial titled “Discharge Summaries” (BCMJ 2017;59:293) suggests that frustrations of dictation have changed little in the past 40 years, since I graduated from medical school. Thank you, to the practitioners who perform the onerous task. Anesthesiologists are primary consumers and appreciate finding a typed, concise oasis of information in the illegible chaos of a hospital chart. Ironically, the technology has long existed for simple and inexpensive one-time systematic adaptation, but for some reason administrative will has been lacking.

At the pre-admission clinic at Vancouver General Hospital in the 1990s, dictation frustrations were dealt with by creating a template and dictating only critical information: demographic (which invariably the admission, discharge, and transfer hospital software put in automatically), diagnostic (presentation, symptom, physical, lab), progress, outcome, recommendations, etc., which were then slotted into blank spaces in the preformatted document, producing consistent, concise, grammatically correct, and legible documents quickly and with minimal effort. This system would be equally efficient with keyboard entry instead of dictation.

Modern e-records can do the same thing. Historical information, which never changes, could be archived on an ongoing basis, and slotted into the appropriate preformatted documents, be they admission notes, progress notes, consultations, or discharge summaries, with minimal effort and without the need to repeat data entry. The history of past health would be repeated automatically on the admitting record and the discharge summary, and a precis of present admission data would be added the next time in the history of past health section. A discharge summary could be primarily generated automatically using the keywords of progress notes, with only the disposition and the dates added, a huge saving in time and energy.

A medical record should be conceived as a block of patient information that is historically fixed but temporally in evolution, rather than the storybook narrative of current hospital charts. This concept could be extended to storing patient information on their MSP card and updating both the consumer and the provider at every health care encounter, completely eliminating the need to send for old records every time. But I am getting ahead of myself. Vancouver Coastal Health transcription bought into such a conceptual change a quarter of a century ago, but further evolution has not occurred. The inertial monster that is the health records establishment in Canada does not seem interested, and it is difficult to identify who to try to influence. A decade ago, when they eliminated paper records older than 40 years, it occurred to me that pediatric operative reports from the 1950s and ’60s would no longer exist because the surgeons and GPs would also have long retired. Meanwhile, that cohort of individuals was entering the age at which they were going to require more health care. I could not identify any route to voice my concerns.

I count the biggest failure in my career as being unable to bring user-friendly medical documentation into the 20th (let alone 21st) century before I retired. I pass on my thoughts to clinicians who have greater administrative skills than I. Good luck moving forward; take heart knowing that technologically and conceptually, at least, there are better ways.
—Laurence W. Lee, MD, FRCPC
Clinical Assistant Professor, Anesthesiology, Pharmacology, and Therapeutics 
UBC Faculty of Medicine