Search

Background: Clinical documentation is essential for communication between health professionals and the provision of quality care to patients., Objective: To examine medical students' perspectives of their education in documentation of clinical care in hospital patients' medical records., Method: A qualitative design using semi-structured interviews with fourth-year medical students was undertaken at a hospital-based clinical school in an Australian university., Results: Several themes reflecting medical students' clinical documentation education emerged from the data: formal clinical documentation education using lectures and tutorials was minimal; most education occurred on the job by junior doctors and student's expressed concerns regarding variation in education between teams and receiving limited feedback on performance. Respondents reported on the importance of feedback for their learning of disease processes and treatments. They suggested that improvements could be made in the timing of clinical documentation education and they stressed the importance of training on the job., Conclusion: On-the-job education with feedback in clinical documentation provides a learning opportunity for medical students and is essential in order to ensure accurate, safe, succinct and timely clinical notes., (© The Author(s) 2016.)

Electronic health records and the Internet will continue to transform how information is accessed and shared. Users of health data such as health professionals, governments, policymakers, researchers and patients themselves need to be able to access the right information at the right time and be confident in the quality of that information, whether personal, aggregated or knowledge based. It is essential to evaluate information systems and applications that claim to improve information quality and access in order to provide evidence that they support healthcare delivery and improve patient outcomes.

Patients have been able to access clinical information from their paper-based health records for a number of years. With the advent of Electronic Medical Records (EMRs) access to this information can now be achieved online using a secure electronic patient portal. The purpose of this study was to investigate maternity patients' use and perceptions of a patient portal developed at the Mater Mothers' Hospital in Brisbane, Australia. A web-based patient portal, one of the first developed and deployed in Australia, was introduced on 26 June 2012. The portal was designed for maternity patients booked at Mater Mothers' Hospital, as an alternative to the paper-based Pregnancy Health Record. Through the portal, maternity patients are able to complete their hospital registration form online and obtain current health information about their pregnancy (via their EMR), as well as access a variety of support tools to use during their pregnancy such as tailored public health advice. A retrospective cross-sectional study design was employed. Usage statistics were extracted from the system for a one year period (1 July 2012 to 30 June 2013). Patients' perceptions of the portal were obtained using an online survey, accessible by maternity patients for two weeks in February 2013 (n=80). Descriptive statistics were employed to analyse the data. Between July 2012 and June 2013, 10,892 maternity patients were offered a patient portal account and access to their EMR. Of those 6,518 created one (60%; 6,518/10,892) and 3,104 went on to request access to their EMR (48%; 3,104/6,518). Of these, 1,751 had their access application granted by 30 June 2013. The majority of maternity patients submitted registration forms online via the patient portal (56.7%). Patients could view their EMR multiple times: there were 671 views of the EMR, 2,781 views of appointment schedules and 135 birth preferences submitted via the EMR. Eighty survey responses were received from EMR account holders, (response rate of 8.1%; 80/985). The majority of respondents indicated they would use the portal and access their EMR for future pregnancies (86.2%; 69/80). Approximately half looked at their EMR after a visit with their care provider (51.3%); 41/80) and 37.5% (30/80) viewed their EMR before, to prepare for their visit. The majority (65.8%) thought that the EMR improved their ability to understand and recall appointments and almost half (48.1%) thought that with the EMR they were less likely to repeat pregnancy information to caregivers. This study provides the first Australian evidence of a patient portal system, tied to an EMR, working effectively in a maternity care context. It provides new evidence that portals can deliver benefits to maternity patients in terms of providing quick and easy access to current personal and general health information and support patients in their ability to recall and prepare for appointments.

The delivery of cancer services is primarily hospital-based; however, General Practitioners (GPs) have a key role to play within the context of a multidisciplinary model of care. In order to fulfill their role in cancer care GPs must receive complete and timely information from appropriate members of the hospital team. The aim of this study was to investigate perceptions of the quality, format and timeliness of the patient information GPs receive from a multidisciplinary hospital-based lung cancer team, and elicit how communication between the team and the GP could be improved. Data were collected using semi-structured interviews with a representative sample (n=22) of members of the hospital team and a sample of GPs (n=8). A grounded theory approach was used to categorise the data. Most communications with GPs were from medical officers; however, GPs desired information from all health professional groups in the hospital-based lung cancer team. Most GPs were dissatisfied with the timing of communication. A multidisciplinary discharge summary was suggested as a means of providing both clinical and social information from the team to the GP. Further developments in electronic health records could improve access to patient information by GPs. Results from this study illustrate the need for GPs to receive information from all members of the multidisciplinary hospital team so that they may fulfill their diverse role in supporting patients through all phases of the cancer journey.

General practitioners (GPs) are an integral part of the multidisciplinary team that care for patients with lung cancer. It is essential that patient information including results of tests, management plans, treatment, and follow-up arrangements are communicated between hospital-based carers and the community-based GP. The aim of this study was to explore GPs' views about the information they need from hospital-based health professionals in the management of their patients with lung cancer. This exploration is undertaken within the context of a multidisciplinary model of care, a relatively new concept in service delivery for cancer patients. Data were collected using a questionnaire that was distributed to the population of 433 GPs from one Australian regional Division of General Practice. Questions related to from whom, what, when and how GPs would like to receive information from the multidisciplinary hospital-based lung cancer team. GPs reported that they wanted information from all members of the multidisciplinary hospital-based lung cancer team, not just physicians. The key triggers for communication included: any change in the patient's condition; following initial outpatient visit; at admission and discharge; and following treatment milestones. Both medical and social information were seen as important to GPs and there was strong support to receive information electronically. This study illustrates the desire by GPs to receive information from all members of the hospital-based lung cancer team if it is relevant to the ongoing care of their patient. Technology-enabled solutions, such as an electronic multidisciplinary discharge summary, the electronic health record and the person-controlled electronic health record, offer strategies to improve both timeliness and access to information.

The exchange of health information between acute care providers (e.g. hospitals) and primary care providers (e.g. general practitioners) has traditionally been via hard copy discharge summaries. In recent years the advent of sophisticated information and communication technology has fuelled developments in electronic discharge referral systems (eDRS), which are credited with enabling more timely and accurate information exchange, enhancing patient care, and ultimately improving patient outcomes. The aim of this paper is to highlight key issues regarding the development and implementation of electronic discharge referral systems. A detailed literature review of information related to electronic discharge summaries was undertaken for publications between 1992 and 2006. While eDRS appear to be beneficial, further improvements are needed before systems are dependable. Through prospective enhancements and increased availability of eDRS internationally, electronic discharge referral systems have the potential to facilitate effective communication exchange across the primary-secondary care interface.

The aim of this study was to assess general practitioners' (GPs') satisfaction with the quality of information in electronic discharge summaries and the timeliness of their receipt of the summaries. The study was conducted in a 75-bed Australian public metropolitan hospital which uses an electronic discharge summary which is mailed to the patients' nominated GP. Eighty-five GPs were surveyed regarding their satisfaction with the content of the electronic discharge summary and the timeliness of receipt. the majority of respondents indicated that they had received the electronic discharge summary within two weeks of the patients' discharge from hospital. The majority also indicated that they were satisfied with all eight documentation data elements. Some GPs indicated that they would prefer to receive the electronic discharge summary electronically by email rather than by conventional mail, and that they would like more information in the "follow-up and recommendations" content areas of the summary. It was concluded that the majority of GPs agreed that the electronic discharge summary was an improvement over the manual discharge summary. Further developments in the safe and secure electronic transfer of discharge summary information needs to be addressed to meet the information needs of GPs.

In this study 85 adult patients attending a Sydney general practice were asked for their views on computer-assisted consultations; 77 (91%) agreed to participate. In general, patients agreed they could still talk easily with their doctor, and felt listened to, while the doctor used the computer (87% & 75% respectively). More than half the patients felt the computer contributed to better treatment, although a quarter believed consultations were prolonged. About half the patients agreed that the doctor did not often explain the role of the computer. Given the national plans for increasing computerisation of health records (HealthConnect), this research suggests that more attention should be given to involving patients in e-health developments.

The profile of health information managers (HIMs) employed within one metropolitan area health service in New South Wales (NSW) was identified, together with which information technology and health informatics knowledge and skills they possess, and which ones they require in their workplace. The subjects worked in a variety of roles: 26% were employed in the area's Information Systems Division developing and implementing point-of-care clinical systems. Health information managers perceived they needed further continuing and formal education in point-of-care clinical systems, decision support systems, the electronic health record, privacy and security, health data collections, and database applications.

The aim of this study was to analyse the inpatient statistics collection relating to stroke patients admitted to a major teaching hospital, with particular reference to length of stay, and to assess the adequacy of the diagnosis related group (DRG) as a predictor of length of stay. The study subjects were selected by DRG to identify all stroke inpatients admitted and discharged between 1 July 1995 and 30 June 2000. There were 1365 stroke discharges (half of whom were over 75 years of age at discharge) over the period of the study. The median length of stay was 8 days, and 67% of the subjects experienced complications and/or comorbidities. Age was significantly associated with increased length of stay of stroke patients, independent of complications or comorbidities. These findings raise the question of whether casemix-based funding should be based solely on DRGs for complicated conditions such as stroke, or whether additional measures such as age should be used for funding allocation. This study provides a model that health information managers and other researchers could use to analyse inpatient statistics collections at state, territory or national levels.

The first conference was held in Adelaide in August 2000. The conference was an initiative of the National Health Information Management Advisory Council (NHIMAC). NHIMAC was established in 1998 by the Australian Health Ministers to advise on options to promote a nationally uniform approach to more effective information management in the health sector. The second conference was held in Brisbane in March 2003, and this paper provides an overview of the key issues addressed there.

Clinician managers need relevant, current and integrated information to assist them in their managerial roles. This study examined the management information needs of clinician managers (doctors, nurses, data managers and a business manager) from a metropolitan teaching hospital. A purposive sample, of 15 clinician managers and five Information Unit staff who provide the clinicians with management reports, was interviewed by one researcher between July and September, 2001. The clinician managers indicated a preference for up-to-date, tabular or graphic management reports specific to their clinical specialty, and for education in interpreting the reports. The Information Unit staff members were willing to assist in these respects, and to present at Clinical Unit meetings to facilitate communication between the information providers and users. Clinician managers also required data for comparison with similar units within the area health service, or state-wide; they used the management reports mainly to assist with staffing and budgetary management. Continuous communication between providers and users of management information is essential to support the management function of clinicians.

The aim of this study was to ascertain which competencies health information managers (HIMs) working in public hospital positions perceived were important for effective performance. A health information management competency model was developed based on the Boyatzis (1982) managerial competency model and modified to take into account previous health information management competency documents and competency studies in the Australian health service management literature. A questionnaire, administered between July 1995 and June 1996, asked a sample of 306 health information managers (HIMs) from 71 New South Wales and Victorian public hospitals to rate the importance of managerial competencies for effective performance in their current roles. The study sample was split, post survey, into two groups, 'managerial HIMs' and 'coder HIMs,' in order to reflect important role differences. The results showed that the Personal and interpersonal skills competency cluster, which included leadership, motivation, problem solving, managing change and negotiation skills, was ranked as most important by managerial HIMs in NSW, and the Clinical classification skills competency cluster was ranked as most important by Victorian managerial HIMs. This difference was thought to be due to the casemix-based funding environment in Victoria at the time of data collection. Nearly all the competencies listed were perceived to be of 'high' to 'medium' importance (on a scale of 'low', 'medium' and 'high') by managerial HIMs from both states. Coder HIMs from both states perceived fewer competencies included in the developed model to be important; this highlights the divergent roles undertaken by 'coder HIMs' and 'managerial HIMs'. Further work is required on competencies of HIMs in roles other than hospital-based positions.