Closing information gaps with shared electronic patient summaries: how much will it matter?

Area of Science:

• Health Informatics
• Clinical Medicine
• Patient Safety

Background:

• Information deficits are a significant contributor to medical errors in healthcare.
• Previous efforts to improve health information flow include electronic patient summaries.

Purpose of the Study:

• To investigate information access and needs within inpatient emergency departments.
• To understand how clinicians manage information deficits.

Main Methods:

• An observational study of unplanned inpatient admissions was conducted.
• Data was collected using structured forms, free-text notes, and post-examination interviews with staff.

Main Results:

• Referrals frequently lacked essential patient history and medication information.
• Clinicians often relied on previous records and patient recall, with 10% of referrals missing crucial data.
• Patients sometimes provided supplementary information, but cognitive impairment affected data acquisition.

Conclusions:

• Despite most referrals containing some history, medication information was frequently sought.
• Information deficits caused stress, increased workload, and led to risky workarounds.
• An easily accessible, up-to-date patient summary is proposed to mitigate these deficits.