How to generate the Patient Summary from the Electronic Health Record

Does the general practitioner (GP) compile the Patient Summary (PS)? This seems to be one of most critical aspects to put in operation the Electronic Health Record (EHR). Which are the difficulties? How can we solve them?

Among the main critical points there are:

  • The nature of Patient Summary, which is a new document introduced with the EHR and not yet “metabolised” by the GP;
  • The time required for document compiling and updating, especially when the doctor does not properly insert data in the specific fields or in coded way, but uses the software mainly for compiling prescriptions and certificates;
  • The economic incentives necessary for its compiling represent for public health an additional cost to be sustained;
  • The completeness and reliability of its content, as the GP could be unaware or not remember all the relevant clinical aspects to be inserted into the PS;
  • The potential liability coming from the previous point, which many GP are worried about;
  • To a lesser extent, the inadequacy of software in use or, sometimes, the need to use a different system for this purpose.

The reality is then evident: the PS process finds difficult to start, so compromising the real usefulness and availability of the EHR as a tool of knowledge and summary of the patient’s health status.

A solution to overcome these problems can be represented by the EHR itself, evolving from a simple container of digital documents into a smart system to classify the clinical information. To reach this goal the EHR should be provided with a clinical logic and IT processes able to build the Patient Summary extracting the needed data from EHR documents.

The list of problems or chronic diseases can be derived, for example, from the treatments lied to pharmacological prescriptions, from ICD9/10 codes, from emergency reports, from Discharge Form and dismissal papers, from the analysis of some laboratory test results (extracted from the structured laboratory report).

Vaccinations could be obtained through the EHR feeding of immunisation certificates in HL7 CDA format, the interventions and the procedures from the Discharge Form and the second ones from the diagnostic test prescriptions.

Anytime a patient document is submitted into EHR, a software agent can access to all patient documents or alternatively to the last Patient Summary, to extract the relevant information and automatically generate an updated Patient Summary.

In this way a sort of Automatic Patient Summary will be available, based on the patient clinical documents, continuously updated, without additional work from GPs.
More information we put into the EHR, more this Summary will result accurate and useful.

Instead of generating a document in batch, we could recreate real-time a Patient Summary using a clinical dashboard which, on demand, collects and visualises the most relevant information.

The moment is now to adopt the ICT and Artificial Intelligence potentialities to create value from information that are inside the EHR!

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