by John Rossheim
What if you could get virtually every doctor at every hospital to use the same discharge-letter template, entering all relevant notes about treatment and patient condition, with lab results and medication information automatically added from a central database? And then electronically transmit that letter to the patient’s primary care physician a day or two after discharge?
That scenario – a futuristic vision here in the United States – is a present-day reality in Denmark’s leading-edge health-care system. Beginning in the 1990s, Denmark has built an extensive and unified HIT infrastructure, using a creative mix of consensus building, market forces, peer pressure among clinicians and deliberate government action on national, regional and even municipal levels. The results are impressive. Among them: more productive physicians, better coordinated care, and a nation of patients who can securely view their own discharge letters and make choices about care providers based on performance data.
Of course, Denmark is not continent-spanning and diverse like America. Denmark has less than 2 percent of the population of the United States, and about 90 percent of its residents are of Danish descent. Still, elements of the Danish health-care model hold valuable lessons for American clinicians, health-care executives and discharge planners.
One of the most qualified teachers of those lessons is Ib Johansen, deputy manager at the Danish Centre for Health Telematics since 1994. Johansen oversees the development, testing and implementation of technology standards for the Danish health-care system and the MedCom standards and quality assurance organization. Johansen recently shared his insights with us regarding how his country’s health-care information system handles discharge data, and what the United States might take away from the Danish approach.
Curaspan: What is the discharge-planning process in Danish hospitals, and how does it incorporate electronic health records (EHR)? How does the one-template solution work as part of the discharge process?
Ib Johansen: When a patient is admitted to a hospital (from the waiting list or in acute condition) there is always a referral, on paper or electronic using our MedCom standards organization’s national template covering all hospitals. When the patient is released, a discharge letter is always sent to the patient’s family doctor (GP). All discharge letters are written in an HIS/EHR system at the hospital and sent electronically using the template.
What information is in the electronic discharge letter?
The discharge letter is a summary of what has happened with the patient in the hospital and of the patient’s condition at discharge. The content is based on history and information in the HIS/EHR in the hospital, including a very short summary of what has happened in the hospital; the main diagnosis and sub-diagnoses coded in ICD-10 and sometimes surgery codes; the main lab results; the medication upon discharge; recommendations for further treatment; and what the patient was told.
When is the discharge letter transmitted?
The discharge process and the writing of the discharge letter are normally handled by the physician on duty, and sent on the day of discharge or the next day. If the senior physician or head of department has additional comments they may be sent as a correction later on, though this doesn’t happen often. Hospitals always use the common discharge summary, a MedCom template. If there are diagnostics pending when the patient is discharged, the results will be sent when they are ready. But the discharge letter doesn’t wait for this.
Does the discharge letter alone cover everything that physician and patient need to know about post-acute care?
We have a discharge summary for hospitalized patients and another for outpatient clinics; the latter is normally a status report for a specific visit. So there may be several reports for ongoing treatment in an outpatient clinic. For patients who will receive home care or rehabilitation after discharge, the discharge letter will be accompanied by a home-care note or a rehabilitation note with recommendations for the rehabilitation.
After discharge, how much of the communication between doctor and hospital is online?
When a patient is discharged, the GP will take over care 100 percent from the hospital. All communication between hospitals and physicians’ practices is electronic, except for some referrals where, for example, images or ECGs are attached. E-mail is widely used for sending lab results to patients, so it plays some role but not much. The number of consultations in 2009 with GPs: 35 million; e-mail consultations: 1.8 million. Though there is higher payment to physicians for e-mail consultation compared to telephone consultation, and that encourages e-mail.
Where is there room for improvement in the Danish patient-discharge process?
The national medication project, which is scheduled for completion by the end of 2011, will implement a unified medication database that automatically incorporates patient information from all medication systems at hospitals, home care and GP. This online system will be automatically updated with medication information: dosage, indication and actual medication administered. The discharge letter will automatically include medication information. Also, all lab results will be available online to doctors and patients by the end of 2010.
We in the United States have to ask ourselves: What has enabled Denmark to make EHR virtually universal? Is it about technology, cultural and political attitudes, demographics or other factors?
The Danish approach is “Let’s see if it works – and why not try?” And the MedCom idea – it’s a nonprofit organization. And of course we are a very small country, with just 5.5 million residents and an area of 43,000 square kilometers. Our patients are well-informed, and everybody uses technology a lot. More than 95 percent of people have access to the Internet, and everyone gets free GP and hospital treatment.
Americans can be obsessive about individualism and local governance. What do you think could motivate a critical mass of American clinicians to accept a national standard discharge template?
Just propose it and document it fully with the involvement of clinical societies, vendors of HIS/EHR systems and EMR systems for GPs, and at least the leading public and private hospitals.
It is difficult to transfer culture and ideas. But part of our approach could easily be transferred: full transparency in standards and agreement on how to implement them. I think it should be done by an organization financed as a public/private company, or a fully private organization.
John Rossheim is a writer and editor who covers information technology, careers and other topics in health care.
