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Abstract
Introduction The British Role 3 Hospital in Camp Bastion, Afghanistan, uses a different electronic patient record (EPR) to Defence Primary Health Care and the two cannot directly communicate. Consequently, hospital discharge information is transferred by printed letter to primary care, introducing a step where information can be lost. This study was designed to test the hypothesis that the primary care EPR contained an accurate summary of the secondary care admission.
Methods Cross-sectional information on consecutive General Internal Medicine patients at the hospital was collected and compared with the primary care EPR.
Results From April 2011 the hospital records of 270 patients were reviewed. 239 primary care records were available for comparison. Of 185 patients discharged back to their unit the EPR of 43.8% contained a comprehensive summary, 23.2% contained the scanned discharge letter and 50.8% contained an account of their hospital admission but not necessarily a comprehensive summary. Of the 54 patients evacuated to the UK, the EPRs of 48.1% contained a summary, 68.1% contained the scanned discharge letter and 75.9% contained some account of their hospital admission. More of the evacuated group had their admission documented in the primary care EPR (p=0.001). Only 56.5% of all primary care records contained some account of the hospital admission.
Discussion The primary care record is not a reliable record of operational hospital admission and presents an unrecognised potential patient safety issue. The systems responsible for the transfer of discharge summary data need to be appraised to prevent it continuing. Retrospective action should be considered to rectify this problem in former hospital patients.
- GENERAL MEDICINE (see Internal Medicine)
- PRIMARY CARE
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Key messages
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The EPR of the Role 3 Hospital in Camp Bastion and the primary care EPR cannot directly communicate. This introduces a manual data transfer step where information is frequently lost.
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Systems should be developed that prospectively improve data transfer between secondary and primary care and retrospectively recover missing information.
Background
The British Armed Forces use an electronic patient record (EPR) called the Defence Medical Information Capability Programme (DMICP) that can be accessed in primary care facilities throughout the world. Among the perceived benefits of EPRs, including DMICP, is immediate record keeping which is known to be more accurate than the later transfer of data from another source or based on human recall. EPRs also provide legible records and accurate prescribing, they allow clinical reminders to be set and enable audit and research using the integrated search tools.1–3 However, the use of the software is only as useful as the quality of data entry and too often this is dependent on the commitment of individual practitioners.4 Specifically with DMICP, we know that there have been problems implementing the system with variable quality in the transfer of the legacy paper records to the EPR as well as variability in read-code usage. (Cox AT, personal communication, 2014).
The Role 3 Hospital in Camp Bastion is a British military hospital based in Helmand Province, Afghanistan. The manning of the hospital during this study was primarily by British and American military medical personnel and it provides secondary medical care for the International Security Assistance Force, entitled civilian contractors and some local nationals. Hospital records are managed using an EPR called the Whole Hospital Information System that integrates demographic, clinical summary and investigations data into each patient record. A summary of each patient episode is generated on discharge from the hospital. A hard copy of this letter is given to the individual to deliver to his medical officer, one is kept in the patient's paper hospital record and one is passed to the defence primary healthcare service department that is colocated within the hospital building. This discharge letter is potentially the only communication between the hospital and a patient's medical officer who if even on the same deployment, may be distantly located. Clearly, it is important that this discharge letter is recorded in the patient's DMICP record as often it includes advice on further management, including rehabilitation, further investigations or occupational limitations.
This study was designed to investigate the documentation of hospital admissions on DMICP following discharge from the deployed Role 3 Hospital in Camp Bastion. The hypothesis to be tested was that the DMICP record for a patient provides an accurate reflection of the inpatient stay.
Methods
Cross-sectional admission details were collected for consecutive British Servicemen and women admitted under the General Internal Medicine (GIM) team at the Role 3 Hospital, Camp Bastion. The GIM team during this study consisted of a GIM consultant and trainee. Successive GIM trainees collected data on consecutive inpatients from April 2011 for 9 months. Demographic data including age, gender and disposal destination were collated. These details were cross-referenced with the patient's DMICP record after completing their operational tour to assess whether the discharge summary was scanned into DMICP, whether the admission was summarised in DMICP without the letter being scanned or whether any record of the hospital episode was documented.
The findings are presented in descriptive form. Statistical analysis was carried out using commercially available software (SPSS PASW Statistics Release V.18.0.0). Quartile–quartile plots and the Kolmogorov–Smirnov and Shapiro–Wilk tests were used to assess distribution normality. Significance testing was performed using the Student t test, the Mann–Whitney test or Fisher's exact test. A two-tailed p<0.05 was considered significant.
Authorisation for this study was obtained from the Research Directorate at the Royal Centre for Defence Medicine as two separate protocols; a first study collecting patient admission details from the hospital (protocol: RCDM/Res/Audit/1036/12/0305) and for the additional data collection using DMICP (protocol: RCDM/Res/Audit/1036/12/0322).
Results
A total of 270 UK military patients were discharged from the hospital from 23 April 2011 to 10 February 2012. At the point of cross-referencing with the DMICP records, 31 patients had left the services and their records were archived and unavailable for review. None of the individuals were discharged on medical grounds. The remaining 239 DMICP records were reviewed. The demographics of the two groups are summarised in Table 1. There was no difference between the groups in terms of age, gender, length of stay or disposal.
Summary of the patient characteristics
The results of the DMICP review are summarised in Table 2. Overall an episode summary, without necessarily the scanned discharge letter, was found in 44.8% of the DMICP records and the scanned discharge letter, without necessarily an episode summary, was present in only 31.8% of records. Both a summary and a scanned discharge summary were found in 20.1%. There was no record at all of the admission to hospital in 43.5% of patients. The proportions in whom the discharge letter was scanned or who had some record of the admission episode were greater in the group that was aeromedically evacuated to the UK (referred to as Role 4) when compared with those returned to their units (RTU). In the Role 4 group the proportion of patients who had no record of their admission dropped to 24.1% (p=0.001).
Summary of the DMICP findings and comparison of the RTU and Role 4 disposal groups
Discussion
These data demonstrate that there are differences in record keeping between those individuals in whom the illness resolved, allowing them to return to their operational roles, and the group of patients with presumably more serious illness that necessitated their return to the UK. A number of reasons might be hypothesised for these lower documentation rates in the RTU group. One reason may be that medical officers did not feel a minor ailment that required only a short hospital stay and completely resolved, required to be documented in the DMICP record. Differences in access to the DMICP system by deployed medical officers may have also played a role; remotely located doctors within Afghanistan had only occasional access to the electronic system and in many cases no access at all. These clinicians may also have been based in different locations to the servicemen and women for whom they were responsible. Both of these reasons might have increased the chances of the correspondence being unintentionally lost or intentionally destroyed. The opposite of these would be true for the Role 4 group who would have returned to the UK. The requirement for aeromedical evacuation from theatre implies that their illnesses are likely to have been more severe and so it would be more likely that their medical officer would feel they warranted recording. Given these characteristics it is surprising, therefore, that so many gaps in the DMICP record were also detected in this group.
This study looked only at the communication between the deployed secondary care facility and defence primary health care. It was not designed to investigate the underlying causes for deficiencies nor did it examine the types or severity of diagnoses that were not recorded in DMICP. We know that the majority of GIM admissions to the Role 3 Hospital are self-limiting, but certain serious conditions, including asthma, heat illness and various cardiac conditions, frequently present on operations and invariably result in transfer to Role 4. Conditions such as these would usually require primary care follow-up and likely downgrading in the UK. It is conceivable, but not demonstrated, that serious conditions, such as these, were not recorded in the DMICP record and patient safety was potentially compromised as a consequence.
Historically, a cadre of specialist medical clerks, whose specific expertise was managing medical records, maintained medical notes through each individual field hospital's medical records office. These roles were made redundant during previous restructuring, and under the current replacement system, it is not always clear whose responsibility it is to maintain these records. The first step in rectifying the current problem may be to identify a clear line of responsibility for data transfer and, if necessary, create a new cadre of clerks with whom this responsibility should lie. Increasing operational access to DMICP to the hospital staff, so that admission information can be entered directly into the patient record, would also improve the communication between the secondary and primary care EPRs.
Conclusions
Regardless of the underlying reasons for the problem in recording patient records, this study clearly shows that the systems in place at the time of this study were inadequate to ensure the timely and reliable transfer of potentially important medical information between secondary and primary care. This information should trigger a review of these systems to ensure greater information security and accuracy in the DMICP record moving forward. An appraisal of how missing data might be transferred retrospectively to the DMICP record might also be considered.
Acknowledgments
The authors are grateful for the assistance of the following: Surg Lt Cdr Matthew O'Shea, Maj Michael Stacey, Maj Jason Biswas, Maj Thomas Fletcher, Sqn Ldr Joanne Rimmer and Maj Samuel White.
Footnotes
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Contributors ATC conceived of the idea for this study and sought approval for it. ATC and TL played an equal role in the design, data collection and analysis. JL contributed to the analysis. SS and DW supervised the other investigators. All the authors were involved in the authorship of the manuscript.
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Competing interests None.
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Provenance and peer review Not commissioned; externally peer reviewed.