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AMA contributes to new guidelines

Two members of the AMA policy team have been thanked for their contributions to the first edition of the Guidelines for on-screen presentation of discharge summaries, developed by the Australian Commission on Safety and Quality Health Care.

Chair of the AMA Council of General Practice, Dr Richard Kidd, and Chair of the AMA Ethics and Medico Legal Committee Dr Chris Moy both took part in developing the guidelines.

Chief Executive Officer of the Commission, Adjunct Professor Debora Picone, expressed her gratitude to the doctors in a recent letter to AMA President Dr Michael Gannon.

“Development of the guidelines was supported by a clinical expert group that included and informed through an extensive national consultation,” Professor Picone wrote.

“I would like to take this opportunity to thank Dr Richard Kidd and Dr Chris Moy from the Australian Medical Association who contributed to this important work.”

The Guidelines for on-screen presentation of discharge summaries are available on the Commission’s website at: https://www.safetyandquality.gov.au/publications/national-guidelines-for…

According to the site, the guidelines specify the sequence, layout and format of the core elements of hospital discharge summaries, as displayed in clinical information systems.

They were developed through extensive research, consultation and iterative testing with more than 70 clinicians.

The guidelines are intended to be adopted by vendors of medical software, and health services that procure and implement systems which generate and present discharge summaries.

“The clinical handover of a patient on discharge from hospital generally occurs using an electronic discharge summary (eDS),” the guidelines say.

“A discharge summary is a collection of information about events during care of a patient by a provider or organisation, in a document produced during a patient’s stay in hospital, as either an admitted or non-admitted patient, and issued when or after the patient leaves the care of the hospital.

“Clinical handover is a known area of potential risk for patient harm, particularly in the transition from acute care to the community setting. Discharge summaries are critical for providing well-coordinated and effective clinical handover because they are the primary communication mechanism between hospitals and primary health care providers.”

In July 2012, the Commission was appointed to develop and manage a clinical safety program for the My Health Record system, which is a secure online summary of health information, personally controlled by individuals.

Patients’ discharge summaries can be added to their My Health Record. As part of the Commission’s clinical safety program, eight clinical safety reviews of the My Health Record system were completed.

The fourth clinical safety review, conducted in 2014, included an end-to-end investigation of the accuracy and data quality of eDS.

The guidelines were endorsed by the National Health Chief Information Officer Forum in August 2016 and presented at the Commission’s Inter-Jurisdictional Committee in October the same year, and are now freely available on the Commission’s website.

Other safety in e-health findings can also be found on the Commission’s website at: https://www.safetyandquality.gov.au/our-work/safety-in-e-health/

Chris Johnson