Computerized discharge summaries: a new window for patient care monitoring.

Abstract

Automated fact extraction from discharge summaries of the hospital chart yielded a useful set of facts for characterizing the clinical history and care of a hospitalized patient. The extracted facts depict the clinical events of a single patient, whereas the aggregate of the facts reflects the hospital's pattern of health care. Automated analysis of the discharge summaries provides good data for monitoring quality of care: Appropriateness and timeliness of hospitalization, effectiveness of diagnostic hypothesis generation, judicious use of resources, iatrogenic problems (surgical complications, other therapeutic mishaps), and inconsistencies (such as an abnormal finding without follow-up) are some of the issues recognizable when studying the care rendered. Fiscal studies are facilitated by the 50 to 100 facts on each patient considered pertinent and significant by the physician. These facts on each patient provide a much better definition of the illness and the resources used than the currently used discharge abstract data for DRG grouping. Medical audit: Ongoing clinical self-audit and cost study should stimulate a hospital's medical staff to constantly improve the quality of patient care management, and to be aware of the cost of the various resources. Alternative treatment patterns can be compared in the institutional audit reports, based on outcome, patient satisfaction, and/or cost. Clinical medicine could use a multi-institutional fact data-base as a retrievable source of yesterday's clinical experience, to guide clinical decisions of today.