Centre for Health Informatics, Australian Institute of Health Innovation, University of New South Wales, Sydney, NSW, Australia.
Med J Aust. 2011 Jan 17;194(2):90-2. doi: 10.5694/j.1326-5377.2011.tb04176.x.
Electronic referrals and discharge summaries can improve the quality and timeliness of clinical communication. The electronic summary care record (SCR) extends the concept of digital health summaries to create a perpetually updated and centrally stored summary of care, extracting key data from local systems after each encounter. The only major SCR evaluation to date, in England, found that rates of usage were low, and any impact on care was difficult to quantify. The SCR is seen by some as a first step to building a national distributed shared electronic health record (SEHR). However, the SCR may be a problematic diversion, creating a need for centralised databases, while the SEHR can function by sharing locally stored records, letters and discharge summaries. Uncertainty about the quality and provenance of SCR data raises concerns about patient safety, as key data may be absent and old data may persist, partly because of a lack of ownership of the summary. A national e-health strategy should emphasise the true stepping stones to a distributed and shared electronic record, including encouraging the uptake and meaningful use of electronic clinical records, clinical messaging, electronic discharge summaries and letters, and services such as decision support and e-prescribing, all of which have good evidence to support them.
电子转诊和出院小结可以提高临床沟通的质量和及时性。电子总结护理记录 (SCR) 将数字健康摘要的概念扩展为创建一个持续更新和集中存储的护理摘要，在每次就诊后从本地系统中提取关键数据。迄今为止，英国进行的唯一一项重大 SCR 评估发现，使用率很低，并且很难量化对护理的任何影响。SCR 被一些人视为构建国家分布式共享电子健康记录 (SEHR) 的第一步。然而，SCR 可能是一个有问题的转移，它需要建立中央数据库，而 SEHR 可以通过共享本地存储的记录、信件和出院小结来发挥作用。SCR 数据的质量和来源的不确定性引起了人们对患者安全的担忧，因为关键数据可能缺失，旧数据可能仍然存在，部分原因是对摘要缺乏所有权。国家电子健康战略应强调实现分布式和共享电子记录的真正步骤，包括鼓励采用和有效使用电子临床记录、临床信息、电子出院小结和信件以及决策支持和电子处方等服务，所有这些都有充分的证据支持。
