Usability of Electronic Health Record–Generated Discharge Summaries: Heuristic Evaluation

Background Obtaining accurate clinical information about recent acute care visits is extremely important for outpatient providers. However, documents used to communicate this are often difficult use. This puts patients at risk of adverse events. Elderly who seen by more providers and have transitions especially vulnerable. Objective study aimed (1) identify the elderly patients’ needed coordinate their care, (2) use assess discharge summaries, (3) provide recommendations help improve quality electronic health record (EHR)–generated thereby increasing patient safety. Methods A literature review, clinician interviews, a survey were categorize data recently discharged patients. Based upon those data, 2 guidelines creating useful summaries created. The new guidelines, along with 17 previously developed medical documentation usability heuristics, applied 4 simulated summaries. Results initial research effort yielded list 29 items that should always be included in 7 “helpful, but not necessary” items. Evaluation deidentified revealed none contained all 36 necessary items; between 14 18 missing. each had several other issues, they differed significantly organization, layout, formatting. Conclusions Variations content structure United States make them unnecessarily Standardization would benefit both patients, lowering transition–related events, providers, helping reduce frustration can contribute burnout. In short term, working EHR vendors follow based study. Meanwhile, additional human factors work determine most effective way organize present facilitate standardization.