BC Patient Summary Overview
A patient summary is a health record extract, at a point in time, comprised of a concise and clinically relevant collection of information (retrospective, concurrent, prospective), including the minimum necessary and sufficient data to inform a patient's treatment at the point of care (ISO/TR 12773-1:2009 Business Requirements for Health Summary Records). Patient summaries can help improve:
- Patient safety through the reduction of preventable harm caused by clinical errors and misjudgments
- Coordination of care and health outcomes during the patient's journey across health services
- Patient experience and satisfaction with care provided
- Clinical workflow efficiencies and provider experience
The patient summary will contain a curated human-readable document in a standardized style and format in alignment with national standards that incorporates a mix of free-text and discrete values from longitudinal and primary care networks or specialist EMRs. The patient summary will enable the replication of text to the health information system (HIS) and uses a file format that can be displayed natively without the use of a third-party viewer. A patient summary is:
- is concise and minimal
- is location/care-setting independent
- is specialty-agnostic (i.e., information in the patient summary is not filtered for a specialty)
- is condition-independent (i.e., the patient summary is not specific to a particular condition)
- is a consistent and easy way for healthcare practitioners to see their patients’ most important health facts at a specific point in time.
- reduces risks to patient safety by providing essential health care information to the health care practitioners who deliver care to a patient.
- reduces the need for patients (and their caregivers) to answer the same questions by different healthcare practitioners.
- improves the patient and practitioner experience by reducing the fragmented approach to accessing health information.
A patient summary is not:
- an exhaustive, comprehensive, longitudinal patient record
- a billing record (transaction level)
- an encounter-specific record
Clinical uses of patient summaries may include:
- Medical Emergencies
- Unfamiliar provider at the point of care
- Coordination/Transitions of care
- The scope includes the following four use case patterns for a curated patient summary by the primary care provider that may occur within the province of BC:
- Attached to eReferral/eConsult/eTransfer and consumed by receiving EMR/HA CIS
- Sent to HA CIS in the event that the patient has been or may be imminently admitted to a tertiary level of care
- Sent to a provincial repository for “on-demand” access for authorized providers to retrieve and view
- Sent to a provincial repository for “on-demand” access for patients and approved proxies to retrieve and view
- Foundational interoperability technologies that will support patient summary sharing include:
- Solution architecture specifications and standards
- A working proof of concept prototype where feasible
- Implementation/deployment plans, budgets, and a benefits/evaluation framework
- Business areas such as (BCMHSUS, Perinatal Services BC, Office of Virtual Health, and regional HAs) will be limited to initial intake and assessment for the creation or contribution to patient summaries. Subsequent separate funding requests will be made for each where applicable.
- End-points include private practice and HA EMRs, HA clinical systems, CareConnect, and patient portals/PHRs.
- Remuneration for providers to curate and/or share patient summaries TBD