Development of discharge letter module onto care2x hospital information system

Abstract

The discharge letter (DL) is an important means to communicate the information of the patient's hospital visit, treatments and care plans to the next caregiver and, possibly also, to the patient. Timely, precise and comprehensive discharge information transfer between patients care providers is critical for ensuring patients safety and effective care. A growing number of hospitals are implementing an open source system, Care2x as hospital information system (HIS) in Tanzania. One of the weaknesses for Care2x is that it cannot generate an electronic discharge letter. The main objective of this study was to develop an electronic discharge letter module and integrate it onto Care2x HIS. Interviews were performed with nine (9) physicians from three (3) hospitals, who were users of Care2x system, with a qualitative structured questionnaire to get their views and opinions on the contents of the discharge letter and on the corresponding usability requirements for it. Thereafter, a literature review on the following terms; Hospital Discharge letter, Hospital Discharge Communication, Care2x was performed. The schema of the new Discharge Letter module for Care2x HIS was developed and added to the existing Care2x schema. The DL module was implemented and users‟ user experiences were collected on the use of the developed discharge letter. In this study, the users were very satisfied with the electronic discharge letter. The users saw that the discharge letter module solved many problems associated with handwritten letter in terms of timeliness of production, the correctness of information, content, and legibility in hospitals which use Care2x.