27.01.16
Setting the standards for electronic documents and records
Source: NHE Jan/Feb 16
Jan Hoogewerf, Health Informatics Unit programme manager at the Royal College of Physicians, discusses the importance of standardising both the structure and content of NHS clinical records.
The Academy of Medical Royal Colleges’ (AoMRC) vision for health informatics, iCare, describes patient records as “the cornerstone of integrated patient care and the main source of data for the service and research” and recommends the standardisation of both structure and content of records right across the NHS.
Electronic document management is an important step towards fully digitised care records, which is hugely beneficial to the timely availability and access to records at point of care. But to ensure a longer-term outcome that supports care delivery, more emphasis should be placed on improvements in recording by medical professionals at point of care, in a standardised and structured way.
Enabling interoperability
Consistent and coherent standards for electronic records are crucial to interoperability, enabling information systems across different medical settings to talk to each other. This is vital to effective integrated care and would provide individuals with easy access to their own records online.
As well as supporting patient care, this standardisation will provide a rich and readily available data source that is valuable for clinical audit and research, also giving clinicians the information necessary for effective appraisal and revalidation. As a result, the requirement of many separate and costly data collections would be significantly reduced, which would in turn assist in easing some of the financial burden often experienced by research and audit programmes.
The Royal College of Physicians’ (RCP) Health Informatics Unit (HIU) started work on the standardisation of patient information 10 years ago, and has published recommendations relating to standards for referrals, admissions, handovers, discharge summaries and outpatient letters. Endorsed by 50 professional bodies, including the AoMRC, these standards are all evidence and consensus based, and were developed in consultation with patients, carers and frontline healthcare professionals.
As pioneers in this field, the work of RCP’s HIU has been recommended by the National Information Board Framework (NIB) in its report entitled ‘Personalised Health and Care 2020’, advocating the requirement for all organisational and clinical systems to implement these standards for the clinical structure and content of patient records. The NHS Standard Contract 2015 also states that the NHS Board intend to use all available commissioning levers in 2016 to help secure the comprehensive adoption of digital standards within the publicly-funded NHS and care arena.
Implementing standards
The focus now is on ensuring that these standards are implemented in all sectors across the NHS. To this end, RCP’s HIU is currently working with the Health and Social Care Information Centre (HSCIC) and the Professional Record Standards Body for health and social care (PRSB). The PRSB is a community interest company that brings together patient and professional bodies, including the royal colleges and Association of Directors of Social Services, to ensure that the record standards developed are focused on the patient and support multi-disciplinary care.
A key aspect of implementation is the development of national electronic message specifications, based on the clinical record standards, which IT system suppliers can take and implement in their own systems. These standards have now been produced by HSCIC for electronic discharge summaries and work is underway on other transfers of care, including information sharing across urgent and emergency care pathways.
National projects
Several national projects are also working in parallel to ensure that information communicated between hospitals and primary care can be reused without re-keying. These include the implementation of SNOMED Clinical Terms in primary care to allow both hospitals and GPs to use the same terminology and codes, and the inclusion of a requirement for GP systems to support standard electronic messages in the national GP Systems of Choice contracts.
These developments in standardised electronic communications are important to patient safety in many ways; one clear example is that information on diagnoses, procedures and medications undertaken in hospital can now be incorporated into the GP practice record without practice staff having to re-key the information, therefore reducing volume of work and the possibility of transcription errors.
In conclusion, there is clearly a strong case for patient- and clinician-led digital standards. Nationally agreed and endorsed standards now exist and NHS managers should be promoting implementation across all services, especially where integration of care across organisations and sectors is a priority.
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