Professional approach to digital record standards

Using the core clinical model

1

Presented byNick BoothClinical Director - Information Standards Delivery

Outline

• The structures of HSCIC and NIB• How will information standards be created• What is the role of health and social care

(The PRSB)• AoMRC clinical record standards• Strategic considerations – the core clinical

model

The Health and Social Care Information Centre

HSCIC collects, analyses and publishes national data and statistical information for commissioners, analysts and clinicians. It also provides systems and infrastructure at a national level and sets standards for health and social care.

HSCIC is an executive non-departmental public body of the Department of Health

The role of the ISCG is to commission services within an agreed strategic framework and then to monitor their delivery against set objectives

NHS England - commissioning on behalf of the ISCG

NIB National Information Board

Structures as at 01 April 2014

NIB

Regulators

SCCI

DH

NHS ENGLAND Professions

CAGNational Information Board

Standardisation Committee for Care Information

Social CarePublic Health

England

PRSB UKTC Classifi-cations

Clinical Models PCISS Data

Dictionary

INFORMATION STANDARDS DELIVERY

HSCIC

Professional Records

Standards Body

Patients

Professional Bodies Regulators

Local Clinicians

Suppliers Local NHS orgs

Health and Social Care Information Centre

Adoption in NHS+SC organisations

SCCINHS

EnglandPHE

DH-SCothers

Information Standards Delivery

NMC, GMC,Regulators

CQC

NICE

Monitor

Collaborative design

Research

Social carers

April 2013

PRSB

PRSBQuality

Assurance

Coherence Brokerage

Advice One Stop

Shop

PatientView

Increased Adoption

Increased Quality

Reduced Cost and Timescale

Work of PCISS

• National Laboratory Medicines Catalogue (PCDIP)– Pathology Catalogue development and implementation

programme

• Ambulance Clinical Documentation Project

• AoMRC multipurpose message• MyCareRecord

• PRSB – management of the HSCIC – PRSB relationship

Foundations for coherent record and data standards

GP2GP

Record Keeping Standards - AoMRC 2008

Clinical Documentation Standards (CDGRS) - Royal College of Physicians / AoMRC 2013

Experience of “Clinical Content” in National Programme for IT

Acute and mental health trust medical directorsAssociation for Clinical BiochemistryAssociation for Palliative Medicine of Great

Britain and IrelandAssociation of British Clinical DiabetologistsAssociation of Cancer PhysiciansAssociation of Directors of Adult Social ServicesAssociation of Surgeons of Great Britain and

IrelandBritish Association for Parenteral and Enteral NutritionBritish Association for Sexual Health and HIVBritish Association of Audiovestibular PhysiciansBritish Association of DermatologistsBritish Association of Oral and Maxillofacial

SurgeonsBritish Association of OtorhinolaryngologyBritish Association of Paediatric SurgeonsBritish Association of Plastic, Reconstructive and Aesthetic Surgeons

Who participated?

And...British Association of Stroke Physicians

British Association of Urological Surgeons

British Cardiovascular Society

British Dietetic Association

British Geriatrics Society

British Infection Association

British Orthodontic Society

British Orthopaedic Association

British Pain Society

British Pharmacological Society

British Psychological Society

British Society for Gastroenterology

British Society for Haematology

British Society for Human Genetics

British Society for Immunology

British Society of Rehabilitation Medicine

British Thoracic Society

Chartered Society of Physiotherapy

Choose and Book clinical leads

Chronic Pain Policy Coalition

Clinical Genetics Society

College of Emergency Medicine

College of Occupational Therapists

Department of Health Informatics Directorate –

Patients and Public Clinical Division

EMIS

Faculty of Occupational Medicine

Faculty of Pharmaceutical Medicine

Faculty of Sport and Exercise Medicine

Health and Care Professions CouncilIn Practice SystemsIntensive Care SocietyLocal Medical Committee ChairsNational VoicesNHS LondonNursing and Midwifery CouncilNutrition SocietyTPPRenal AssociationRoyal College of AnaesthetistsRoyal College of General PractitionersRoyal College of MidwivesRoyal College of NursingRoyal College of Obstetricians and GynaecologistsRoyal College of OphthalmologistsRoyal College of Paediatrics and Child HealthRoyal College of PathologistsRoyal College of PhysiciansRoyal College of Physicians – Patient and Carer NetworkRoyal College of Physicians and Surgeons GlasgowRoyal College of Physicians of EdinburghRoyal College of PsychiatristsRoyal College of RadiologistsRoyal College of Surgeons of EdinburghRoyal Pharmaceutical Society of Great BritainSociety of British Neurological SurgeonsUK Terminology Centre

And who signed them off..Association for Clinical Biochemistry

Association for Palliative Medicine of Great Britain &

Ireland

Association of British Clinical Diabetologists

Association of Cancer Physicians

Association of Surgeons of Great Britain and Ireland

British Association for Parenteral & Enteral Nutrition

British Association of Audiovestibular Physicians

British Association of Dermatologists

British Association of Otorhinolaryngology (Ears, Nose

and Throat) (ENT – UK)

British Association of Plastic, Reconstructive and

Aesthetic Surgeons

British Association of Stroke Physicians

British Association of Urological Surgeons

British Cardiovascular Society

British Dietetic Association

British Geriatrics Society

British Infection Association

British Orthodontic Society

British Orthopaedic Association

British Pain Society

British Psychological Society

British Society for Gastroenterology

British Society for Haematology

British Society for Genetic Medicine

British Society for Immunology

British Thoracic Society

Chartered Society of Physiotherapy

Chronic Pain Policy Coalition (CPPC)

Clinical Genetics Society

College of Emergency Medicine

College of Occupational Therapists

Faculty of Occupational Medicine

Faculty of Sport and Exercise Medicine

Intensive Care Society

Renal Association

Royal College of Anaesthetists

Royal College of General Practitioners

Royal College of Midwives

Royal College of Nursing

Royal College of Obstetricians and Gynaecologists

(RCOG)

Royal College of Ophthalmologists

Royal College of Paediatrics and Child Health

Royal College of Pathologists

Royal College of Physicians and Surgeons Glasgow

Royal College of Physicians of Edinburgh

Royal College of Psychiatrists

Royal College of Radiologists

Royal College of Surgeons of Edinburgh

The Royal College of Surgeons of England

Royal Pharmaceutical Society (RPS)

Society of British Neurological Surgeons

The Core Clinical Headings and Model

http://www.rcplondon.ac.uk/resources/standards-clinical-structure-and-content-patient-records

Core Clinical Model

• These are the key core headings which are used to convey meaningful clinical information in a structured fashion

• Information under each heading can be coded or left in narrative form

Core headings

1. GP Practice

2. Patient Demographics

3. Participation in research

4. Clinical Summary

5. Reasons for Contact

6. Presenting complaints or issues

7. Family History

8. Diagnoses

9. Procedures

10.Assessment Scales

11. Investigations and Results

12. Problems and issues

13. Patient and carer concerns

14. Medications and Medical Devices

15. Allergies and adverse reaction

16. Safety Alerts

17. Plan and Requested Actions

18. Information given

19. Legal information

20. Person Completing Record

Core model can facilitate?

• Communication• Information reuse

– Clinical Audit– Commissioning– Choice– Continuing Professional Development– Research

Confidence and Quality

Information Movement

Primary Care Secondary Care Social Care

Clinical Message

*PRESENTING ISSUE

*DIAGNOSES

CURRENT PROBLEMS AND ISSUES

*OPERATIONS AND PROCEDURES

FAMILY HISTORY

INVESTIGATIONS AND RESULTS

MEDICATIONS

ALLERGIES AND ADVERSE REACTIONS

Core InformationReferrer

Admission

HandoverDischarge

By agreeing a ‘core’ information standard we can allow individual systems to share information

This ‘core’ information can then be saved on each individual system

The core information is enriched at each step

Newcastle Discharge

Venogram done 13/6/12

Arrived on system 13/6/12

Apply the core clinical headings to extract key clinical information from...

• Hospital eDischarge Summary (eDS)• Nursing Documentation• Emergency Department eDS• Outpatient Letters• Handover Documents• Referral Letters• Transfer Documentation

Discussion

Standards for the clinical structure and content of patient records

http://www.rcplondon.ac.uk/projects/healthcare-record-standards