Information Standards for Clinical Records

1. Information Standards for Clinical Records 22 October 2008 Royal College of Physicians

2. Aims for today Explain the rationale for clinical standards for the structure and content of patient records Describe progress so far Increase and broaden participation Identify the next priority areas Explore how this can be taken forward

3. What standards are needed for electronic patient records? A unique patient identifier Common identifiers for professionals and organisations Relevant specialty identifiers Standard definitions for demographic, administrative and organisational data A comprehensive clinical terminology for coding Professionally developed and agreed standards for the structure and content of the record, appropriate to the context in which it is being used

4. Why? Quality of the record Quality of care Patient�s safety Increased efficiency Secondary uses of the data

5. Quality of the record �The most common issue which affected the accuracy of clinical coding was the quality of the source documentation� PbR Data Assurance Framework 2007/08 Audit Commission Aug 2008 �The Healthcare Commission has once again identified record keeping as one of the weakest areas of NHS performance in its annual health check� E-Health Insider October 2008 Variations in reporting of endoscopies by different endoscopists Spencer et al Clinical Medicine 2007;7:23-27

6. Why? Quality of the record Quality of care Patient safety Increased efficiency Secondary uses of the data

7. Quality of Care Record design can affect patient outcomes Wyatt JC & Wright P Design should help use of patients data. Lancet 1998;352:1375-8 (& 1539-43) Structured records improve care and doctors performance Mann R & Williams JG Standards in medical record keeping. Clinical Medicine 2003;3:329-332

8. What might trigger a performance assessment by the GMC?www.gmc-uk.org/concerns/doctors_under_investigation/performance_assessments.asp a tendency to use inappropriate or outdated techniques; a basic lack of knowledge/poor judgement; a lack of familiarity with basic clinical/administrative procedures; poor record keeping or failure to keep up-to-date records; inadequate practice arrangements; concerns over referral rates; inadequate hygiene arrangements; poor prescribing.

9. Why standards for the record? Quality of the record Quality of care Patient safety Increased efficiency Secondary uses of the data

10. Patient Safety �The transfer of a patient to the care of the oncoming team is the point at which the patient is most vulnerable�. Poor or incomplete information is often handed over with potentially disastrous consequences� Guidance on Safe Handover Royal College of Surgeons March 2007

11. Why? Quality of the record Quality of care Patient�s safety Increased efficiency Secondary uses of the data

12. Increased efficiency Reduction in the need for staff to learn new approaches in new environments Reduced duplication of data entry in electronic records Data capture appropriate to the clinical context

13. Secondary uses of the data �For the future the multiple methods and systems for collecting data must be reduced. Data must be collected as the by-product of clinical care.� Bristol Royal Infirmary Inquiry July 2001 Structured, coded records are necessary for data aggregation and analysis, in order to support: Activity analysis Audit Research Performance

14. Gastroenterology 50% sites unable to provide activity data on endoscopy Evaluating Innovations in the delivery of endoscopy services Williams et al 2008 SDO Programme Final Report National audits unable to use routinely collected data (Colonoscopy; ERCP; IBD)

15. Research Opportunities are emerging to integrate patient care and research Retrospective studies Disease registries Multicentre trials

16. Record StandardsWhat have we achieved so far? A standard structure for all admission, handover and discharge documentation Supported by Connecting for Health Evidence based � literature & practice Wide consensus Piloted in practice Endorsement by the Academy of Medical Royal Colleges

17. What do we want to achieve today? Identification of other clinical contexts where standardisation of the record is needed Prioritisation of the top 5 in each specialty or discipline (Assessment of commonality) A clear view as to how each specialty or discipline would gain consensus