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Standardising the content of clinical letters

Standardising the content of clinical letters. Standards for medical records Outcome based commissioning Towards a paperless NHS. ?. GP Surgery . District General . Hospital A&E . GP Surgery .  ASDA. District General . Treatment centre . Electronic Health Records.

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Standardising the content of clinical letters

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  1. Standardising the content of clinical letters Prof Iain Carpenter Health Informatics Unit

  2. Standards for medical records • Outcome based commissioning • Towards a paperless NHS

  3. ?

  4. GP Surgery  District General 

  5. Hospital A&E  GP Surgery   ASDA District General  Treatment centre 

  6. Electronic Health Records • Structured to match the way we work • Clinician engagement • Patient involvement • Clinical acceptance

  7. Developing standards for content and structure • On-line questionnaire on each of the proposed headings • Admission - 3,000 responses with detailed comments from 1,900 (91% said ‘a good thing’) • Handover and Discharge > 3,000 responses

  8. Developing national standards

  9. Outpatient and Referral Standards

  10. Core Headings and Editorial Principles

  11. Review of standards consistency

  12. The data for clinical outcomes • Based on NICE quality indicators • We believe principal data source will be primary care systems • Sources of secondary care clinical outcome data will be HES and hospital communications to primary care

  13. Delivering the paperless NHS • “I’m pushing for the end of 2015 to eradicate paper from the NHS. No more referral letters or lost records because we won’t have paper anymore in the health service,”

  14. March 2013 • announcement of requirements for data returns from primary care • Sept 2013 • announcement of requirements for data returns from secondary care

  15. “The requirements will be so great that the only way to achieve them will be to implement electronic health records” • Financial penalties for failing to achieve requirements from 2018

  16. Delivering the paperless NHS • Paperless between primary and secondary care

  17. Outpatient and referral letters

  18. Referral template

  19. Outcome based commissioning and discharge summaries

  20. Measuring Outcomes Severity of illness scales

  21. http://www.connectingforhealth.nhs.uk/systemsandservices/clinrecords/24hourhttp://www.connectingforhealth.nhs.uk/systemsandservices/clinrecords/24hour

  22. Information on the discharge summary project available at: • http://www.connectingforhealth.nhs.uk/systemsandservices/clinrecords/toolkit/24hour • http://tinyurl.com/discharge-summary

  23. Delivering the paperless NHS • Full Electronic Health Records

  24. Meeting the data return requirements 2018 2010 HES CES

  25. From mapping to interoperability

  26. From mapping to interoperability

  27. Standardised record structure Standardised record structure

  28. Summary • Standards for structure and content • Paperless between primary and secondary care • Outcome based commissioning • CQIN ?

  29. Further information • Informatics@rcplondon.ac.uk

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