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Computerised reporting and terminology

Computerised reporting and terminology. John Williams BSG Endoscopy Section Symposium 19 March 2002. The current situation. 33% endoscopists still record on paper

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Computerised reporting and terminology

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  1. Computerised reporting and terminology John Williams BSG Endoscopy Section Symposium 19 March 2002

  2. The current situation • 33% endoscopists still record on paper • 79% have no computerised system in support of the rest of their work (BSG Information Working Party Baseline Survey 2000; replies from 55% of UK hospitals)

  3. Survey - qualitative comments • The following needs were specified in free text (251 replies) • Integration of systems (70) • Better departmental system (50) • Better or first endoscopy system (37) • Better IT support (36) • More resources or staff (35) • Better external links (31) • Better technology including image processing (22) • Better aggregate data (18)

  4. Overview • Fundamental requirements • Content of the record • Common standards • Integration and linkage • Other issues • Work of the BSG Information Working Party

  5. Purpose of the endoscopy record • Primary purpose • Procedure record for the individual patient • Source of data for communication • Secondary purpose • Source of data for aggregation for • activity analysis • audit • performance review • monitoring of training • research

  6. Requirements to meet these purposes • Primary purpose • comprehensive record of the procedure • linkage to other records - path, admin etc • linkage to data on other contacts - out-patient, in-patient, telephone etc • Secondary purpose • accurate, structured, coded data • common standards and definitions

  7. Overview • Fundamental requirements • Content of the record • Common standards • Integration and linkage • Other issues • Work of the BSG Information Working Party

  8. Data content of the record • Demographic • Administrative • Clinical • Technical The following guidance for the minimum content of the record has been agreed by the Endoscopy Committee:

  9. Pre-procedure - structured text • Demographic details about the patient • Administrative details (date, episode type, urgency) • Procedure • Referral source • Endoscopist • Whether supervised • Indication for procedure • ASA status/Rockall score • Instrument used

  10. Procedure - structured text • Sedation • Endoscopic findings • Specimens obtained • Endoscopic diagnosis • Therapeutic interventions • Results of intervention • Extent of examination • Limitations of examination • Time taken (total and to caecum) • Complications (technical and clinical)

  11. Record content - other information • Images • Annotated text to images • Free text comments • Discharge arrangements • Follow-up arrangements • Treatment recommended • Post procedure complications • Information given • Patient satisfaction • Final diagnosis

  12. Overview • Fundamental requirements • Content of the record • Common standards • Integration and linkage • Other issues • Work of the BSG Information Working Party

  13. Common standards (http://www.isb.nhs.uk) • Language and terminology • Minimal Standard Terminology (MST) (http://www.omed.org) • Headings • Headings forcommunicating clinical information (http://www.nhsia.nhs.uk/headings ) • Codes • SNOMED-CT (http://www.nhsia.nhs.uk/terms/pages/snomedct) • Administrative definitions • National Patient Access Team (http://www.health.secure.net/channels/npat or Eric.Gatling@doh.gsi.gov.uk)

  14. Do standards matter? • Quality of reports and communications • Common understanding of report content • Accurate and comparable data • eg NCEPOD are proposing to collect mortality data following endoscopy • HES data for 1999/00 identified 80,036 endoscopic procedures • Data from GI units in Wales alone identified 60,579 endoscopic procedures in 2000 • There were an additional 4,364 procedures undertaken in community hospitals in Wales

  15. Overview • Fundamental requirements • Content of the record • Common standards • Integration and linkage • Other issues • Work of the BSG Information Working Party

  16. Integration & Linkage • The endoscopy record will need to be part of a single clinical electronic record covering all patient contacts • It must also link to other systems within the organisation (eg Patient Administration; Pathology; Radiology)

  17. Other issues • All professionals who come into contact with the patient will need to be identified • Innovative methods of data entry need to be explored • Image storage will probably require an integrated approach within the organisation

  18. BSG Information Working Party • Has addressed these issues • A suite of documents is on the BSG website bsg.org.uk (in the members section), including: • specification of requirements for clinical systems in support of gastroenterology • content of the endoscopy record • image capture and storage • requirements for pathology systems • glossary of terms • Feedback would be welcome (j.g.williams@swan.ac.uk)

  19. Further work • The Working Party is exploring how potential solutions can be assessed for the benefit of colleagues, using a commercial consultancy • A generic version of the specification of requirements is intended to ensure compatibility between specialties and diciplines. It is available on the Academy of Medical Royal Colleges website (aomrc.org.uk)

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