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Paperless Patient Records - Fact or Fantasy? City University Joint Symposium 2002

Paperless Patient Records - Fact or Fantasy? City University Joint Symposium 2002. Dr Peter Drury Head of Information Policy, Department of Health. Electronic Records: The (neverending) NHS story. Principles of Information for Health. Information and information systems will be person-based

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Paperless Patient Records - Fact or Fantasy? City University Joint Symposium 2002

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  1. Paperless Patient Records - Fact or Fantasy? City University Joint Symposium 2002 Dr Peter Drury Head of Information Policy, Department of Health

  2. Electronic Records: The (neverending) NHS story

  3. Principles of Information for Health • Information and information systems will be person-based • Systems will be integrated to achieve a whole systems approach • Management information will be derived from systems used in direct patient care • Information will be secure and confidential • Information will be shared across the NHS and ultimately across health and social care

  4. The NHS Plan Providing a health service fit for the 21st century by shaping its services around the needs and preferences of patients: • far greater information on staying healthy and using health services • more information on the care planned and likely outcomes • reduced waiting for tests, diagnosis and treatment • easier access to medical records • convenient appointment booking

  5. A patient pathway

  6. Definitions • Electronic Patient Record - a record of periodic care provided by one institution, typically an acute hospital • Electronic Health Record - the concept of a longitudinal record of a patient’s health and healthcare to combine information from primary healthcare with periodic care from other institutions

  7. Why do we need an Electronic Patient Record? Labs A&E X Ray Therapies Patient Administration System Nursing Rx Theatre Chiropody HOME

  8. Imaging MCPs Prescribing Pharmacy Radiology Labs PAS History of Healthcare IT Strategic Focus / Trend 1980s 1990s 2000s Stand-alone islands of information Big-box HISS Solutions Integrated EPR Components PAS PAS Laboratory Radiology Nursing Pharmacy Financials Laboratory Radiology Interface Engine Nursing

  9. Six levels of EPR in secondary care (England) 6 Advanced multimedia and telematics Telemedicine, multimedia, PACS system. 5 Speciality specific support Special clinical modules, document imaging. 4 Clinical knowledge and decision support Electronic access to knowledge bases, embedded guidelines, rules, electronic alerts, expert system support 3 Clinical activity support Electronic clinical orders, results reporting, prescribing, multi-professional care pathways 2 Integrated clinical diagnosis & treatment Integrated master patient index, departmental systems. 1 Clinical administrative data Patient administration and interdependent department systems.

  10. EXTERNAL COMMUNICATION Referrals & discharges including transfers of care Periodic reviews (chronic conditions) Booked appointments, HES data Other clinical letters CLINICAL NOTING Characteristics History Family history Social circumstances Examination findings Test results Diagnosis Outcome Actions Assessment Treatment Clinical administration Participation Role Views Problems Alerts Reasons for encounter DEMOGRAPHICS NHS Number Name Address Date of Birth Sex Registered GP Next of kin Clinical and non-clinical communications INTERNAL ADMINISTRATION Dates (Scheduled, actual) Locations (wards etc) Actions (theatre apt) Review dates Electronic Patient Records EPR

  11. The EHR will hold summarised key data about patients, such as name, address, NHS Number, registered GP and contact details, previous treatments, ongoing conditions, current medication, allergies and the date of any next appointments. The EHR will be securely protected, created with patient consent, with individual changes made only by authorised staff. Press release: reference 2001/0062

  12. Overview of the EHR The first generation EHR will contain: • Patient demographics, including NHS number • Emergency core dataset • Information provided by patients • Links to more detailed information in EPRs • Links to care professionals involved in a patient’s current care

  13. EHR supports different organisational and EPR boundaries

  14. EXTERNAL COMMUNICATION Links to information in EPRs Links to care professionals involved in on-going care PATIENT PROVIDED INFORMATION Next of Kin Donor Information Values, beliefs, wishes Consent to sharing EHR information Validation of information in EHR Qualification of information in EHR Non-prescription medications DEMOGRAPHICS NHS Number Name, Address Date of Birth, Sex Registered GP/Contact details HA/EHR identifier Potential ‘Patient URL’ EMERGENCY CARE CLINICAL INFORMATION Alerts, Allergies Current Medications Diagnoses (Ongoing, Significant) Current appointments (D), Vaccs and Imms (D) Electronic Health Records EHR

  15. The minimum first generation EHR by 2005

  16. Generational development of the EHR 2005-2010

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