Standards for Electronic Patient Records Update

1. Standards for Electronic Patient RecordsUpdate Prof Iain Carpenter Health Informatics Unit& Professional Record Standards Body

2. 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,”

3. The Challenge • Meaningful Clinical information from Electronic Health Records

4. Current situation – record keeping • Now: • Records learnt by apprenticeship • No agreed standards • Differences between clinicians, departments, trusts • EPRs also can cause problems: • Piles of electronic pages instead of paper ones • Information can’t be shared safely between systems

5. Electronic records Patient management Research Disease registers Screening programmes Central returns Audit

6. Current situation- sharing information

7. Patient management Research Disease registers Screening programmes Central returns Audit

8. Clinical record standards • Structured to match the way we work • Patient and clinician involvement • Evidence based • Clinical and patient body acceptance

9. Integrated structure and content standards

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15. e-Referrals • Work with EMIS, InPractice and TPP to incorporate headings into templates • Templates made available on systems and communicated via mailshots • Engaged with LMCs • Piloted with InPractice and EMIS • Discussions with Choose and Book

16. Referral template

17. Core headings Core Information Admission Referrer The core information is enriched at each step 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 Handover Discharge

18. Ambulance care records

19. www.theprsb.org.uk

20. Role of PRSB • Brokering development of record standards • Editorial Principles • Stakeholders • professional assurance of record standards • Assurance criteria

21. Role of PRSB • prioritisation of standards development • Prioritisation principles • care professional guidance for those working on technical implementation of standards • Including system suppliers and vendors

22. HSCIC and PRSB Implementation Programme • Dissemination and communication • Technical products • Early implementers • Implementation guidance covering all aspects

23. Current issues • Care.data • Hospital.data • Paperless between primary and secondary care • E-referral • Digital care plans

24. Meeting the data return requirements 2020 2015 care.data big.data

25. Semantic Interoperability Care home record GP record Radiology system Hospital EHR

26. Summary • Problems with paper and electronic records • Standards for structure and content • Paperless between primary and secondary care • Full electronic health records • Delivering the data return requirements

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

28. Standardised record structure Standardised record structure