Towards the Single Patient Record: Clinical Documents

1. Towards the Single Patient Record: Clinical Documents Ann Wrightson

2. Contents • What is a document? • Clinical viewpoint • Technical viewpoint • Where do documents come from? • Federated document stores and patient identity

3. Clinical viewpoint

4. Header Content Record element 1 Document header Record element 2-n Document body Document wrapper What’s a Document? A clinical communication describing a care event or episode of care A collection of clinical information stated at a particular time about a particular patient A source of information important for patient safety, eg medications, allergies

5. Wrapper, header and body • Wrapper • Not part of the document itself (may be removed) • Specific to a particular use of a document • May replicate items from the header or body • Header • Patient identity and demographics • Administrative information • Body • Clinical information • Key elements for patient safety are computable where possible

6. Priorities for Patient Safety • Core data 1 • Medicines Meds

7. Diags Allerg Probs Tests Proc Meds Priorities for Patient Safety • Core data 2 • Diagnoses • Procedures • Allergies • Tests

8. Social Family Care plan Exam findings Diags Allerg Probs Tests Proc Meds Priorities for Patient Safety • Additional elements • Social circumstances • Family history • Care plan • Etc.

9. Social Family Care plan Exam findings Diags Allerg Probs Tests Proc Meds Priorities for Patient Safety • Additional elements • Blood pressure • Head circumference • Weight • Height • Door to needle time • Etc.

10. Technical viewpoint

11. Content Header 0123450123 “The document” Patient Identity Recorded demographics Human readable

12. MPI, WDS “The” document ? Patient identity as recorded in the document allows the document to “belong” to an individual Patient Identity Recorded demographics Human readable Patient demographics as recorded in the document supports patient record administration.

13. Classification of this document in some context, e.g. as a clinical event or care plan “The” document Metadata to support records management of the document as an e-record Clinical Classification Records management Patient Identity Recorded demographics Human readable

14. Clinical Classification Records management Functional Metadata for Business Processes Processable, computable clinical information: “Record Components” Patient Identity Recorded demographics Human readable

15. Clinical Classification Records management Functional Metadata for Business Processes Processable, computable clinical information: “Record Components” Patient Identity Recorded demographics Human readable Document header Header Content Record element 1 Document body Record element 2-n

16. Clinical Classification Records management Functional Metadata for Business Processes Processable, computable clinical information: “Record Components” Patient Identity Recorded demographics Human readable Header Content Record element 1 Record element 2-n Folders may be actual collections, or views constructed using information from the documents Document participates in business process Envelope/wrapper for transport

17. Clinical Classification Records management Functional Metadata for Business Processes Processable, computable clinical information: “Record Components” Patient Identity Recorded demographics Human readable Header Content Record element 1 Document header Record element 2-n Document body Document wrapper

18. Local document store

19. Electronic document store Document scanning Content Header 0123450123 Scanned paper documents - Selected pre-electronic medical records - Correspondence

20. Patient folder Document scanning Scanned paper documents - Selected pre-electronic medical records - Correspondence Electronic document store

21. Patient folder Content Header 0123450123 “Born digital” narrative & preformatted documents Clinical correspondence eg prepared with MS Word templates

22. LIMS Disease specific systems Social care Content Header Header 0123450123 Content Record element 1 Record element 2-n “Born digital” narrative & preformatted documents Clinical correspondence eg prepared with MS Word templates Computable record components appear when they can be safely derived from input data

23. Welsh Clinical Portal MPI, WDS Document scanning LIMS Disease specific systems Social care View documents in WCP WCP makes documents available in a patient record …and creates them

24. Federated document stores …one way we might deliver clinical documents in the Single Patient Record

25. New LHBs in Wales Each LHB has its own document store (Same technology, separate instances) Each LHB has its own MPI (Same technology, separate instances)

26. Record stores (and PACS) wider integration using eg IHE XDS supporting “pull” requests

27. WDS PDS Record stores (and PACS) wider integration using eg IHE XDS supporting “pull” requests MPIs will also work in a federated way WDS already in place with link to PDS

28. End of slide set