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Professional approach to digital record standards

Professional approach to digital record standards. Using the core clinical model. Presented by Nick Booth Clinical Director - Information Standards Delivery. Outline. The structures of HSCIC and NIB How will information standards be created

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Professional approach to digital record standards

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  1. Professional approach to digital record standards Using the core clinical model Presented by Nick Booth Clinical Director - Information Standards Delivery

  2. Outline • The structures of HSCIC and NIB • How will information standards be created • What is the role of health and social care (The PRSB) • AoMRC clinical record standards • Strategic considerations – the core clinical model

  3. The Health and Social Care Information Centre HSCIC collects, analyses and publishes national data and statistical information for commissioners, analysts and clinicians. It also provides systems and infrastructure at a national level and sets standards for health and social care. HSCIC is an executive non-departmental public bodyof the Department of Health

  4. NHS England - commissioning on behalf of the ISCG NIB National Information Board The role of the ISCG is to commission services within an agreed strategic framework and then to monitor their delivery against set objectives

  5. Structures as at 01 April 2014 Social Care Public Health England National Information Board Standardisation Committee for Care Information INFORMATION STANDARDS DELIVERY PRSB UKTC Classifi-cations Clinical Models PCISS Data Dictionary HSCIC

  6. Collaborative design Information Standards Delivery SCCI NHS England PHE DH-SC others Monitor CQC Research NMC, GMC, Regulators Social carers NICE

  7. April2013

  8. PRSB

  9. Work of PCISS • National Laboratory Medicines Catalogue (PCDIP) • Pathology Catalogue development and implementation programme • Ambulance Clinical Documentation Project • AoMRC multipurpose message • MyCareRecord • PRSB – management of the HSCIC – PRSB relationship

  10. Foundations for coherent record and data standards GP2GP Record Keeping Standards - AoMRC 2008 Clinical Documentation Standards (CDGRS) - Royal College of Physicians / AoMRC 2013 Experience of “Clinical Content” in National Programme for IT

  11. Acute and mental health trust medical directors Association for Clinical Biochemistry Association for Palliative Medicine of Great Britain and Ireland Association of British Clinical Diabetologists Association of Cancer Physicians Association of Directors of Adult Social Services Association of Surgeons of Great Britain and Ireland British Association for Parenteral and Enteral Nutrition British Association for Sexual Health and HIV British Association of Audiovestibular Physicians British Association of Dermatologists British Association of Oral and Maxillofacial Surgeons British Association of Otorhinolaryngology British Association of Paediatric Surgeons British Association of Plastic, Reconstructive and Aesthetic Surgeons Who participated?

  12. And... Health and Care Professions Council In Practice Systems Intensive Care Society Local Medical Committee Chairs National Voices NHS London Nursing and Midwifery Council Nutrition Society TPP Renal Association Royal College of Anaesthetists Royal College of General Practitioners Royal College of Midwives Royal College of Nursing Royal College of Obstetricians and Gynaecologists Royal College of Ophthalmologists Royal College of Paediatrics and Child Health Royal College of Pathologists Royal College of Physicians Royal College of Physicians – Patient and Carer Network Royal College of Physicians and Surgeons Glasgow Royal College of Physicians of Edinburgh Royal College of Psychiatrists Royal College of Radiologists Royal College of Surgeons of Edinburgh Royal Pharmaceutical Society of Great Britain Society of British Neurological Surgeons UK Terminology Centre British Association of Stroke Physicians British Association of Urological Surgeons British Cardiovascular Society British Dietetic Association British Geriatrics Society British Infection Association British Orthodontic Society British Orthopaedic Association British Pain Society British Pharmacological Society British Psychological Society British Society for Gastroenterology British Society for Haematology British Society for Human Genetics British Society for Immunology British Society of Rehabilitation Medicine British Thoracic Society Chartered Society of Physiotherapy Choose and Book clinical leads Chronic Pain Policy Coalition Clinical Genetics Society College of Emergency Medicine College of Occupational Therapists Department of Health Informatics Directorate – Patients and Public Clinical Division EMIS Faculty of Occupational Medicine Faculty of Pharmaceutical Medicine Faculty of Sport and Exercise Medicine

  13. And who signed them off.. British Thoracic Society Chartered Society of Physiotherapy Chronic Pain Policy Coalition (CPPC) Clinical Genetics Society College of Emergency Medicine College of Occupational Therapists Faculty of Occupational Medicine Faculty of Sport and Exercise Medicine Intensive Care Society Renal Association Royal College of Anaesthetists Royal College of General Practitioners Royal College of Midwives Royal College of Nursing Royal College of Obstetricians and Gynaecologists (RCOG) Royal College of Ophthalmologists Royal College of Paediatrics and Child Health Royal College of Pathologists Royal College of Physicians and Surgeons Glasgow Royal College of Physicians of Edinburgh Royal College of Psychiatrists Royal College of Radiologists Royal College of Surgeons of Edinburgh The Royal College of Surgeons of England Royal Pharmaceutical Society (RPS) Society of British Neurological Surgeons Association for Clinical Biochemistry Association for Palliative Medicine of Great Britain & Ireland Association of British Clinical Diabetologists Association of Cancer Physicians Association of Surgeons of Great Britain and Ireland British Association for Parenteral & Enteral Nutrition British Association of Audiovestibular Physicians British Association of Dermatologists British Association of Otorhinolaryngology (Ears, Nose and Throat) (ENT – UK) British Association of Plastic, Reconstructive and Aesthetic Surgeons British Association of Stroke Physicians British Association of Urological Surgeons British Cardiovascular Society British Dietetic Association British Geriatrics Society British Infection Association British Orthodontic Society British Orthopaedic Association British Pain Society British Psychological Society British Society for Gastroenterology British Society for Haematology British Society for Genetic Medicine British Society for Immunology

  14. The Core Clinical Headings and Model http://www.rcplondon.ac.uk/resources/standards-clinical-structure-and-content-patient-records

  15. Core Clinical Model • These are the key core headings which are used to convey meaningful clinical information in a structured fashion • Information under each heading can be coded or left in narrative form

  16. Core headings 1. GP Practice 2. Patient Demographics 3. Participation in research 4. Clinical Summary 5. Reasons for Contact 6. Presenting complaints or issues 7. Family History 8. Diagnoses 9. Procedures 10.Assessment Scales 11. Investigations and Results 12. Problems and issues 13. Patient and carer concerns 14. Medications and Medical Devices 15. Allergies and adverse reaction 16. Safety Alerts 17. Plan and Requested Actions 18. Information given 19. Legal information 20. Person Completing Record

  17. Core model can facilitate? • Communication • Information reuse • Clinical Audit • Commissioning • Choice • Continuing Professional Development • Research Confidence and Quality

  18. Information Movement Clinical Message

  19. 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

  20. Newcastle Discharge • Venogram done 13/6/12 • Arrived on system 13/6/12

  21. Apply the core clinical headings to extract key clinical information from... • Hospital eDischarge Summary (eDS) • Nursing Documentation • Emergency Department eDS • Outpatient Letters • Handover Documents • Referral Letters • Transfer Documentation

  22. Discussion Standards for the clinical structure and content of patient records http://www.rcplondon.ac.uk/projects/healthcare-record-standards

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