Gurminder Khamba Clinical Lead for Secondary Care G urminder.khamba@hscic.gov.uk

1. How do professional record standards support timely communication and information flows for all participants in health and social care? Gurminder Khamba Clinical Lead for Secondary Care Gurminder.khamba@hscic.gov.uk

2. Outline • The Need For Standards • Clinical Document Generic Record Standards • PRSB • CDA

6. Sharing of clinical information across systems • allows new ways of working • reduces repetition of work • reduces potential errors • allows safe and consistent sharing of information • supports Information Governance

7. Information Flow

9. Clinical Message • It’s about the patient and their problem • Problem being chest pain, arm pain, leg pain etc. • It needs context • Background of other medical problems, medications, living conditions • What we want done with it

11. Information Stored Clinical Message

12. However the information stored in each system is unique • The terminologies and classifications for each system use nomenclature and coding schema which are not easily made compatible

13. Clinical Translation Translation

14. How we Share Information • Verbal • Letters • Fax • Email • PDF • Spreadsheet

15. However we would like to be more clever with information exchange. • Clinicians and Systems are expecting standard information • Demographics, Problem list, Medications etc.

16. The Clinical Model • Clinical Documentation has a certain workflow to it which is universal to clinical method used by clinicians

17. The clinical document for it to make sense is hierarchal and structured. • Each of the sections contains information which is pertinent and logical and often context and time sensitive.

18. Presenting Complaint • History of Presenting Complaint • Medications • Results • Differential • Plan

19. Core Clinical Model

20. There is no reason why certain information under these sections cannot be used to pre-populate for the destination system • However, Computer Systems are simple

21. Computers need to be told everything all the time • “Medications history” and “Drug history” might mean the same to a human • But to a computer it is completely different.

22. Standardisation • Therefore, these headings need to be standardised and used uniformly across the health and social care spectrum.

23. 2008 documentation available from RCP and AoMRC websites

26. Initial Priorities • Deployment of a full set of electronic referral, transfer & discharge documents, incorporating the core model for clinical coded data • Fully assured technical standards with agreed professional data components • Focus on specific use cases based on market demand e.g. Medications, Mental Health Discharge Summary

27. April2013

28. Founder Members

29. PRSB - Functions

30. PRSB - Value Proposition

31. Clinical Document Architecture

32. Header Body Section Entries • Level 1 • CDA Header is Described • Document Type(s) • Level 2 • Assumes XML Body Content • Prescribes: • the Sections, • their Order • and Section Identifier Codes • Level 3 • CDA Entries • Vocabulary [Codes] • Relationships • Semantics

33. Header • Document Type • Sender • Receiver • Patient Body T E X T • Section(s) • Admission Details • Primary/Secondary Diagnosis • Observations • Medications • Follow-up C O D E D • Entries • Admission Details • Primary/Secondary Diagnosis • Observations • Medications

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

35. Standards which are professionally assured are needed to ensure that information can flow across systems and care settings • By ensuring that standards are built into clinical documentation, the use of data to provide information to help guide service will add much valued insight.