"How do Professional Record Standards Support Timely Communication & Information Flows for all Participants in Health & Social Care"? Gurminder khamba (Clinical Lead for Secondary Care, HSCIC) discusses this question at the Healthcare Efficiency Through Technology Expo 2013.
2. How do professional record standards
support timely communication and
information flows for all participants in
health and social care?
3. Outline
• The Need For Standards
• Clinical Document Generic Record Standards
• PRSB
• CDA
4.
5. • Sharing of clinical information across systems
• Allows new ways of working
• Reduces Repetition of work
• Reduces Potential Errors
• Allows mistakes to carry forward
• Information Governance
7. Clinical Message
• Its 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
8. • Does he have Ischaemic Heart Disease?
Patient A Has Chest Pain
• Needs Physiotherapy and Occupational therapy
Patient B having difficulty mobilising
• Need to work with Social services
Patient C needs Residential
Placement
10. • 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
12. How we Share Information
• Verbal
• Letters
• Fax
• Email
• PDF
• Spreadsheet
13. • However we would like to be more clever with
information exchange.
• Clinicians and Systems are expecting
standard information
– Demographics, Problem list, Medications etc.
14. The Clinical Model
• Clinical Documentation has a certain
workflow to it which is universal to clinical
method used by clinicians
15. • 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.
16. • Presenting Complaint
• History of Presenting Complaint
• Medications
• Results
• Differential
• Plan
17. REASON FOR CONTACT text
*PRESENTING ISSUE Text or code (and/or mapped code for CDS)
*DIAGNOSES Text or code (and/or mapped code for CDS)
CURRENT PROBLEMS AND ISSUES Text or code
*OPERATIONS AND PROCEDURES Text or code (and/or mapped code for CDS)
FAMILY HISTORY Text or code
INVESTIGATIONS AND RESULTS Text or code (PBCL or NLMC)
MEDICATIONS Text or code (DM+D archetype)
ALLERGIES AND ADVERSE REACTIONS Text or code (archetype)
RISKS AND WARNINGS Text...needs more professional input
STRUCTURED SCALES Needs further development of outcomes +
frameworks
MANAGEMENT PLAN text
PATIENT AND CARERS CONCERNS text
INFORMATION GIVEN TO PATIENT text
RELEVANT LEGAL INFORMATION Text and (pointers?)
Core Clinical Model
18. • There is no reason why certain information
under these sections cannot be used to pre
populated for the destination system
• However Computer Systems are simple
19. • 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
25. Founder Members
National Voices Royal College of Physicians
Allied Health Professions Federation Royal College of Nursing
British Computer Society Royal College of General Practitioners
Royal College of Pathologists Academy of Medical Royal Colleges
Royal College of Surgeons of England Royal College of Psychiatrists
Association of Directors of Adult
Social Services
Royal College of Paediatrics and Child
Health
27. PRSB - Value Proposition
One
Stop
Shop
Patients
View
Increased
Adoption
Increased
Quality
Reduced
Cost and
Timescale
28. Initial Priorities
• Medication data standards / 4 countries All
provider sector
• Deployment of a full set of electronic referral,
transfer and discharge documents
incorporating the core model for clinical
coded data
• Fully assured technical standards with
agreed professional data components
30. •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
Header
Body
Section
Entries
31. • 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.
Notes de l'éditeur
Quality assurance of processes to assure information and record standards development for health and social careBrokerage of specific projects to develop standards with appropriate health and social care professional groupsAdvice on a coherent set of information standards to monitor high quality health and social careInsight to prevent multiple standards overlapTo advise how patient data for care is sufficiently reliable and accurate to determine quality and safetyTo adviseon achieving and maintaining appropriate skills in information and informatics within the professional communities of health and social care
One stop shop for professional data and record standards in Health andSocial CareAvoid multiple professionalengagement burden for NHS-CB and Standards Delivery OrganisationThe professional assurance function will incorporates views from patients/publicSingle focus of professional expertise which will allow whole system understanding of coherent and interoperable professional informationLink with regulators, higher professional standards of health care provision, and professional competency Common data for care, care quality and professional appraisal/revalidation ensures high quality of data
This is an example of a discharge summary from Newcastle to my practice. Up to 90% of all patient discharges are sent electronically within 4hrs and are available for the GP system