How do professional record standards support timely communication and information flows for all participants in health and social care?

1

Gurminder KhambaClinical Lead for Secondary CareGurminder.khamba@hscic.gov.uk

Outline

• The Need For Standards

• Clinical Document Generic Record Standards

• PRSB

• CDA

• 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

Information Flow

Primary CareSecondary

Care

Social Care Allied

Professions

Message

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

Patient A Has Chest Pain

• Does he have Ischaemic Heart Disease?

Patient B having difficulty mobilising

• Needs Physiotherapy and Occupational therapy

Patient C needs Residential Placement

• Need to work with Social Services

Information Stored

Primary Care Secondary Care Social Care

Clinical Message

• 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

Clinical Translation

Japanese Arabic Russian

Translation

How we Share Information

• Verbal• Letters• Fax• Email• PDF• Spreadsheet

• However we would like to be more clever with information exchange.

• Clinicians and Systems are expecting standard information– Demographics, Problem list, Medications etc.

The Clinical Model

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

• 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.

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

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

• 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

• 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.

Standardisation

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

2008 documentation available from RCP and AoMRC websites

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

April 2013

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 CollegesRoyal College of Surgeons of England Royal College of Psychiatrists

Association of Directors of Adult Social Services

Royal College of Paediatrics and Child Health

PRSB - Functions

PRSBQuality

Assurance

Coherence Brokerage

Advice

PRSB - Value Proposition

One Stop Shop

PatientView

Increased Adoption

Increased Quality

Reduced Cost and Timescale

CLINICAL DOCUMENT ARCHITECTURE

• 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

Header• Document Type• Sender• Receiver• Patient

BodySection(s)

• Admission Details• Primary/Secondary

Diagnosis• Observations• Medications• Follow-up

Entries• Admission Details• Primary/Secondary

Diagnosis• Observations• Medications

C

O

D

E

D

T

E

X

T

Newcastle Discharge

Venogram done 13/6/12

Arrived on system 13/6/12

• 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.