How do Professional Record Standards Support Timely Communication & Information Flows for all Participants in Health & Social Care?
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"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.
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How do Professional Record Standards Support Timely Communication & Information Flows for all Participants in Health & Social Care?
- 1. Professional Records Standards Timely Gurminder Khamba: Clinical Lead for Secondary Care
- 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
- 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
- 6. Information Flow Primary Care Secondary Care Social Care Allied Professions Message
- 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
- 11. Clinical Translation Japanese Arabic Russian Translation
- 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
- 20. Standardisation • Therefore these headings need to be standardised and used uniformly across the health and social care spectrum.
- 21. 2008 documentation available from RCP and AoMRC websites
- 24. April 2013
- 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.
Notas del editor
- 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