Professional Records Standards
Timely
Gurminder Khamba: Clinical Lead for Secondary Care
How do professional record standards
support timely communication and
information flows for all participants in
health and...
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 Poten...
Information Flow
Primary Care
Secondary
Care
Social Care
Allied
Professions
Message
Clinical Message
• Its about the patient and their problem
• Problem being chest pain, arm pain, leg pain
etc.
• It needs ...
• Does he have Ischaemic Heart Disease?
Patient A Has Chest Pain
• Needs Physiotherapy and Occupational therapy
Patient B ...
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 nome...
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 infor...
The Clinical Model
• Clinical Documentation has a certain
workflow to it which is universal to clinical
method used by cli...
• The clinical document for it to make sense is
hierarchal and structured.
• Each of the sections contains information
whi...
• 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...
• There is no reason why certain information
under these sections cannot be used to pre
populated for the destination syst...
• Computers need to be told everything all the
time
• Medications History and Drug history might
mean the same to a human
...
Standardisation
• Therefore these headings need to be
standardised and used uniformly across the
health and social care sp...
2008 documentation available from RCP and AoMRC websites
April 2013
Founder Members
National Voices Royal College of Physicians
Allied Health Professions Federation Royal College of Nursing
...
PRSB - Functions
PRSB
Quality
Assurance
Coherence
Brokerage
Advice
PRSB - Value Proposition
One
Stop
Shop
Patients
View
Increased
Adoption
Increased
Quality
Reduced
Cost and
Timescale
Initial Priorities
• Medication data standards / 4 countries  All
provider sector
• Deployment of a full set of electroni...
CLINICAL DOCUMENT
ARCHITECTURE
•Level 1
–CDA Header is Described
–Document Type(s)
•Level 2
–Assumes XML Body Content
–Prescribes:
•the Sections,
•their ...
• Standards which are professionally assured
are needed to ensure that information can
flow across systems and care settin...
How do Professional Record Standards Support Timely Communication & Information Flows for all Participants in Health & Soc...
How do Professional Record Standards Support Timely Communication & Information Flows for all Participants in Health & Soc...
How do Professional Record Standards Support Timely Communication & Information Flows for all Participants in Health & Soc...
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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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  • 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
  • How do Professional Record Standards Support Timely Communication & Information Flows for all Participants in Health & Social Care?

    1. 1. Professional Records Standards Timely Gurminder Khamba: Clinical Lead for Secondary Care
    2. 2. How do professional record standards support timely communication and information flows for all participants in health and social care?
    3. 3. Outline • The Need For Standards • Clinical Document Generic Record Standards • PRSB • CDA
    4. 4. • 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
    5. 5. Information Flow Primary Care Secondary Care Social Care Allied Professions Message
    6. 6. 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
    7. 7. • 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
    8. 8. Information Stored Primary Care Secondary Care Social Care Clinical Message
    9. 9. • 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
    10. 10. Clinical Translation Japanese Arabic Russian Translation
    11. 11. How we Share Information • Verbal • Letters • Fax • Email • PDF • Spreadsheet
    12. 12. • However we would like to be more clever with information exchange. • Clinicians and Systems are expecting standard information – Demographics, Problem list, Medications etc.
    13. 13. The Clinical Model • Clinical Documentation has a certain workflow to it which is universal to clinical method used by clinicians
    14. 14. • 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.
    15. 15. • Presenting Complaint • History of Presenting Complaint • Medications • Results • Differential • Plan
    16. 16. 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
    17. 17. • 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
    18. 18. • 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
    19. 19. Standardisation • Therefore these headings need to be standardised and used uniformly across the health and social care spectrum.
    20. 20. 2008 documentation available from RCP and AoMRC websites
    21. 21. April 2013
    22. 22. 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
    23. 23. PRSB - Functions PRSB Quality Assurance Coherence Brokerage Advice
    24. 24. PRSB - Value Proposition One Stop Shop Patients View Increased Adoption Increased Quality Reduced Cost and Timescale
    25. 25. 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
    26. 26. CLINICAL DOCUMENT ARCHITECTURE
    27. 27. •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
    28. 28. • 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.
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