Delivering a paperless system between primary and secondary care. Jan Hoogewerf Health Informatics Unit 1 st October 2013

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1 Delivering a paperless system between primary and secondary care Jan Hoogewerf Health Informatics Unit 1 st October 2013

2 Why standards are needed Now: Records learnt by apprenticeship No agreed standards Differences between clinicians, depts, trusts With EPRs, variation causes problems: Information can t be shared safely between systems Tailoring and complex mappings required

3 Why standards are needed With standards-based EPRs: Single patient-centred clinical record, bringing together information from different systems: More integrated care Less time spent searching for information, duplicate recording, duplicate tests Improved safety, better decision making Better information for audit, research, commissioning

4 How do we achieve the vision? Electronic patient records, available whenever and wherever they are needed + Information standards, including: Record structure and content Identification - NHS number Coding - SNOMED CT Information governance and consent Technical standards ITK, HL7 etc + Coding

5 Record standards

6 Record standards Structured to match the way we work Patient and clinician involvement Evidence based Clinical and patient body acceptance

7 Initial work On-line questionnaire on each of the proposed headings Admission - 3,000 responses with detailed comments from 1,900 (91% said a good thing ) Handover and Discharge > 3,000 responses

8 Development process

9 Admission, handover, discharge and generic standards

13 Measuring outcomes Severity of illness scales

14 Outpatient and referral standards

15 Core headings and editorial principles

16 Review of standards HISTORY DESCRIPTION TECHNICAL NOTE History of Each Presenting Complaint or Issue History since last contact Information directly related to the development and characteristics of each presenting complaint. Including if the information is given by the patient or their carer. History since last attendance, discharge from hospital, etc. This is linked to 'Presenting Complaint or Issue', so they would need to relate to each other in the IT system - impacting on messaging standards. SNOMED CT and/or plain text, and or/images No NHS DD entry. SNOMED CT and/or plain text Information brought by patient For example Patient Passport, diary data, pre-completed questionnaire, etc. No NHS DD entry. Attributes: *Type of information (e.g. passport, diary) *Source of information (e.g. internet) *Copy of information (Word, PDF etc.) May just be plain text.

18 Technical Annexes

20 Implementing the standards Embedded in Guidance and good practice eg GMC Tomorrow s Doctors NHSLA risk management standards Education eg foundation years curriculum Revalidation Audit tools ( ) NHS CFH e-discharge summary project Information Sharing Challenge Fund & ITK Safer Hospitals, Safer Wards & Technology Fund

21 Paperless between primary and secondary care

22 National drivers Paperless communications between primary and secondary care by 2015 Full electronic patient records by 2018 Care.data new national acute data requirements

23 CFH electronic discharge summary A gold standard electronic discharge summary Developed in a collaborative project between primary and secondary care Implementation toolkit published in summer 2011 Aim to enable summaries to be sent and received directly and safely between computer systems.

25 e-referrals Work with EMIS, InPractice and TPP to incorporate headings into templates Templates made available on systems and communicated via mailshots Engaged with LMCs Piloted with InPractice and EMIS Discussions with Choose and Book

26 Referral template

27 National CDA Message HSCIC developing HL7 CDA message: Incorporates all RCP headings SNOMED CT for all headings Example templates for each document type Plan to publish by end of the year Collaborative site/support for implementers Phased approach: increasing levels of structured data, where appropriate, to enable re-use

28 Core headings Referrer Handover *PRESENTING ISSUE *DIAGNOSES Core Information The core information is enriched at each step CURRENT PROBLEMS AND ISSUES By agreeing a core information standard we can *OPERATIONS AND PROCEDURES allow individual systems to share information This core FAMILY information HISTORY can then be saved on each individual system INVESTIGATIONS AND RESULTS MEDICATIONS ALLERGIES AND ADVERSE REACTIONS Admission Discharge

30 PRSB founder members National Voices Allied Health Professions Federation British Computer Society Royal College of Pathologists Royal College of Surgeons of England Association of Directors of Adult Social Services Royal College of Physicians Royal College of Nursing Royal College of General Practitioners Academy of Medical Royal Colleges Royal College of Psychiatrists Royal College of Paediatrics and Child Health

31 Role of PRSB provides overall governance of care record content standards professional assurance of standards prioritisation of standards development care professional guidance for those working on technical implementation of standards

32 Further information

Evidence on the quality of medical note keeping: Guidance for use at appraisal and revalidation

Health Informatics Unit Evidence on the quality of medical note keeping: Guidance for use at appraisal and revalidation April 2011 Funded by: Acknowledgements This project was funded by the Academy of