Information Standards for Clinical Records

1
Information Standards for Clinical Records

• 22 October 2008
• Royal College of Physicians

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Aims for today

• Explain the rationale for clinical standards for
  the structure and content of patient records
• Describe progress so far
• Increase and broaden participation
• Identify the next priority areas
• Explore how this can be taken forward

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What standards are needed for electronic patient
records?

• A unique patient identifier
• Common identifiers for professionals and
  organisations
• Relevant specialty identifiers
• Standard definitions for demographic,
  administrative and organisational data
• A comprehensive clinical terminology for coding
• Professionally developed and agreed standards for
  the structure and content of the record,
  appropriate to the context in which it is being
  used

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Why?

• Quality of the record
• Quality of care
• Patients safety
• Increased efficiency
• Secondary uses of the data

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Quality of the record

• The most common issue which affected the
  accuracy of clinical coding was the quality of
  the source documentation PbR Data Assurance
  Framework 2007/08 Audit Commission Aug 2008
• The Healthcare Commission has once again
  identified record keeping as one of the weakest
  areas of NHS performance in its annual health
  check E-Health Insider October 2008
• Variations in reporting of endoscopies by
  different endoscopists Spencer et al Clinical
  Medicine 2007723-27

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Why?

• Quality of the record
• Quality of care
• Patient safety
• Increased efficiency
• Secondary uses of the data

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Quality of Care

• Record design can affect patient outcomes
• Wyatt JC Wright P Design should help use of
  patients data. Lancet 19983521375-8 ( 1539-43)
• Structured records improve care and doctors
  performance
• Mann R Williams JG Standards in medical record
  keeping. Clinical Medicine 20033329-332

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What might trigger a performance assessment by
the GMC?www.gmc-uk.org/concerns/doctors_under_inv
estigation/performance_assessments.asp

• a tendency to use inappropriate or outdated
  techniques
• a basic lack of knowledge/poor judgement
• a lack of familiarity with basic
  clinical/administrative procedures
• poor record keeping or failure to keep up-to-date
  records
• inadequate practice arrangements
• concerns over referral rates
• inadequate hygiene arrangements
• poor prescribing.

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Why standards for the record?

• Quality of the record
• Quality of care
• Patient safety
• Increased efficiency
• Secondary uses of the data

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Patient Safety

• The transfer of a patient to the care of the
  oncoming team is the point at which the patient
  is most vulnerable. Poor or incomplete
  information is often handed over with potentially
  disastrous consequences Guidance on Safe
  Handover Royal College of Surgeons March 2007

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Why?

• Quality of the record
• Quality of care
• Patients safety
• Increased efficiency
• Secondary uses of the data

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Increased efficiency

• Reduction in the need for staff to learn new
  approaches in new environments
• Reduced duplication of data entry in electronic
  records
• Data capture appropriate to the clinical context

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Secondary uses of the data

• For the future the multiple methods and systems
  for collecting data must be reduced. Data must be
  collected as the by-product of clinical care.
  Bristol Royal Infirmary Inquiry July 2001
• Structured, coded records are necessary for data
  aggregation and analysis, in order to support
• Activity analysis
• Audit
• Research
• Performance

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Gastroenterology

• 50 sites unable to provide activity data on
  endoscopy Evaluating Innovations in the delivery
  of endoscopy services Williams et al 2008 SDO
  Programme Final Report
• National audits unable to use routinely collected
  data (Colonoscopy ERCP IBD)

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Research

• Opportunities are emerging to integrate patient
  care and research
• Retrospective studies
• Disease registries
• Multicentre trials

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Record StandardsWhat have we achieved so far?

• A standard structure for all admission, handover
  and discharge documentation
• Supported by Connecting for Health
• Evidence based literature practice
• Wide consensus
• Piloted in practice
• Endorsement by the Academy of Medical Royal
  Colleges

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What do we want to achieve today?

• Identification of other clinical contexts where
  standardisation of the record is needed
• Prioritisation of the top 5 in each specialty or
  discipline
• (Assessment of commonality)
• A clear view as to how each specialty or
  discipline would gain consensus