Medical Records Achieving professional consensus

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Medical RecordsAchieving professional consensus

• Professor Iain CarpenterHealth Informatics Unit

RCP, 15th July 2010
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• Where will the clinical data for the electronic
  health record come from?

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Where is there clinical data at present?
Patient management
Research
Screening programmes
Disease registers
Central returns
Audit
Clinic

• Clinical data is held in disparate applications

That have different purposes
And different ownership
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What would be the solution?

• Data should be recorded in a clinical record
  focused on the patient
• The record should support all contexts in which
  the patient is seen
• And be interoperable with other systems as
  appropriate
• The structure and content will have to be
  standardised

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Ownership and clinical engagement

• Engaging the clinicians
• What will change for me?
• Relate it to what we do everyday, eg Admission
  clerking
• It is coming, best that it should reflect best
  clinical practice as it is done
• If left to a few clinical enthusiasts and IT
  techies, it may
• reflect the preferences of the individual
  clinicians who were enthused and took part
• or the technical requirements of the system
• and not reflect the clinical practice of the
  majority

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Structure and Content Standards for the medical
record

• Research and published evidence base
• Professional consensus
• Practicing hospital doctors
• RCP Patient Carer Network
• The Medical Royal Colleges and Specialists
  Societies
• The Academy of Medical Royal Colleges
• Uptake
• Regulators
• Defence organisations
• Professional bodies
• Educational programmes

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Views of information in the patient focused record
In-patients
Out patients
Endoscopy
Specialist nurse telephone support
Mrs Jones
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GP Surgery ?
Hospital?
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Hospital AE ?
GP Surgery ?
? ASDA
Treatment centre ?
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Summary

• Provenance of the clinical data
• Day to day practice
• Clinicians are engaged when it relates to what
  they recognise as their every day work
• The records must be patient centred
• The same record follows the patient
• The patient can access their whole record from
  wherever they are
• The professionals will therefore also be access
  it to deliver the required care
• Everything else follows from the digital patient
  focused record
• Clinical Outcome
• Quality of care
• Service planning and monitoring
• Increased efficiency for clinical and
  epidemiological research