Health Informatics Unit Gaining consensus on record standards

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Health Informatics UnitGaining consensus on
record standards

• Iain Carpenter
• 22nd October 2008

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• Why standardise clinical information recording?
• What does it mean?
• What are the implications?
• How does one get consensus?

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Standardising patient level data

• Patient level data is what drives clinical care
• It also provides the info for outcomes and
  indicators of quality of care
• When standardised, can be used routinely for
  benchmarking, audit research etc.
• Several specialist societies have developed
  datasets for their specialty same clinical
  signs but recorded differently

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Medical Record Standards Development steps

• Gather the evidence
• Create draft headings
• Consult
• Workshops
• Professional bodies
• Practising doctors
• Revise
• Pilot
• In hospital practice
• In vitro inter-observer reliability
• Submit to Academy of Medical Royal Colleges and
  ISB

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Headings and Definitions for Acute Admission

• Started from the research evidence
• and
• Polled Doctors to enquire whether they thought it
  would be a good thing (before seeing anything)
• Drs.net poll - 21 in favour of a standard
  admission clerking structure across NHS
• RCP poll 84 in favour of a standard admission
  clerking structure across NHS

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Medical Record Structure and Content Standards

• Reviewed the literature in 2003 and updated in
  2008
• Analysed admission, handover and discharge
  proformas used by hospitals (n50)
• Drafted headings documents

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Medical Record Structure and Content Standards

• Held workshops for input on drafts with
  practicing clinicians, patients including GPs for
  discharge summary. Workshop also held with
  representatives from the RCP Patient/Carer
  Network
• Online questionnaires (tested and piloted)
  targeting, consultants, registrars and junior
  doctors via the deaneries.
• Admission questionnaire completed by 3,082
  doctors within two weeks (email sent to RCP
  fellows and members, and via the BMA to its
  membership)
• Handover and discharge questionnaires received
  1703 and 1454 respectively

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Questionnaire questions

• Is this heading useful?
• Is this heading clear and unambiguous?
• Do you use a proforma with this heading?
• Should this heading be mandatory ?
• Comments

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Medical Record Structure and Content Standards

• Hospital pilots in different geographical
  locations, care settings and specialties
  including mental health and paediatrics.
  Completed proformas during inpatient care and
  commented via feedback questionnaire
• Design workshops to develop proformas with junior
  and senior doctors
• Admission 10 sites
• Handover and discharge- 11 and 8 sites
  respectively (n13)

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Medical Record Structure and Content Standards

• Ongoing consultations with other medical colleges
  and specialist societies. Started by writing to
  the presidents or chairs and asking for a nominee
  to work with, then sent documents and asked for
  feedback.
• Consulted with other groups including
• medical directors and/or their nominees (acute
  trusts)- emailed twice during the project and
  received comments on the standards (n50
  commented)
• RCP Medical Specialties Board, RCP Clinical
  Standards Board
• RCP GP Committee,
• BMA sub-speciality committees,

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Medical Record Structure and Content Standards

• Ongoing process of analysis and updating of
  headings at specific points e.g. after initial
  workshop, questionnaire and pilot results.
• Final documents sent to colleges and specialist
  societies presidents and chairs and their
  nominees for approval before being sent to the
  Academy of Medical Royal Colleges for sign-off.

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• If the care professionals dont do it, the IT
  techies will and that would be unfortunate!
• Patients and carers should be involved at every
  step.

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Summary

• Structured records have undoubted benefits and
  are essential for electronic records
• Consultation showed that
• The medical profession overwhelmingly supports
  the concept
• It is possible to get profession wide acceptance
  of a common structure across the NHS
• This seems to be a mechanism that may show a way
  forward for all of health (and social?) care
• It is the first step on a long road to IT systems
  that meet the needs of patients and staff and are
  intuitive to use

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