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Medical Records Achieving professional consensus

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Title: Medical Records Achieving professional consensus


1
Medical RecordsAchieving professional consensus
  • Professor Iain CarpenterHealth Informatics Unit

RCP, 15th July 2010
2
  • Where will the clinical data for the electronic
    health record come from?

3
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
4
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

5
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

6
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

7
Views of information in the patient focused record
In-patients
Out patients
Endoscopy
Specialist nurse telephone support
Mrs Jones
8
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9
GP Surgery ?
Hospital?
10
Hospital AE ?
GP Surgery ?
? ASDA
Treatment centre ?
11
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12
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13
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14
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
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