Standards set for the structure of medical records
23 Oct 2008
Profession-wide standards for medical records in hospitals have been agreed for the first time.
The standards, developed by the Royal College of Physicians and NHS Connecting for Health, and backed by the Academy of Medical Royal Colleges, set out the structure of the clinical content doctors should record on admission, at handover, at out of hours handover and at discharge.
A spokesperson for CfH said it is working closely with suppliers to ensure the standards are built into their systems.
She added: "Implementation of the new record keeping standards is being managed according to requirements of local programmes. The records will first be incorporated into paper pro-formas, before being introduced into electronic records.
"The new standards are also being incorporated into the design of Cerner and Lorenzo. We are currently working with suppliers to draw up plans for implementation of the standards in acute trusts across the country."
Professor John Williams, director of the RCP Health Informatics Unit, also told E-Health Insider that incorporating the standards into electronic records would depend on the work CfH does with suppliers. But he expects the standards to be in use in every hospital in paper format over the next year.
“There isn’t a specific timescale for this to happen, and we haven’t been didactic, but I would like to see the structured proformas in use over the next year. We hope that they will be part of the training of junior doctors as they join; so the first milestone will be the next intake of house officers,” he said.
CfH and the RCP say the standards will improve safety by standardising the information held on patients during their hospital stay, reducing the likelihood of mistakes and of information being missing at admission, handover and discharge.
They should also mean that clinical information in electronic records should only need to be recorded once, improving efficiency and saving time. And they should simplify the implementation of new clinical information systems, as they can all be built to the same structure standards.
Professor Ian Gilmore, president of the RCP, said: “The biggest single factor in delivering high quality, safe healthcare is the timely availability of accurate relevant information about the patient. I cannot overstate the importance of this vital development in getting that information to the bedside where it is urgently needed.”
The RCP Health informatics Unit has been funded by CfH to develop the standards. It has piloted the prototypes in hospitals and sent them out for consultation to patients, carers, other medical royal colleges and specialty societies.
The RCP said more than 3,000 doctors responded to the consultation on admission headings, with more than 90% agreeing that there should be structured documentation across the NHS.
The Royal College of General Practitioners was consulted on the discharge standards and GPs took part in pilots in 13 hospitals. The RCP and CfH say this means they should deliver the information GPs want and need.
Professor Michael Thick, chief clinical officer for CfH, said: “It is absolutely vital that these standards are drawn up by and for healthcare professionals and we welcome the backing of the Academy of Medical Royal Colleges.
“We must now continue to work closely with a range of professionals to further develop the standards, ensuring that they meet the priorities of different professions, helping to provide the best care possible.”
Professor Williams said the RCP was currently working with CfH and the profession to decide where the next work should be undertaken on record standards.
He also told E-Health Insider the new standards would work alongside other standards, such as the NHS Number and SNOMED CT coding, and standards that still need to be developed, including a unique identifier for every professional.
“This is one component in a whole raft of standards that are needed,” he said.
The standards have been published following criticism in last week’s annual health check from the Healthcare Commission that record keeping remains one of the weakest areas of NHS performance.
The NHS Alliance also published a report last week showing that one in four GPs believe patient safety has been put at risk in the past six months because hospitals have failed to provide adequate discharge summaries.
Related articles:
The new standards are the subject of the latest column from NHS Connecting for Health to be published by E-Health Insider and EHI Primary Care. Read it in the comment and analysis section of the sites.
Fiona Barr
© 2008 E-HEALTH-MEDIA LTD. ALL RIGHTS RESERVED.
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1 very welcome....23 Oct 08 08:37 ....and only 5 years after CFH let contracts for the whole of England for systems that , as it turns out, were not specified to do this and therefore can't do it. 2 re: very welcome....23 Oct 08 09:50 >>systems that , as it turns out, were not specified to do this and therefore can't do it<< And yet another round of contract change notices takes the heat off LSP delivery dates for clinical functionality - what very little heat there seems to be anyway :-( Send in the clowns... 3 In what sense a standard?23 Oct 08 11:14 Doesn't the NHS (and Social Care) Information Standards Board have some role in this? Yet I can't find any mention of this new standard in the Excel spreadsheet from their website (www.isb.nhs.uk) that lists all the standards (though it's hardly designed to be user friendly so I might have overlooked it). Perhaps they are the body that ought to be ensuring that issues such as fit with the current system specifications are taken into account? After the clowns, maybe the jugglers? 4 Discharge Summary and Drugs23 Oct 08 12:38 I do hope that the standard arrived at includes standardisation of drugs in the discharge summary - I hope that they are not going to be free text fields?! Where can one view the details of the specifications of the standard? 5 Approved by the CUI team?23 Oct 08 14:22 Have these "draft" templates been approved by the Common User Interface team? And if not, can someone at CfH get their act together and make sure there is a common approach to clinical IT development! 6 Linklyn@e-health-media.com 23 Oct 08 16:11 The standards are on the RCP's website. There is a link at the end of the column about the standards in the comment and analysis section - but we seem to have missed it off the news story. Lot's more information here: www.rcplondon.ac.uk/clinical-standards/hiu/Pages/Health-Informatics-Unit.aspx Lyn Whitfield, managing editor, E-Health Insider. 7 This is old news.... again23 Oct 08 20:49 So this thread is a repeat the comments made last month demonstrate this is a conceptually ideal but flawed ideal..... If anyone else here has tried to use the guidelines, you'll find them difficult to get to work in any NHS environment where plurality is alive and well.... Physios from acute Trust, OTs from PCT, psychologist from Mental Health Trust, Social Workers from Council, Doctors from Acute Trust, IST from South African company, PET scanner from a different outlet, etc etc. And each wants its own records for medicolegal purposes It just isn't working in reality as it does on paper.... now there's a surprise 8 computerization corruption of records24 Oct 08 06:21 It has become extraordinarily difficult to track the course of an illness when the transfer records consist of hundreds of pages of computerization generated lists of clinically useless details and utter chaos in presenting medication administration documentation, laboratory results, and contemporaneous listing of orders. Computerization has corrupted the medical record and these standards must be a requirement in all EMRs. Sincerely, Propensity 9 Deja vu24 Oct 08 09:49 This is a reincarnation of the "Headings Project" that started in IMG days and was inherited (and eventually terminated) by the NHSIA. It didn't work then and it almost certainly won't work now for all the same reasons. 10 The Perfect Solution24 Oct 08 11:57 I note that this article has 3 organisations: Royal College of Physicians, CFH & Royal Colleges, then there is another article (Click Here suggesting an ISO and soemwhere there is the Information Standards Board. CLEARLY, what we need is an "information standards accreditation board accreditation board" this organisation would be empowered to accredit other organsiations to accredit standards for the NHS. It could be called Board for the Accreditation and Leverage of Legal Standards (BALLS) 11 Information Standards Board24 Oct 08 13:37 It is my understanding, as an appraiser for the Information Standards board, that it is NOT the role of the Information Standards Board for Health and Social Care (ISB HaSC) to approve clinical standards whether they are for record keeping or clinical care, this is the role of the professional bodies and regulators etc. The role of ISB HaSC is to assure and approve the instantiations of these professional standards as they become information standards i.e. as they become implemented within systems. At this point the potential information standards are appraised with respect to implementability, interoperability and safety. If during the process of piloting evidence suggests that there are issues with the professional standard this would be fed back to the appropriate professional bodies. ISB HaSC are always keen to encourage the submission of information standards to the approval process as this is the means by which the service and suppliers of systems to the service are informed of the need to implement and become conformant with new standards. I am sure that ISB HaSC would be pleased to receive a submission to cover the implementation of the RCP Record Standards within clinical systems. 12 Re: Information Standards Board24 Oct 08 15:59 If the ISB appraiser is dissociating the Board from clinical activities then it's a bit difficult to understand why its schedule of forthcoming standards includes items such as clinical imaging procedure representations and DM+D. Also, the distinction between a "clinical", "professional" or "information" standard seems rather meaningless when discussing information standards used within and/or across professions, and I wasn't aware - as the comment seems to imply - that ISB was only dealing with standards for information "systems" (IT). Additionally, who integrates the views of numerous professional and regulatory bodies around the approval of standards for records, clinical interfaces, clinical terms etc? Surely, this is part of ISB's remit and why it includes members from bodies such as the GMC? As for submitting this new standard to ISB, it seems that the RCP and CfH (and probably others) already believe this to be a standard without the ISB's appraisal! Perhaps inter-professional consensus is just too difficult in which case we perhaps ought to ask what is the rationale for continuing with NPfIT?
13 Standards set for the structure of medical recordsj.g.williams@swansea.ac.uk 24 Oct 08 16:30 Just to clarify some of the issues which have been raised: 1 The Information Standards Board has seen these standards but does not yet have a process for approval of professional standards of this nature. We are liaising closely with them on this. They have been endorsed by the Academy of Medical Royal Colleges. 2 There is still much detail to be worked through under the headings that have been described. This will include drugs. 3 There has been close liaison with the Common User Interface team, who have already shown how the standards can be incorporated. 4 This is not a flawed ideal. The need is supported by more than 90% of more than 3,000 doctors who responded to the consultation and the standards have been piloted successfully in 13 hospitals. 5 This is not a reincarnation of the Headings Project, which was a top-down attempt to meet the need of all disciplines and professions in one approach to communications. This is a bottom-up approach, addressing the requirements for a standardised approach to the clerking of medical admissions by doctors, and the communications needed at handover and discharge. We will now be working with other professions and disciplines to meet their needs in many other clinical contexts, integrating these into a generic approach wherever possible. John Williams 14 Further clarification needed24 Oct 08 16:49 So is this an information "standard" for physicians, hospital doctors, all doctors, all hospital clinicians, all clinicians, or what? 15 Will these new templates be openEHR archetyped?26 Oct 08 15:41 Will CfH be developing these very useful word templates into openEHR archetype templates? This would ensure standardisation of data entry across/between healthcare providers. And make it "relatively easy" for all clinical IT system suppliers - not just iSOFT/Lorenzo and CERNER/Millenium - to incorporate into their systems. |
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