Call for Toolkit discharge standards

Tags: A CfH DH Discharge letters Interoperability toolkit Paul Jones Standards

19 Jan 2010

NHS Connecting for Health has invited suppliers to help develop and test standards for electronic discharge summaries in an extension to its interoperability toolkit programme.

Suppliers have until 31 March this year to complete proof of concept proposals; just one day before the Department of Health target that all NHS trusts should be delivering discharge summaries to GPs within 24 hours comes into force.

The majority of trusts are widely expected to miss the target, with some suppliers suggesting that as few as 20% of hospitals will be delivering discharge summaries within 24 hours by next April.

EHI Primary Care understands that the main problem trusts have been facing has not been generating the letter, but delivering it from hospital to GP practice - something the standards are designed to tackle.

The DH IT agency’s documentation says a key objective is to prove the new emerging standard definition and to support and accelerate introduction of electronic discharge summaries to interoperability toolkit standards across NHS England.

It adds: “Electronic discharge summaries are a key Clinical 5 objective under the DH Operating Framework for 2010.”

CfH said successful proof of concept projects would need to successfully send and receive real discharge summaries between different systems in accordance with the toolkit standards by 31 March.

Suppliers will also be expected to demonstrate how their solution can be replicated “economically, beneficially and rapidly at scale across the NHS.”

The document says a bonus success criterion for any project would be that integration is achieved in a live NHS trust environment; although NHS customer involvement is not a pre-requisite for a candidate project.

The document says projects are expected to be supplier led but should be aligned with and coordinate a wider team of acute, middleware and primary care supplier partners.

It adds: “The solution must clearly demonstrate interoperability between different supplier systems as part of the end-to-end solution.”

Philip Young, director at document management specialists PCTI, said the message would provide a consistent standard in delivering electronic discharge solutions across England.

He added: "Having been involved in the development of the message we're very much looking forward to receiving it into an existing EDT Server deployment in order to participate in the proof of concept phase.

"Our intention is to demonstrate multi vendor discharge documents, created in the new message format and for these to be collected and delivered to GP practices using differing clinical platforms using our proven EDT technology."

CfH said the scope of the interoperability toolkit, announced in April last year by DH chief information officer Christine Connelly, had been extended and that there was an opportunity to include additional proof of concepts for a wider range of NHS systems.

It released the first ‘layer’ of the toolkit in September, based on about 22 messaging standards plus guidance.

Chief technology officer Paul Jones told E Health Insider that the toolkit had the potential to drive down the cost of interoperability and innovation an open up the NHS IT market to new players.

Suppliers interested in submitting a proof of concept proposal for electronic discharge summaries are asked to immediately register their interest, with proposals submitted no later than Monday 8 February.

Proofs of concept will be expected to meet all success criteria by 31 March and CfH said it would evaluate the proofs of concept and report by 30 April 2010.

Fiona Barr

Toolkit to nail interoperability - Jones (29 Oct 2009) (10)
DH announces ‘app store’ style toolkit (28 Apr 2009) (1)
Discharge summary target 'to be missed' (24 Nov 2009) (14)
CQC criticises discharge summaries (27 Oct 2009) (4)

Readers Comments

The 'original vision'

19 Jan 10 15:11

References to structured discharge summaries and their benefits litter the CfH literature from the outset.

Unlike so many vaunted ambitions this was low hanging fruit. It was also desperately wanted by clinicians. Many existing systems at the time were capable of supporting a defined standard with relatively little effort.

>>Minimum to be Achieved by December 2006 (Phase 2).... Messaging between Local Systems to include medium to highly structured clinical documents (e.g., referral letters and discharge summaries).<<

Integrated Care Records Service, Part 3 – Common Requirments, Output Based Specification 2.0 Page 169

Elsewhere in the same document we find

>>Clinical Document Architecture CDA: An XML vocabulary designed to provide an exchange model for clinical documents such as discharge summaries and progress notes.<< Page 200

And only now the NHS asks (not tells) suppliers what they might do in this area? What has been going on since 2003?

This could feature as exhibit A in the swollen catalogue of NPfIT's non-delivery and incompetence.

Defined Standard

20 Jan 10 09:13

"Defined Standards" - and here is the problem.

It's not the job of the software vendors to define what goes into the discharge summary - they will do whatever the commissioner of the software asks for - since they will be paying for it.

It's the job of the professions with the ISB and other bodies to decide on the message and content.

Some of us have been demanding a defined standard for discharge summaries for the past 15 years.

Let's stop flogging the software vendors for not doing what someone should have been doing?

XML Kettering (?)

stephane.guegan@nhs.net

20 Jan 10 10:23

Hi,

We have been using XML Kettering standard for years and assumed that this was the "default" standard. This is delivered via DTS / EDT and is accepted by most GP system suppliers.

Should this be used as a standard accross the NHS or are we trying to define anoter standard yet again?

Agreed

20 Jan 10 10:56

Comments 2 and 3 are spot on.

This, as usual, is jumbled up thinking in CfH somewhere and seems to be confusing a standard for a message (surely this should be the Kettering XML) with an end to end solution.

One has to wonder why somebody thinks that a "solution" can be provided. At the hospital end you have any number of systems, all of which can somehow be adapted to send a standard message, and GP systems, which if there was the will (and there has not been) then they can be adapted to receive this message. At the hospital end integration is the key and there is no way you can come up with a "system" that will sit in anywhere and do the same job for all.

What is so difficult, as others have said, we already have the standard if only someone would ratify it!

I predict another great white Elephant costing millions and delivering nothing.

Re: White elephants

20 Jan 10 11:24

Post 4 hits the target!

NHS IT has been trampled by a herd of white elephants led by the matriarchal CfH.

Members of the herd include enterprises such as:

SNOMED - whatever happened to that? Is anyone in the NHS actually using it or is it still mainly Read Codes?
The ISB itself - what has it been doing all these years? Why aren't the standards in place?

I'm sure there are lots of others ... and they all cost money.

Where is the Kettering Specification?

20 Jan 10 21:54

Could someone please point me at the Kettering specification for discharge summaries. Not even Google can find it?

Check out the RCP website

21 Jan 10 11:11

Google "RCP discharge template" and you will find the Royal College of Physicians recommedations for the discharge summary content and layout which has been "tried and tested" by a number of NHS hospitals.

Ketering XML

21 Jan 10 19:33

I have been looking for the specification of the Kettering XML discharge summaries. I know that the work originally began in the 1990s. Could someone point to a copy of the XML specification? The RCP specification is just a form.

Is it me?

22 Jan 10 09:33

I don't want to get caught up in the debate about delayed standards, but if the Acute trusts mentioned are able to produce a discharge letter within 24 hours, why don't they send this as an attachment from a discharge NHSMail account to a generic NHSMail account at the practice?

OK, so this doesn't embed into the GP system and will have to be attached manually (which is what happens with scanned paper copies now anyway), but at least it gets the information about the patient to the practice in a timely manner and the message transfer is safe and auditable.

It's not the prettiest of solutions, but it does work and could be put in place quite quickly - as shown by the ERDIP project back in 2003!

Re: ERDIP

22 Jan 10 10:46

Interestingly, the incoming management team of NPfIT declined the offer of a briefing from the ERDIP senior managers back in the autumn of 2002.

When CfH has finally been killed off - hopefully some time later this year - the next generation of NHS IT strategists could do worse than review what was learnt from the activities of both ERDIP (NHSIA) and the IMG of the 1990s. Whatever its faults, the IMG legacy includes some standards that have stood the test of time and numerous (imperfect) systems - installed in an NHS environment where organisations had freedom of choiceand action - that have delivered real benefits over a number of years.

There has been precious little progress since and - on finance grounds alone (see the £800m story) - it's extremely unlikely that CfH will ever be able to match this.

Yes it is you!

22 Jan 10 10:52

I wonder how exactly that is auditable?

Is your vision to keep sent mail items on individual patients as an audit trail?

Scanning in or whatever is ok and yes we should get on and do what is possible. The point is that doing it properly is possible and those who cannot either send or receive EDI messages should start to feel a bit of pain.

I think that the observation that most trusts get their discharge letter written in time is false

david.green@colchesterhospital.nhs.uk

22 Jan 10 12:38

In my experience getting discharge summaries written in good time is a challenge and the observation in this article may be an assumption. Our own data shows that very few are completed in advance of the discharge in such a way that a satisfactory document which has been pharmacy checked is available to be printed and handed to the patient as well as sent to the GP. This is often due to bed pressure when planning is discarded in favour of bed management which in turn may be driven by 4 hour waits. There needs to be more work done during a patient's pathway to ensure that this objcetive can be met with a document that is both ready and of acceptable quality. Too many letters get there in time but contain poor quality unchecked data.

Discharge Summaries are Vital

25 Jan 10 10:01

If there is one thing patients need to be assured of, it is that their GP and community services know what happened in hospital.

Good systems will deliver the discharge summary electronically to the right people within 24 hours.

Poor systems whether manual or automated will make sure that there is no discharge summary or, if there is, the discharge summary is sent to the wrong people.

The patient then spends an inordinate amount of time in confirming medication and follow-through for their health care.

Any patient and health care delivery needs to have discharge documentation as a central requirement.

That we are now looking for a separate solution from the National Care Record Service (NCRS) tells us that after six years, NCRS is not justifiable. Nor is it possible to implement discharge summaries without an appropriately advanced NCRS.

Do you fear Catch 22?

Oh Perlease. NHSMail not the answer

25 Jan 10 14:08

Unstructured, so only thing the GP practice can do is print it out and scan it. And unusable to send securely to the patient.

Kettering via DTS is the strategic solution we should have been left to roll out from the start.

Please don't let those %&*% at the centre pay yet more money to reinvent something we have had working for a long time, and would have made universal if the GP system suppliers werent so deflected by their grandiose thinking.

Garbage in, garbage out? transmission and quality are not the same!

25 Jan 10 20:53

Aren't there two - or more - seperate problems?

1. Discharge letters and summaries are produced on computers - why is it so dificult to transmit them electronically? My local Trust can do it for Electronic Discharge letters via ICE and pathlinks.

2. Content of Electronic Discharge Letters

I have young relatives in different hospitals and am a GP.

two of the three relatives grumble about having to maintain electronic records throughout the patient's stay - but all that is needed for discharge is to press a few buttoms: the patient record is there.

The third has to do all the work at the last minute - or beyond.

Separate issue: when will acute Trusts and pharmacies get round to e-prescribing and recording batch numbers?

The Blame Game

26 Jan 10 09:41

To commenter #14

I refer you to comment #2 - and in particular the last sentance.....

"Let's stop flogging the software vendors for not doing what someone should have been doing?"