Post on 29-Dec-2015
Medical RecordsMedical RecordsAchieving professional consensusAchieving professional consensus
Professor Iain CarpenterProfessor Iain Carpenter
Health Informatics UnitHealth Informatics Unit
RCP, 15th July 2010
Where will the clinical Where will the clinical data for the electronic data for the electronic health record come health record come
from?from?
Where is there clinical data at present?Where is there clinical data at present?
Patientmanagement
Audit
Screeningprogrammes
Diseaseregisters
Clinic
Research
Centralreturns
Clinical data is held in disparate applicationsClinical data is held in disparate applications
That have different purposesThat have different purposes
And different ownershipAnd different ownership
What would be the solution?What would be the solution?
DData should be recorded in a clinical record ata should be recorded in a clinical record focused on the patientfocused on the patient
The record should support all contexts in which The record should support all contexts in which the patient is seenthe patient is seen
And be interoperable with other systems as And be interoperable with other systems as appropriateappropriate
The structure and content will have to be The structure and content will have to be standardisedstandardised
Ownership and clinical engagementOwnership and clinical engagement
Engaging the cliniciansEngaging the clinicians What will change for me?What will change for me? Relate it to what we do everyday, eg Admission clerkingRelate it to what we do everyday, eg Admission clerking
It is coming, best that it should reflect best clinical practice ‘as it is It is coming, best that it should reflect best clinical practice ‘as it is done’done’
If left to a few clinical enthusiasts and IT techies, it may:If left to a few clinical enthusiasts and IT techies, it may: reflect the preferences of the individual clinicians who were enthused and took reflect the preferences of the individual clinicians who were enthused and took
partpart or the technical requirements of the systemor the technical requirements of the system and not reflect the clinical practice of the majorityand not reflect the clinical practice of the majority
Structure and Content Standards for Structure and Content Standards for the medical recordthe medical record Research and published evidence baseResearch and published evidence base
Professional consensusProfessional consensus Practicing hospital doctorsPracticing hospital doctors RCP Patient Carer NetworkRCP Patient Carer Network The Medical Royal Colleges and Specialists SocietiesThe Medical Royal Colleges and Specialists Societies
The Academy of Medical Royal CollegesThe Academy of Medical Royal Colleges
UptakeUptake RegulatorsRegulators Defence organisationsDefence organisations Professional bodiesProfessional bodies Educational programmesEducational programmes
Outpatients
Endoscopy
Specialist nurse
telephonesupport
In-patients
Views of information in the patient focused
record
Mrs Jones
GP Surgery GP Surgery
HospitalHospital
Hospital A&E Hospital A&E
Treatment centre Treatment centre
GP Surgery GP Surgery
ASDA ASDA
SummarySummary
Provenance of the clinical dataProvenance of the clinical data Day to day practiceDay to day practice
Clinicians are engaged when it relates to what they Clinicians are engaged when it relates to what they recognise as their every day workrecognise as their every day work
The records must be patient centred The records must be patient centred The same record follows the patientThe same record follows the patient The patient can access their whole record from wherever they areThe patient can access their whole record from wherever they are The professionals will therefore also be access it to deliver the required careThe professionals will therefore also be access it to deliver the required care
Everything else follows from the digital patient focused Everything else follows from the digital patient focused recordrecord Clinical OutcomeClinical Outcome Quality of careQuality of care Service planning and monitoring Service planning and monitoring Increased efficiency for clinical and epidemiological researchIncreased efficiency for clinical and epidemiological research