Medical Records Achieving professional consensus Professor Iain Carpenter Health Informatics Unit RCP, 15 th July 2010.

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