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Prof. Iain Carpenter from the Health Informatics Unit emphasizes the urgent need to transition to a paperless NHS by the end of 2015. Current challenges include inconsistent record-keeping standards across clinicians and departments, leading to potential issues in patient information sharing and management. The necessity for structured clinical records that align with healthcare practices has never been greater. By unifying and standardizing electronic health records, the NHS can enhance patient care and streamline processes, ultimately improving health outcomes.
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Standards for Electronic Patient RecordsUpdate Prof Iain Carpenter Health Informatics Unit& Professional Record Standards Body
Delivering the paperless NHS • “I’m pushing for the end of 2015 to eradicate paper from the NHS. No more referral letters or lost records because we won’t have paper anymore in the health service,”
The Challenge • Meaningful Clinical information from Electronic Health Records
Current situation – record keeping • Now: • Records learnt by apprenticeship • No agreed standards • Differences between clinicians, departments, trusts • EPRs also can cause problems: • Piles of electronic pages instead of paper ones • Information can’t be shared safely between systems
Electronic records Patient management Research Disease registers Screening programmes Central returns Audit
Patient management Research Disease registers Screening programmes Central returns Audit
Clinical record standards • Structured to match the way we work • Patient and clinician involvement • Evidence based • Clinical and patient body acceptance
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e-Referrals • Work with EMIS, InPractice and TPP to incorporate headings into templates • Templates made available on systems and communicated via mailshots • Engaged with LMCs • Piloted with InPractice and EMIS • Discussions with Choose and Book
Core headings Core Information Admission Referrer The core information is enriched at each step By agreeing a ‘core’ information standard we can allow individual systems to share information This ‘core’ information can then be saved on each individual system Handover Discharge
Role of PRSB • Brokering development of record standards • Editorial Principles • Stakeholders • professional assurance of record standards • Assurance criteria
Role of PRSB • prioritisation of standards development • Prioritisation principles • care professional guidance for those working on technical implementation of standards • Including system suppliers and vendors
HSCIC and PRSB Implementation Programme • Dissemination and communication • Technical products • Early implementers • Implementation guidance covering all aspects
Current issues • Care.data • Hospital.data • Paperless between primary and secondary care • E-referral • Digital care plans
Meeting the data return requirements 2020 2015 care.data big.data
Semantic Interoperability Care home record GP record Radiology system Hospital EHR
Summary • Problems with paper and electronic records • Standards for structure and content • Paperless between primary and secondary care • Full electronic health records • Delivering the data return requirements
Further information • Informatics@rcplondon.ac.uk
Standardised record structure Standardised record structure
