Records, standards and coding: What, why and how

Information for chief clinical information officers These slides are provided by the Professional Record Standards Body to help you explain: How important good record keeping is to your Trust What are the standards for records Why it is important that staff keep accurate records in line with standards The benefits

Information for chief clinical information officers We recommend that you use them as a prompt and encourage conversation and discussion as part of the session, useful as potential content for a discussion on the topic including examples and stories from your own experience.

Good clinical care depends on high quality information

Why are we here? To provide high quality care, which is safe, timely, effective, efficient equitable, patient-centred and sustainable. CCM/presentations/SW0912

Why ‘write’ things down? Recording our thoughts, deliberations, rationale for decisions helps all clinicians to understand the patient’s condition and their progress whilst under our care. CCM/presentations/SW0912

Why ‘write’ things down? It is also important for: Legal and regulatory reasons To inform audit Service evaluation Billing – so we are appropriately paid for the complexity of work we do CCM/presentations/SW0912

Why ‘write’ things down? When you see a patient for the first time in the middle of the night when they are sick, what do you do? You look at the notes. So the quality and content of the notes is really important. CCM/presentations/SW0912

Why ‘write’ things down? The next time you are writing something in the notes, imagine that you are the night time doctor and write something that will be useful for them. In doing so you will likely write something that is helpful for all of the reasons discussed. CCM/presentations/SW0912

Why code things? It’s clinically important: Analysis – audit, service evaluation, epidemiology, planning of service provision To drive new tools such as clinical decision support Information sharing – coding enhances interoperability And it’s essential to billing CCM/presentations/SW0912

Medical records The medical record has legal status If it isn’t there – it didn’t happen A signature confirms the authenticity CCM/presentations/SW0912

The role of standards in today’s care

Standards for record keeping Why have standards? Patients, healthcare and systems are complex Standards bring order to complexity They are essential to creating a digitally enabled NHS Standards allow us to capture, share and retrieve the right information in real time to provide the best care. IT systems use standards to read, store and extract information so it is timely, accurate and relevant.

Standards for record keeping What are the standards? The standards structure information under a set of agreed headings so it can be recorded fully and accurately during the patient journey. They are developed by expert reference groups from across health and social care through the PRSB and are endorsed and adopted by colleges, professional and patient groups who are the PRSB’s members.

Standards for record keeping Why are they essential to integrating care? These standards are essential to safely sharing clinically accurate and meaningful data across care providers. The standards are being developed on a phased basis, and as they are introduced, systems in hospitals and elsewhere will change and adapt to reflect them.

Standards for record keeping How you can get involved Implementation is key Help ensure that the standards are relevant to your work Do they makes sense to how you work and care for your patients? Paperless 2020 In turn, the NHS can work towards being paperless by 2020 – because information will be available and transferable.

What does a digital health record look like? Full name: John M Smith, Mary Brown Designation: Consultant Surgeon, Senior Clinical Nurse Contact No: Bleep or extension Date: dd/mm/yyyy Time: 24hr clock Errors and alterations: corrected and signed formal addendum The most senior clinician present identified and recorded CCM/presentations/SW0912

Coding clinical information Record ALL the relevant diagnoses and procedures to reflect the episode of care: Primary diagnosis Secondary diagnoses Co-morbidities Primary procedure Secondary procedures Complications Etc CCM/presentations/SW0912

Using the digital health record Complete all required (clinical and administrative) fields has the diagnosis / problem list been reviewed? are all co-morbidities & secondary diagnoses current or no longer present? have other documents / forms / notes been completed appropriately? Safe, effective & efficient patient care relies on high quality data

Starting to use standards: e-discharge summary

Why the e-discharge summary? It’s essential to timely, safe patient handovers from hospitals to GPs Until now there have been no common standards There is an urgent need to improve patient safety and continuity of care by developing digitised discharge summaries. The PRSB has tested and agreed standards for the clinical information contained in electronic discharge summaries

What is in the e-discharge summary? The e-discharge summary includes necessary patient details, information on diagnoses, procedures, allergies, medications and adverse reactions. The structured headings also include entries for patient/carer information. Patient portals are coming online – patients want to see their own data and be able to contribute to it – so the benefits aren’t just for clinicians.

Timing and roll-out of the e-discharge summary 2015 - All hospitals were obliged to send discharge summaries electronically. 2016- NHS trusts and GPs should be using the PRSB information headings for e-discharge summaries by year-end. 2018 - The coding behind these standards will be mandatory.

E-discharge summary - what next? Referrals Secondary to primary care completes “one half of the circle”. Sending structured, coded, clinical information to secondary care at referral from primary care completes the circle. Medicines and reconciliation GP to hospital – GPs send structured coded data to hospitals for reconciliation and in-patient prescription. Hospital to GP – hospitals send structured, coded, information to the GP for reconciliation and ongoing home medication The safety benefits of this are profound compared with what we have now.

Informatics – the way of the future?

What we should be aiming for... “Clinical informaticians transform health care by analyzing, designing, implementing, and evaluating information and communication systems that enhance individual and population health outcomes, improve patient care, and strengthen the clinician-patient relationship.” J Am Med Inform Assoc. 2009 Mar-Apr;16(2):153-7 CCM/presentations/SW0912

Data essentials: data dictionaries / classifications / terminology The NHS Data Dictionary covers all datasets and data items used in the NHS Classifications – ICD-10 / OPCS 4 Terminologies – SNOMED CT CCM/presentations/SW0912

Why this matters? In future all information shared between systems will be coded Terminology and classifications are designed for very different purposes and thus are structured differently. Current classifications are used to categorise a completed episode of care according to pre-determined classification codes; the classifications support indirectly related activities such as epidemiology, payment and population monitoring. They do not however provide the vocabulary a clinician wishes to use for recording activity related to the specific care of a patient within the electronic patient record. CCM/presentations/SW0912

Classifications – e.g. ICD-10 Provides a structured framework for statistical information Ensure that items are included and counted only once for reporting Nationally and internationally recognised, governed by rules and conventions NOT suitable for recording clinical care

Terminologies – e.g. SNOMED CT Provide a clinically meaningful vocabulary for clinicians to record activity Contains a hierarchy reflecting the logical relationships between clinical concepts e.g. pneumonia is a type of infection – so searching for patients with infection will automatically find patients with pneumonia Nationally and internationally recognised, governed by rules and conventions IS suitable for recording clinical care

More on classification and terminologies It is inevitable there are some similarities between the two as they are both designed to relate to clinically relevant content. However there are fundamental differences, some of which are highlighted on the next slide. CCM/presentations/SW0912

Key differences In classifications, because these represent areas of interest to monitor populations, the category can incorporate data that is elsewhere within the record For example there may be a different code for a particular disorder depending on the age of the patient. In a terminology the term for the disorder would be the same for all ages and the age would be held elsewhere on the record. CCM/presentations/SW0912

Key differences – cont’d A statistical classification must be confined to a limited number of mutually exclusive categories and each category is structured to ensure all instances have been included, for example, to report on all types of skin cancer. This results in codes with descriptions such as NOS (Not Otherwise Specified) and NEC (Not Elsewhere Classified) which have a specific meaning within the classifications These do not and should not exist in the terminology in relation to the direct care of the patient. CCM/presentations/SW0912

Key differences – cont’d Terminologies need to be dynamic and updated frequently to cope with the changing needs of clinical care as they provide the dictionary for data entry. The classifications need to remain stable over time to enable consistent trend reporting. CCM/presentations/SW0912