Towards the Single Patient Record: Clinical Documents Ann Wrightson

Contents  What is a document?  Clinical viewpoint  Technical viewpoint  Where do documents come from?  Federated document stores and patient identity

Clinical viewpoint

What’s a Document? Content Header Record element 1 Record element 2-n Document header Document body A clinical communication describing a care event or episode of care A collection of clinical information stated at a particular time about a particular patient A source of information important for patient safety, eg medications, allergies Document wrapper

Wrapper, header and body  Wrapper  Not part of the document itself (may be removed)  Specific to a particular use of a document  May replicate items from the header or body  Header  Patient identity and demographics  Administrative information  Body  Clinical information  Key elements for patient safety are computable where possible

Priorities for Patient Safety  Core data 1  Medicines Meds

 Core data 2  Diagnoses  Procedures  Allergies  Tests Diags Allerg Probs TestsProc Meds Priorities for Patient Safety

 Additional elements  Social circumstances  Family history  Care plan  Etc. Social Family Care plan Exam findings Diags Allerg Probs TestsProc Meds Priorities for Patient Safety

 Additional elements  Blood pressure  Head circumference  Weight  Height  Door to needle time  Etc. Social Family Care plan Exam findings Diags Allerg Probs TestsProc Meds Priorities for Patient Safety

Technical viewpoint

“The document” Patient Identity Recorded demographics Human readable Header Content

“The” document Patient Identity Recorded demographics Human readable Patient identity as recorded in the document allows the document to “belong” to an individual Patient demographics as recorded in the document supports patient record administration. MPI, WDS ?

“The” document Clinical Classification Records management Patient Identity Recorded demographics Human readable Classification of this document in some context, e.g. as a clinical event or care plan Metadata to support records management of the document as an e-record

Processable, computable clinical information: “Record Components” Functional Metadata for Business Processes Clinical Classification Records management Patient Identity Recorded demographics Human readable

Processable, computable clinical information: “Record Components” Functional Metadata for Business Processes Clinical Classification Records management Patient Identity Recorded demographics Human readable Content Header Record element 1 Record element 2-n Document header Document body

Processable, computable clinical information: “Record Components” Functional Metadata for Business Processes Clinical Classification Records management Patient Identity Recorded demographics Human readable Content Header Record element 1 Record element 2-n Envelope/wrapper for transport Folders may be actual collections, or views constructed using information from the documents Document participates in business process

Processable, computable clinical information: “Record Components” Functional Metadata for Business Processes Clinical Classification Records management Patient Identity Recorded demographics Human readable Content Header Record element 1 Record element 2-n Document header Document body Document wrapper

Local document store

Scanned paper documents Document scanning - Selected pre-electronic medical records - Correspondence Electronic document store Header Content

Scanned paper documents Document scanning - Selected pre-electronic medical records - Correspondence Electronic document store Patient folder

“Born digital” narrative & preformatted documents Clinical correspondence eg prepared with MS Word templates Patient folder Header Content

LIMS Disease specific systems Social care “Born digital” narrative & preformatted documents Clinical correspondence eg prepared with MS Word templates Header Content Header Record element 1 Record element 2-n Computable record components appear when they can be safely derived from input data

View documents in WCP WCP makes documents available in a patient record …and creates them LIMS Disease specific systems Social care Document scanning Welsh Clinical Portal MPI, WDS

Federated document stores …one way we might deliver clinical documents in the Single Patient Record

Each LHB has its own document store (Same technology, separate instances) Each LHB has its own MPI (Same technology, separate instances) New LHBs in Wales

Record stores (and PACS) wider integration using eg IHE XDS supporting “pull” requests

MPIs will also work in a federated way WDS already in place with link to PDS WDS PDS

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