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

Where will the clinical data for the electronic health record come from?

Where is there clinical data at present? Patient management Audit Screening programmes Disease registers Clinic Research Central returns Clinical data is held in disparate applications That have different purposes And different ownership

What would be the solution? D ata should be recorded in a clinical record focused on the patient D ata should be recorded in a clinical record focused on the patient The record should support all contexts in which the patient is seen The record should support all contexts in which the patient is seen And be interoperable with other systems as appropriate And be interoperable with other systems as appropriate The structure and content will have to be standardised The structure and content will have to be standardised

Ownership and clinical engagement Engaging the clinicians Engaging the clinicians What will change for me? What will change for me? Relate it to what we do everyday, eg Admission clerking Relate it to what we do everyday, eg Admission clerking It is coming, best that it should reflect best clinical practice ‘as it is done’ It is coming, best that it should reflect best clinical practice ‘as it is 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 part reflect the preferences of the individual clinicians who were enthused and took part or the technical requirements of the system or the technical requirements of the system and not reflect the clinical practice of the majority and not reflect the clinical practice of the majority

Structure and Content Standards for the medical record Research and published evidence base Research and published evidence base Professional consensus Professional consensus Practicing hospital doctors Practicing hospital doctors RCP Patient Carer Network RCP Patient Carer Network The Medical Royal Colleges and Specialists Societies The Medical Royal Colleges and Specialists Societies The Academy of Medical Royal Colleges The Academy of Medical Royal Colleges Uptake Uptake Regulators Regulators Defence organisations Defence organisations Professional bodies Professional bodies Educational programmes Educational programmes

Out patients Endoscopy Specialist nurse telephone support In-patients Views of information in the patient focused record Mrs Jones

GP Surgery  Hospital 

Hospital A&E  Treatment centre  GP Surgery   ASDA

Summary Provenance of the clinical data Provenance of the clinical data Day to day practice Day to day practice Clinicians are engaged when it relates to what they recognise as their every day work Clinicians are engaged when it relates to what they recognise as their every day work The records must be patient centred The records must be patient centred The same record follows the patient The same record follows the patient The patient can access their whole record from wherever they are The patient can access their whole record from wherever they are The professionals will therefore also be access it to deliver the required care The professionals will therefore also be access it to deliver the required care Everything else follows from the digital patient focused record Everything else follows from the digital patient focused record Clinical Outcome Clinical Outcome Quality of care Quality of care Service planning and monitoring Service planning and monitoring Increased efficiency for clinical and epidemiological research Increased efficiency for clinical and epidemiological research