1. Computerised reporting and terminology John Williams BSG Endoscopy Section Symposium 19 March 2002

2. The current situation 33% endoscopists still record on paper 79% have no computerised system in support of the rest of their work (BSG Information Working Party Baseline Survey 2000; replies from 55% of UK hospitals)

3. Survey - qualitative comments The following needs were specified in free text (251 replies) –Integration of systems (70) –Better departmental system (50) –Better or first endoscopy system (37) –Better IT support (36) –More resources or staff (35) –Better external links (31) –Better technology including image processing (22) –Better aggregate data (18)

4. Overview Fundamental requirements Content of the record Common standards Integration and linkage Other issues Work of the BSG Information Working Party

5. Purpose of the endoscopy record Primary purpose –Procedure record for the individual patient –Source of data for communication Secondary purpose –Source of data for aggregation for activity analysis audit performance review monitoring of training research

6. Requirements to meet these purposes Primary purpose –comprehensive record of the procedure –linkage to other records - path, admin etc –linkage to data on other contacts - out-patient, in-patient, telephone etc Secondary purpose –accurate, structured, coded data –common standards and definitions

7. Overview Fundamental requirements Content of the record Common standards Integration and linkage Other issues Work of the BSG Information Working Party

8. Data content of the record Demographic Administrative Clinical Technical The following guidance for the minimum content of the record has been agreed by the Endoscopy Committee:

9. Pre-procedure - structured text Demographic details about the patient Administrative details (date, episode type, urgency) Procedure Referral source Endoscopist Whether supervised Indication for procedure ASA status/Rockall score Instrument used

10. Procedure - structured text Sedation Endoscopic findings Specimens obtained Endoscopic diagnosis Therapeutic interventions Results of intervention Extent of examination Limitations of examination Time taken (total and to caecum) Complications (technical and clinical)

11. Record content - other information Images Annotated text to images Free text comments Discharge arrangements Follow-up arrangements Treatment recommended Post procedure complications Information given Patient satisfaction Final diagnosis

12. Overview Fundamental requirements Content of the record Common standards Integration and linkage Other issues Work of the BSG Information Working Party

13. Common standards (http://www.isb.nhs.uk) Language and terminology –Minimal Standard Terminology (MST) ( http://www.omed.org) Headings –Headings for communicating clinical information ( http://www.nhsia.nhs.uk/headings ) Codes –SNOMED-CT ( http://www.nhsia.nhs.uk/terms/pages/snomedct) Administrative definitions –National Patient Access Team (http://www.health.secure.net/channels/npat or Eric.Gatling@doh.gsi.gov.uk)

14. Do standards matter? Quality of reports and communications Common understanding of report content Accurate and comparable data –eg NCEPOD are proposing to collect mortality data following endoscopy HES data for 1999/00 identified 80,036 endoscopic procedures Data from GI units in Wales alone identified 60,579 endoscopic procedures in 2000 There were an additional 4,364 procedures undertaken in community hospitals in Wales

15. Overview Fundamental requirements Content of the record Common standards Integration and linkage Other issues Work of the BSG Information Working Party

16. Integration & Linkage The endoscopy record will need to be part of a single clinical electronic record covering all patient contacts It must also link to other systems within the organisation (eg Patient Administration; Pathology; Radiology)

17. Other issues All professionals who come into contact with the patient will need to be identified Innovative methods of data entry need to be explored Image storage will probably require an integrated approach within the organisation

18. BSG Information Working Party Has addressed these issues A suite of documents is on the BSG website bsg.org.uk (in the members section), including: –specification of requirements for clinical systems in support of gastroenterology –content of the endoscopy record –image capture and storage –requirements for pathology systems –glossary of terms Feedback would be welcome (j.g.williams@swan.ac.uk)

19. Further work The Working Party is exploring how potential solutions can be assessed for the benefit of colleagues, using a commercial consultancy A generic version of the specification of requirements is intended to ensure compatibility between specialties and diciplines. It is available on the Academy of Medical Royal Colleges website (aomrc.org.uk)