Getting records up to standard

Professor Iain Carpenter and Professor Michael Thick

In the latest column from NHS Connecting for Health, chief clinical officer Professor Michael Thick is joined by Professor Iain Carpenter, associate director for records standards in the Health Informatics Unit at the Royal College of Physicians. They jointly talk about the standards the two organisations have just released for patient records.

Standardising the format of patient records is key to improving patient safety. The recent Health Informatics Review highlighted the importance of improving information standards across the NHS, and the need for clinicians to have the right patient information, at the right time, to deliver better, safer care.

Now, for the first time, profession-wide standards for patient records have been developed in a project co-ordinated by the Royal College of Physicians in partnership with NHS Connecting for Health and agreed by the Academy of Medical Royal Colleges.

The standards, officially launched yesterday [add link to EHI news story], are intended to improve safety by standardising the information held on patients throughout their stay in hospital, reducing the likelihood of mistakes and missing information at admission, handover and discharge.

When it comes to electronic patient records, the main challenge now is to work closely with suppliers on the technical requirements which will bring these standards to bear on them.

Variation and its dangers

We know that there is too much variation in medical record keeping both within individual hospitals and across different settings; the recently released Healthcare Commission annual health check once again identified record keeping as one of the weakest areas of NHS performance.

This has huge implications for patient safety – clinicians often have to repeatedly ask patients for the same information during their hospital stay and mistakes can occur. Inconsistent data also reduces the effectiveness of clinical auditing and information gathering for research purposes.

The new headings for electronic patient records provide a clear structure for the clinical content of admission, handover and discharge records of patients admitted to hospital.

Looking for consensus

The 36 headings include information such as observations and findings, investigation results and past medical history, and have been drawn up by the RCP’s Health Informatics Unit in consultation with a whole range of medical professionals, as well as patients and their carers.

The unit initially sent out both the proposed headings and a questionnaire to all of these groups, receiving responses from more than 3,000 clinicians. More than 90% agreed that medical records needed to be structured across the NHS.

Interestingly, many of the patients’ priorities were different from those of clinicians. Patients felt that their concerns, expectations and wishes for their care must be included, and that there should be a clear record of the information shared with them and their carers. These views were incorporated into the headings.

The standards had to be tested in real, clinical settings. A prototype admission record structured with the new headings was piloted in ten hospitals between June and August 2007. The majority of consultants said they felt that the new headings gave them a good picture of the patient’s presenting condition.

Some of the junior doctors and consultants felt that some additional sub-headings were needed, as well as more space for free text. The comments were taken on board. An example admission pro-forma that complies with the new standards has been developed by the RCP and can be downloaded by hospitals and tailored to their specific requirements if necessary.

Similarly, the headings for the handover documents and discharge summaries were piloted, this time in 13 hospitals and with their associated GPs between December 2007 and February 2008. A high proportion of the doctors working with the handover documents said they felt the headings provided the information they needed, as did the GPs who piloted the discharge summaries. Again, the piloting exercise proved extremely useful in identifying extra information to be added, including follow-up plans and identified risks.

New standards and their benefits

What are the next steps for the new standards? They now need to be developed in further detail to identify common patterns of clinical documentation below the headings. Initially, they will be used for paper record pro-formas. Eventually, they will be built into technical standards to support standards compliant systems.

The change in clinical practice that the record keeping standards will drive forward is a key enabler for the delivery of automated record-keeping. The two developments should work in tandem, and CfH will align the technical specifications to the professional standards to maximise benefits.

However, it is when the electronic records start to be used that the benefits will truly start to show. Clinical information will only need to be recorded once, improving efficiency and saving time. In turn, this will increase the quality and safety of clinical practice.

Routine clinical data will also be able to be incorporated into the design of large scale research, bringing even greater long-term patient benefits.

Next steps

The task is now to build on the partnership working already begun with suppliers, healthcare professionals and patients.

The RCP’s Health Informatics Unit and CfH are working with suppliers to develop the technical requirements to support the records. The suppliers have now started to use the standards to create pro-forma records, and these will be used as the basis for further consultation within the healthcare professions.

Information needs to be collected and used in a way which can bring about the best possible patient benefits, both for day to day clinical care and longer-term medical research purpose. Standardising the format of medical records is the first and most vital step in this journey.

Related articles

Healthcare check highlights record keeping issues

Link

The new standards can be viewed on the RCP’s website