NHS Scotland eHealth Programme Clinical Information Presentation - PDF document

NHS Scotland eHealth Programme Clinical Information Presentation Standard Version: 5.2 Date: 29 th February 2012

Contents 1 Introduction............................................................................................. 2 2 Proposed Information Headings ........................................................... 3 2.1 Potential Clinical Content .................................................................................................. 4 3 Related standards................................................................................... 5 Page 1

1 Introduction The Clinical Change Leadership Group recommended that consistent display of clinical information in IT systems will support patient safety by bringing consistency of practice and avoiding variation. Training effort would also be reduced by defining layouts and formats that are intuitively usable and are found consistently wherever clinicians work in NHS Scotland. The Clinical Portal Programme Board and the Scottish Association of Medical Directors have recommended that there should be a consistent approach to presentation of clinical information in all clinical portals implemented across NHS Scotland. In addition, the Royal College of Physicians of Edinburgh will shortly publish a manifesto, which will include a recommendation that information displayed in clinical IT systems should be presented in a more consistent manner across NHS Scotland. The aim of the Clinical Change Leadership Group is to develop and publish an eHealth standard which will recommend a high-level standard format for the presentation of clinical information to Boards implementing clinical IT systems as a minimum requirement, allowing for additional local information and/or documentation. It is recognised that there will be some variety in front-end delivery mechanisms and the standard would therefore focus on consistent use of headings to group types of information rather than expecting all Clinical Portals, for example, to look exactly the same. Indeed it is considered to be desirable that clinicians 1 have the ability to customise their portals around the needs of their practice and personal preferences. Therefore some standardisation of the way in which this clinical data is presented is required but it should not be at the expense of innovation - i.e. adopting these standards as a minimum will not stifle the local need to add additional fields/headings where appropriate. Any published eHealth Standard should be applicable to all clinical IT systems however it is recognised that the costs associated with reconfiguration of existing systems are likely to be excessive and therefore it is not expected that the standard will be applied to legacy systems or where suppliers would have to make significant changes to their products. It is anticipated that future implementation of clinical IT systems, such as clinical portals or Patient Management Systems should adopt this standard unless there is a justifiable reason not to do so. This document outlines the basis of the content for the proposed eHealth Clinical Information Presentation Standard. It describes a series of information group “headings” to support retrieval of clinical information and also makes a recommendation for how certain types of information, which are commonly viewed by clinicians, should be presented to avoid clinical risk. Wherever possible, existing data standards and definitions have been proposed and the degree of standardisation suggested in this document is a minimum requirement. The standard was developed with clinical input from across NHSScotland, including representation from Boards engaged in clinical portal developments. Although the standard will be applicable to any clinical IT system this document focuses on how the proposed information display standard would work in the context of a clinical portal. 1 The term “Clinician” is used throughout this document to include Doctors; Nurses; Midwives and Allied Healthcare Professionals. Page 2

2 Proposed Information Headings The following table describes the headings that are proposed to support information retrieval in clinical systems. These would be recommended as the minimum standard, however additional headings could be included as necessary. Heading Subheadings or examples of information ( Please note: These are only examples of information and not intended to be a definitive list of sub headings) • Demographics A Demographics and contacts • Next of kin • Services involved in care • Carer details • Family History B Social & Personal Summary • Social History • Home circumstances • Lifestyle choices C Alerts & Risks Examples include: • Child protection alert • Alert that patient has DNAR form available • Warning for community staff that patient has dangerous dog D Healthcare encounters Examples Include • Inpatient/ Daycase Admissions • Waiting list Appointments • Outpatient clinic attendances • Therapy Appointments • Emergency Department attendances • Out of Hours attendances • Organ Donation E Patient Needs/Preferences • Patient and family wishes • patient support needs F Allergies and adverse events • Diagnoses G Clinical history: • Problems/Issues • Procedures / Interventions H Correspondence All letters including: • Referral • Admission • Discharge • Outpatient clinic Page 3

• A&E letters • AHP letters etc. • Active/ Ongoing I Medication, immunisation & Devices * • Inactive/ • Completed • Immunisations • Devices J Notification and Legal documents Would include such things as: • DNACPR form, • Mental Health Act docs • Adults with Incapacity form • Labs K Investigations & Results • Radiology • Other Diagnostic Test results • Pending/Outstanding Requests L Clinical Notes Would include any documentation about patients other than letter sent to other healthcare professionals e.g. • Pre-op assessments • Progress notes • Care plans • Images ( videos, medical images etc) • Vital signs M Observations • Anaesthetic charts • Structured scores *The way in which medication prescriptions and their administration are presented is currently under review. 2.1 Potential Clinical Content Information accessed using one of these headings in a clinical portal may be available in different formats. For example, under the heading of “Investigations and Results” laboratory results may be viewed directly from a lab system or as a document from SCI store; Radiology images will be available by viewing through PACS and endoscopy test reports may be available from a local endoscopy system. Whether the clinical data is derived from recorded data in a clinical IT system or whether it is available as a document, is less important than clinicians knowing that the same types of information can be found under the same headings. However, the actual source of the data being viewed is important to enable clinicians to put that data into context. There are a number of ways of doing this. For example, the data source may be indicated by hovering over the data as a “tool tip”, or the data heading may simply have its source in brackets or as a separate data descriptor. Page 4

3 Related standards Documents may be generated electronically or may be available as scanned images. When documents are generated electronically, tags or metadata are added which enable those documents to be managed and filed so they can subsequently be retrieved easily. This necessitates a consistent approach to naming of document types and subtypes. The NHS Scotland Clinical Document Indexing Standard has recently been revised. The latest version can be found at: http://www.ehealth.scot.nhs.uk/?page_id=372 This standard includes a list of document types and subtypes, with associated definitions, and includes metadata requirements for scanned or electronically generated documents. NHS Scotland has already adopted the use of the Common User Interface standard for information display (http://www.mscui.com) in its user interface standard from 2009 (http://www.ehealth.scot.nhs.uk/?page_id=372). For the purposes of the Clinical Information Presentation Standard it is recommended that clinical systems should adopt the CUI standard for display of the patient banner, dates and display of medication as a minimum ( http://www.mscui.com/DesignGuide/DesignGuide.aspx) unless there are technical reasons why this can not be implemented. eHealth Programmes February 2012 Page 5