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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. Header. Content. Record element 1.

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contents
Contents
  • What is a document?
    • Clinical viewpoint
    • Technical viewpoint
  • Where do documents come from?
  • Federated document stores and patient identity
what s a document

Header

Content

Record element 1

Document header

Record element 2-n

Document body

Document wrapper

What’s a Document?

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

wrapper header and body
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
Priorities for Patient Safety
  • Core data 1
    • Medicines

Meds

priorities for patient safety1

Diags

Allerg Probs

Tests Proc

Meds

Priorities for Patient Safety
  • Core data 2
    • Diagnoses
    • Procedures
    • Allergies
    • Tests
priorities for patient safety2

Social

Family Care

plan

Exam findings

Diags

Allerg Probs

Tests Proc

Meds

Priorities for Patient Safety
  • Additional elements
    • Social circumstances
    • Family history
    • Care plan
    • Etc.
priorities for patient safety3

Social

Family Care

plan

Exam findings

Diags

Allerg Probs

Tests Proc

Meds

Priorities for Patient Safety
  • Additional elements
    • Blood pressure
    • Head circumference
    • Weight
    • Height
    • Door to needle time
    • Etc.
slide11

Content

Header 0123450123

“The

document”

Patient Identity

Recorded

demographics

Human

readable

slide12

MPI,

WDS

“The”

document

?

Patient identity as recorded in the document allows the document to “belong” to an individual

Patient Identity

Recorded

demographics

Human

readable

Patient demographics as recorded in the document supports patient record administration.

slide13

Classification of this document in some context, e.g. as a clinical event or care plan

“The”

document

Metadata to support records management of the document as an e-record

Clinical

Classification

Records management

Patient Identity

Recorded

demographics

Human

readable

slide14

Clinical

Classification

Records management

Functional

Metadata for

Business

Processes

Processable,

computable

clinical

information:

“Record

Components”

Patient Identity

Recorded

demographics

Human

readable

slide15

Clinical

Classification

Records

management

Functional

Metadata for

Business

Processes

Processable,

computable

clinical

information:

“Record

Components”

Patient Identity

Recorded

demographics

Human

readable

Document header

Header

Content

Record element 1

Document body

Record element 2-n

slide16

Clinical

Classification

Records

management

Functional

Metadata for

Business

Processes

Processable,

computable

clinical

information:

“Record

Components”

Patient Identity

Recorded

demographics

Human

readable

Header

Content

Record element 1

Record element 2-n

Folders may be actual collections, or views constructed using information from the documents

Document participates in business process

Envelope/wrapper

for transport

slide17

Clinical

Classification

Records

management

Functional

Metadata for

Business

Processes

Processable,

computable

clinical

information:

“Record

Components”

Patient Identity

Recorded

demographics

Human

readable

Header

Content

Record element 1

Document header

Record element 2-n

Document body

Document wrapper

scanned paper documents

Electronic

document

store

Document scanning

Content

Header 0123450123

Scanned paper documents

- Selected pre-electronic medical records

- Correspondence

scanned paper documents1

Patient folder

Document scanning

Scanned paper documents

- Selected pre-electronic medical records

- Correspondence

Electronic

document

store

born digital narrative preformatted documents

Patient folder

Content

Header 0123450123

“Born digital” narrative & preformatted documents

Clinical correspondence eg prepared with

MS Word templates

born digital narrative preformatted documents1

LIMS

Disease specific systems

Social care

Content

Header

Header 0123450123

Content

Record element 1

Record element 2-n

“Born digital” narrative & preformatted documents

Clinical correspondence eg prepared with

MS Word templates

Computable record components appear when they can be safely derived from input data

view documents in wcp

Welsh

Clinical

Portal

MPI,

WDS

Document scanning

LIMS

Disease specific systems

Social care

View documents in WCP

WCP makes documents available in a patient record

…and creates them

federated document stores

Federated document stores

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

slide25

New LHBs in Wales

Each LHB has its own document store

(Same technology, separate instances)

Each LHB has its own MPI

(Same technology, separate instances)

slide27

WDS

PDS

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