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Medical Records Achieving professional consensus

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?. Clinical data is held in disparate applications.

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Medical Records Achieving professional consensus

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  1. Medical RecordsAchieving professional consensus Professor Iain CarpenterHealth Informatics Unit RCP, 15th July 2010

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

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

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

  5. Ownership and clinical engagement • Engaging the clinicians • What will change for me? • 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’ • 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 • or the technical requirements of the system • and not reflect the clinical practice of the majority

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

  7. Views of information in the patient focused record In-patients Out patients Endoscopy Specialist nurse telephone support MrsJones

  8. GP Surgery  Hospital

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

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

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