Select Committee on Health Written Evidence


Evidence submitted by the Royal College of Physicians (EPR 48)

  The Royal College of Physicians (RCP) plays a leading role in the delivery of high quality patient care by setting standards of medical practice and promoting clinical excellence. We provide physicians in the United Kingdom and overseas with education, training and support throughout their careers. As an independent body representing over 20,000 Fellows and Members worldwide, we advise and work with government, the public, patients and other professions to improve health and healthcare.

1.  INTRODUCTION

  1.1  The Royal College of Physicians welcomes the opportunity to contribute to this inquiry. For many years the College has championed the need for better, more structured health records, and the need for these to be developed in electronic form, to bring benefits to patients. (1)

  1.2  The debate about electronic patient records (EPRs) is bedevilled by a lack of clear definition and therefore common understanding of what the term EPR means. It is clear that concepts have shifted within the National Programme for IT within the last few years, which has added to the confusion.

  1.3  The current concept appears to assume that a useful individual summary health record can be accumulated by coalescing a wide variety of communications about a patient. We believe that this will be of limited value in practice.

  1.4  The EPR should be the cornerstone of the individual patient's health record. Health care is delivered in widely differing contexts but the underlying processes are always the same—the patient is assessed, actions are planed and executed and the patient is reviewed. This sequence may take place over a matter of minutes in the emergency situation, or many months in the management of chronic disease. However, the capture of essential data on assessment (whether from the patient's history, examination or test results) and the planning and execution of actions (whether talking to the patient, prescribing drugs, arranging tests or performing complex procedures) will contain essential pieces of information that need to be captured to build up the electronic record.

  1.5  Against this background it is possible to develop a concept of the electronic patient record that is:

    —  truly patient-focused;

    —  built using a common, generic architecture but customised for appropriate use in the wide variety of contexts in which the patient is seen (from nurse-led community care to highly specialised tertiary units);

    —  summarised at a high level to contain essential data of relevance to other carers;

    —  also containing very detailed data of relevance only to those who look after patients in specific contexts;

    —  a mix of structured and unstructured (free-text) data;

    —  protected and accessible on a need-to-know basis.

  1.6  It is not possible to build such a record by extracting data from systems that support the processes of care (such as scheduling, booking, ordering and communicating). There is a need to address how data are recorded in the course of patient/professional interaction, as well as through the ordering and execution of investigations and procedures.

  1.7  The concepts outlined above imply

    —  a need for an agreed, common architecture for the record;

    —  common standards for data entry, particularly in structured records; and

    —  a preparedness amongst health professionals to collect data as accurately as possible and to these common standards.

  1.8  The need for such common standards is seen as important by physicians. A recent poll of RCP Fellows and Members was overwhelmingly in favour. (2)

Table 1

RESULT OF POLL OF RCP MEMBERS AND FELLOWS

  In answer to the question: "The same, standardised headings should be used in all NHS hospitals in the admission clerking of Acute Medical Admissions".

  Results:

Strongly
agree

Agree

No opinion

Disagree
Strongly
disagree

Total
GradeConsultantCount 20133833 3520627
% within
Grade
32.153.95.3 5.63.2100.0%

Specialist Registrar

Count
77195 114217 342

% within
Grade
22.557.03.2 12.35.0100.0

Non consultant career grade

Count
615 020 23
% within
Grade
26.165.20 8.70100.0

SHOCount 15253 3248
% within
Grade
31.352.16.3 6.34.2100.0

OtherCount 17233 3147
% within
Grade
36.248.96.4 6.42.1100.0

Total
Count 31659650 85401,087
% within
Grade
29.154.84.6 7.83.7100.0


2.   What patient information will be held on the new local and national electronic record systems?

  This question needs to be considered in two parts: local data and national data.

2.1  Local data

  2.1.1  The data which are held in the record at a local level will depend on the context in which the patient is seen. Thus a general practitioner or district nurse may need relatively little information, seen as a summary of the overall patient story. On the other hand, a gastroenterologist will need a detailed record of the patient's endoscopy findings, and a cardiothoracic surgeon will need a detailed theatre record or cardiac assessment. The definition of this detail and the structure of the record to record it should be agreed nationally, based on work undertaken by appropriate professional bodies such as the Royal Colleges and Specialist Societies. To date the Colleges have not been requested to undertake this work but it is an area where clinical engagement and leadership could be very profitably harnessed.

  2.1.2  The Royal College of Physicians has already pioneered the development of standards for record-keeping in the context of the acute medical admission, based on a review of the evidence relating to benefit; two polls of practising hospital doctors to ascertain their views; and a wide assessment of current practice. The Royal College of Physicians has developed both generic medical record-keeping standards and standards for the structure and content of the acute medical admission. Further work will be undertaken to address other contexts.

2.2  National data

  2.2.1  The data which are held at a national level must be sufficiently comprehensive to enable primarily the safe and efficient care of the patient when first seen by a practitioner who does not know their story and, secondly, to support a wide variety of secondary purposes. The latter use will be discussed below. In order to inform the primary purpose of the care of the patient, information is needed on:

    —  the patient's current problems;

    —  active diagnoses;

    —  significant past history including both illnesses and operations;

    —  relevant social circumstances;

    —  current drugs and other treatments;

    —  allergies; and

    —  patient wishes.

3.   How should data held on the new systems be used for purposes other than the delivery of health care?

  3.1  The Royal College of Physicians supports the use of data held in the patient record for other purposes including individual performance monitoring, service development and clinical research. However, work done by the College has shown currently data extracted from paper records and held centrally are not fit for these purposes. (3) The findings of this work strongly support the need for structured records, as described in the introduction to this submission. They also suggest the need for professional engagement, preferably through professional bodies such as the Royal Colleges, who can give strong leadership to the profession.

  3.2  We have shown that data can support clinical research if collected rigorously and in structured form but this requires the health record to be clinically rich, the data to be collected to common standards, and professional attention to the accuracy of the data recorded. (4)

4.   Should patients be able to prevent their personal data being placed on systems?

  We believe that patients should have the right to veto the recording of certain data (which might include the whole record) but should be made aware of the risks to their personal health care this brings. Having considered the arguments, we believe this should be handled on an opt-out basis rather than an opt-in basis for hospital-based medicine. Patients should be fully informed of those data items which will be held on their summary record, and given the opportunity to object. Due to the timescales involved we have not had the opportunity to consult our Patient and Carer Network (a group of 75 patients, carers and members of the public recruited to help the College with its work) on this topic in detail, but hope to do so during the course on your enquiry. The topic is scheduled to be discussed at a workshop on 17 April 2007. However, we have encouraged the Network to respond directly to the Inquiry with their own personal comments.

5.   Who will have access to locally- and nationally-held information and under what circumstances?

  Access for patient care should be on a need-to-know basis. All users should be identifiable and the NHS should invest in rigorous security systems that identify the user without relying solely on passwords. If such systems are instituted we believe patient confidentiality can be adequately protected.

  Access for secondary purposes depends upon whether the data are anonymised. Those responsible for individual patient care should continue to have access to identifiable data when monitoring performance or developing services. Use of data for research should be protocol-driven and only with consent of patient if identifiable data are used. Wherever possible data should be anonymised, and sophisticated techniques used to ensure this when different datasets are linked.

Royal College of Physicians

March 2007

REFERENCES (1)   Standards in Medical Record Keeping, Robin Mann and John Williams, ClinMed 2003;3:329-32,

(2)   Result of Poll of RCP members and Fellows.

(3)   Engaging Physicians in improving data quality in the NHS

http://hiu.rcplondon.ac.uk/documents/EngagingCliniciansDataQualityNHS.pdf

(4)   Williams J G, Cheung W Y, Cohen D, Hutchings H, Longo M, Russell IT. The value of routine data in health technology assessment: can randomised trials rely on existing electronic data? Health Technology Assessment 2003; vol 7: no 26.





 
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