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:
— 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 |
| Grade | Consultant | Count
| 201 | 338 | 33
| 35 | 20 | 627
|
| | % within
Grade
| 32.1 | 53.9 | 5.3
| 5.6 | 3.2 | 100.0%
|
| Specialist Registrar
|
Count | 77 | 195
| 11 | 42 | 17 |
342 |
| | % within
Grade
| 22.5 | 57.0 | 3.2
| 12.3 | 5.0 | 100.0
|
| Non consultant career grade
|
Count | 6 | 15
| 0 | 2 | 0 |
23 |
| | % within
Grade
| 26.1 | 65.2 | 0
| 8.7 | 0 | 100.0
|
| SHO | Count
| 15 | 25 | 3 |
3 | 2 | 48 |
| | % within
Grade
| 31.3 | 52.1 | 6.3
| 6.3 | 4.2 | 100.0
|
| Other | Count
| 17 | 23 | 3 |
3 | 1 | 47 |
| | % within
Grade
| 36.2 | 48.9 | 6.4
| 6.4 | 2.1 | 100.0
|
Total | | Count
| 316 | 596 | 50
| 85 | 40 | 1,087
|
| | % within
Grade
| 29.1 | 54.8 | 4.6
| 7.8 | 3.7 | 100.0
|
| | |
| | | |
| |
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;
— significant past history including both illnesses
and operations;
— relevant social circumstances;
— current drugs and other treatments;
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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