Implementation Guidance

Transcription

2 Contents 1. Purpose 3 2. Background 3 3. AoMRC headings overview 4 4. Why should you update your edischarge summary? 5 5. Are all headings mandatory? 6 6. Which headings do I need to use? Error! Bookmark not defined. 7. Implementing the headings locally 7 8. Specific guidance 8 9. Recommended approach Contact us Appendix A Organisations which signed off the record standards headings Appendix B AoMRC edischarge summary headings: Appendix C Example edischarge summary Appendix D Kings College example mappings for edischarge summary 21 2 Copyright 2015, Health and Social Care Information Centre.

3 1. Purpose The purpose of this document is to provide guidance for the implementation of the Academy of Medical Royal Colleges (AoMRC) headings in 24 hour edischarge summaries sent from hospitals to registered GPs for inpatient and day cases. 2. Background The National Information Board published its framework for action in November 2014 which states: We propose the adoption of the Academy of Medical Royal Colleges publication Standards for the clinical structure and content of patient records with a requirement that all organisations and clinical systems should implement the standards, following consultation and completion of an impact assessment. The Academy of Medical Royal Colleges' (AoMRC) Standards for the clinical structure and content of patient records (PDF 5.3Mb) 1 were published in The scope included headings for admission, discharge, handover, referral and outpatient letters. The Transfer of Care initiative 2 has been established with the primary purpose of driving the establishment and uptake of consistent professional and technical data standards across the health and care sector. With particular focus on the documents which support the transfer of care between organisations and care providers. The Transfer of Care initiative is part of a wider interoperability programme run collaboratively by NHS England and the HSCIC. The initial focus of the Transfer of Care initiative is 24 hour edischarge summaries. The 2015/16 NHS Standard Contract required acute and mental health NHS Trusts to send inpatient and day case edischarge summaries subject to the 24 hour rule to GP practices electronically by 1st October NHS Standard Contract 2016/17 mandates the use of AoMRC headings for edischarge summaries for deployment by 1 st December 2016 The NHS Standard Contract 2016/17 mandates the use of AoMRC headings for sending edischarge summaries from 1 st December This is another step towards the strategic objective of moving to electronic structured and coded messages. 1 Content_of_Patient_Records_0713.pdf Copyright 2015, Health and Social Care Information Centre.

4 Future requirements will include: The implementation of the Transfer of Care ITK Clinical Document Architecture (CDA) 3 messaging specification. The implementation of SNOMED CT and dm+d as the preferred national terminologies to share information between organisations. The implementation of a national transport mechanism to share edischarge summaries with organisations outside the local catchment area (i.e. MESH). 3. AoMRC headings overview The AoMRC standards were developed in extensive consultation with representatives from across the medical professions and specialist societies; healthcare professionals from multidisciplinary backgrounds; patients; carers and health information technology professionals. The development of the AoMRC standards was commissioned by the HSCIC. It was led by the Health Informatics Unit (HIU) of the Royal College of Physicians, with the aim of producing evidence and consensus based national standards for the structure and content of clinical records. The standards have been endorsed as fit for purpose by 50 organisations that give professional leadership to the medical, nursing and clinical professions. Please see Appendix A for the list of organisations which signed off the record standards. They were signed off as fit for purpose for the whole medical profession by the AoMRC in April The standards were adopted by the Professional Records Standards Body (PRSB). The PRSB is a Community Interest Company owned by UK health and social care professional bodies and patient organisations. The PRSB articles of association state that its business is to specifically carry out activities that ensure that the requirements of those who provide and receive care can be fully expressed in the structure and content of health and social care records. The PRSB has done further work on assuring the edischarge summary headings earlier this year. The edischarge summary project report is available at the PRSB website 4. The record standards were also tested by junior doctors as part of the PRSB project 5 earlier this year. Section 4 of the AoMRC standards document lists the headings and sub-headings for edischarge summaries. Please see the next page for an example of a heading and subheadings for allergies and adverse reaction: 3 The HL7 Clinical Document Architecture (CDA) is an XML-based markup standard intended to specify the encoding, structure and semantics of clinical documents for exchange. CDA is an ANSI-certified standard from Health Level Seven International (HL7.org). Release 1.0 was published in November, 2000 and Release 2.0 was published with the HL Normative Edition Copyright 2015, Health and Social Care Information Centre.

5 4. Why should you update your edischarge summary? There are a number of benefits of using the AoMRC headings in edischarge summaries for a variety of stakeholders. The benefits for patients, GPs and hospital clinicians are as follows: Patients Increased patient safety through availability of complete, accurate and timely information. GPs Avoiding unnecessary readmissions caused by inadequate information on discharge. Information resource for the patient and carer as well as the GP to inform their care and help them take control of their health management. A patient no longer needs to remember information from recent episodes as the information will be with the GP in a consistent and timely fashion. Quicker onward referrals from GPs. Plans are being drawn up to bring the same structure and consistency to referral messages. Many of the headings and sub headings will be common across both discharge and referral. This means the creation of an edischarge will become much easier in the future by reusing information provided in the referral and simply adding in the changes made during the episode of care. Carers have the information they need to work with clinicians to ensure the patient receives the care they need. Time saved in chasing missing information in discharge summaries. Information received in a consistent manner and in a way that ensures there is a single fit for purpose way of assimilating this into GP systems. 5 Copyright 2015, Health and Social Care Information Centre.

6 Quality information which can be easily understood by patients and GPs for further discussion/ongoing care. Hospital Clinicians Adoption and use of clinically assured clinical data and content standards by frontline clinicians, clinical networks, and NHS trusts. Consistent approach to collation of information enhancing the ability to gather information for secondary uses. Reduced communication with GP clarifying content of the handwritten discharge summary, freeing up more clinical time. Provision of a core of high quality clinical information which is comparable across the NHS. Improving the quality of the edischarge summary content. If trusts are not using the standard, it is possible that they are missing out clinical information that should be included. By implementing now, trusts are keeping up to date with best practice and can evolve with the standards. By implementing now this ensures less work needs to be done in the future, and it will be a process of maintaining the system rather than major changes. 5. Are all headings mandatory? The PRSB has consulted with professional bodies on the optionality status of edischarge summary headings. This specifies whether a heading is mandatory, required or optional; see Table 1 for these definitions. Table 1 Optionality status definitions 6 Copyright 2015, Health and Social Care Information Centre.

7 Table 2 specifies the optionality status for the main headings in the edischarge summary, currently all sub-headings are optional. The optionality status for other communications, e.g. outpatient and referrals has yet to be agreed. Please see Appendix B for the AoMRC edischarge summary headings and sub-headings. Please see Appendix C for an example edischarge summary using the AoMRC headings. Mandatory Required Optional GP practice Admission details Assessment scales Patient demographics Procedures Social context Discharge details Special requirements Participation in research Clinical summary Medication and medical devices Investigations and results Diagnosis Safety alerts Patient and carer concerns Allergies and adverse reactions Plan and requested Legal information actions Distribution list Referral details Information given Person completing record Table 2 AoMRC headings by optionality status 6. Implementing the headings locally All sub-headings are optional. The information under each heading must include free text narrative. You may wish to include SNOMED CT (codes and description) in line with the Personalised Health and Care 2020 framework for action which recommends SNOMED CT and the dictionary of medicines and devices (dm+d). Please note: The receiving GP systems are not due to be able to receive SNOMED CT or dm+d encoded information until 2017 at the earliest, however we recommend you speak to your receiving GP practices to understand their plans. In future years the ambition is for SNOMED CT to be the only clinical terminology in use in the NHS by The order in which headings appear in the edischarge summaries can be agreed locally. Eventually when structured messages using the Transfer of Care ITK CDA messaging specification are used to send and receive edischarge summaries (2017/18 NHS standard contract), the relative order of the sections in the received document will be able to be configured by the receiver to suit their workflow and specialism. The information can be displayed in any format as designed by the end user and supplier. Different IT systems can display the same content in different ways. Where there is a heading and a sub-heading with the same name, e.g. Special requirements, there is no need to display the heading as well as the sub-heading. 7 Copyright 2015, Health and Social Care Information Centre.

8 When headings are displayed, the first letter of the first word should be capitalised. It is recommended that as per the Accessible Information Standard implementation guidance document 6 a minimum font size of 12 point, preferably 14 is used with a clear, uncluttered and sans serif font such as Arial. All headings should be displayed using the same font size and font face e.g. Arial. When there is no appropriate section for a specific piece of information, the following actions should occur Include the information in the Clinical summary section. Raise an issue to the Transfer of Care team by ing information.standards@hscic.gov.uk. Please state, why the new heading is required. 7. Specific guidance Diagnosis In situations where a diagnosis is unknown or uncertain it should be recommended to record symptoms or possibly examination findings under the diagnosis heading. Allergies and adverse reactions As allergies and adverse reactions is a mandatory heading. It is essential that if no allergies or adverse reactions are identified, then this heading should appear in the edischarge Summary with the text "No known drug allergies or adverse reactions". GP Practice If the patient is not registered with a GP practice, then this heading should appear in the edischarge summary with the text "No known GP practice". 8. Recommended approach 1. Identify key stakeholders and develop plan Raise awareness and engage with the key stakeholders involved in the production and receipt of the edischarge summaries. Identify a Chief Clinical Information Officer or Clinical Lead to be responsible for the implementation of the AoMRC headings in edischarge summaries. Gain Clinical buy-in: Involve the clinicians who complete and receive the edischarge Summary so they understand why change is needed and the benefits of implementing these headings. This is essential and without this the project will fail. This needs to include hospital clinicians and GPs who will receive and use the edischarge Summary in ongoing care. Set up a project and develop a plan for delivery: As with any project you need a structure, and an understanding of what you are trying to achieve and who is involved. This planning will give the framework for the entire piece of work. Establishing a sponsor, resource availability and budget at this stage is critical as well as having an agreed plan, Copyright 2015, Health and Social Care Information Centre.

9 formal scope and objectives. A thorough communication plan is also an essential part of this stage. 2. Map local headings to the AoMRC headings Assign a local Chief Clinical Information Officer (CCIO) or Clinical Lead to sign off the mapping of local headings to the AoMRC headings. Identify the fields used in the local systems to capture heading information. You may wish to use Appendix B to map local clinical headings and sub-headings to the AoMRC headings. o For example, Kings College Hospital NHS Foundation Trust mapped their existing headings and sub-headings to the AoMRC headings. Please see Appendix D for the example Kings College edischarge summary mappings. o If you have any issues in understanding certain headings or sub-headings, please use the clinical descriptions in the section 4 of the AoMRC Standards for the clinical structure and content of patient records 7. Use the self-assessment tool to check your compliance with the AoMRC headings Engage with system suppliers to configure systems Once mapping is complete, the next step is to initiate supplier support to create a test environment to update the edischarge summary template headings. For each AoMRC heading and sub-heading, make sure you identify a field within your local clinical system where this information can be pre-populated or captured. It is recommended that most of the fields are pre-populated to minimise data entry at the point of creating edischarge summaries. 4. Testing To ensure that the new AoMRC headings work correctly, it is recommended that the mappings are tested with a few pilot GP practices first. See the Standardisation Committee for Care Information (SCCI) information standard for clinical risk management and reporting 8 which includes guidance on Clinical Risk Management file and plan, hazard log, Clinical Safety Case and Report and Safety Incident Management log 7 Content_of_Patient_Records_0713.pdf Copyright 2015, Health and Social Care Information Centre.

10 5. Reconfigure sending and receiving systems Apply lessons learned from testing and agree timescales for reconfiguring sending and receiving systems. 6. Wider Roll-out Commence wider roll-out of edischarge from all departments to all GP practices. When considering the wider roll-out, it is vital to raise awareness and involve end users; such as hospital clinicians, GPs and Practice Managers in the planning stage. Please ensure your clinicians are aware of the go-live date and engaged throughout the project. 9. Contact us Join the Transfer of Care mailing list by ing to be kept informed of future updates regarding the Transfer of Care initiative including dates of webinars, events and the latest news regarding our work. If you have any queries for the PRSB, please Chat with us about Interoperability by becoming a member of our LinkedIn group by visiting and search for NHS Interoperability Toolkit. Find out more about the Transfer of Care initiative on our website 10 Copyright 2015, Health and Social Care Information Centre.

11 10. Appendix A Organisations which signed off the record standards headings Association for Clinical Biochemistry Association for Palliative Medicine of Great Britain & Ireland Association of British Clinical Diabetologists Association of Cancer Physicians Association of Surgeons of Great Britain and Ireland British Association for Parenteral & Enteral Nutrition British Association of Audiovestibular Physicians British Association of Dermatologists British Association of Otorhinolaryngology (Ears, Nose and Throat) (ENT UK) British Association of Plastic, Reconstructive and Aesthetic Surgeons British Association of Stroke Physicians British Association of Urological Surgeons British Cardiovascular Society British Dietetic Association British Geriatrics Society British Infection Association British Orthodontic Society British Orthopaedic Association British Pain Society British Psychological Society British Society for Gastroenterology British Society for Haematology British Society for Genetic Medicine British Society for Immunology British Thoracic Society Chartered Society of Physiotherapy Chronic Pain Policy Coalition (CPPC) Clinical Genetics Society College of Emergency Medicine College of Occupational Therapists Faculty of Occupational Medicine Faculty of Sport and Exercise Medicine Intensive Care Society Renal Association Royal College of Anaesthetists Royal College of General Practitioners Royal College of Midwives Royal College of Nursing Royal College of Obstetricians and Gynaecologists (RCOG) Royal College of Ophthalmologists Royal College of Paediatrics and Child Health Royal College of Pathologists Royal College of Physicians and Surgeons Glasgow Royal College of Physicians of Edinburgh Royal College of Psychiatrists Royal College of Radiologists Royal College of Surgeons of Edinburgh The Royal College of Surgeons of England Royal Pharmaceutical Society (RPS) Society of British Neurological Surgeons 11 Copyright 2015, Health and Social Care Information Centre.

12 11. Appendix B AoMRC edischarge summary headings and sub headings: This appendix is provided to help with mapping to the Academy of Medical Royal Colleges headings. It describes all the main headings and sub-headings for edischarge summaries. The main headings have been grouped according to the mandatory/required/optional status in the Academy guidelines. Note this does NOT dictate the order in which they appear in the final letter, this may be agreed locally. Please note all sub-headings are planned to be optional in the NHS Standard Contract for 2016/17. It is worth noting that in future years these are likely to become mandatory. Mandatory headings: 12 Copyright 2015, Health and Social Care Information Centre.

19 12. Appendix C Example edischarge summary An example edischarge summary using the AoMRC headings with test patient content has been included for your use. GP practice GP name: Dr J Orenz GP practice address: 1 MGP House, Overtown, W Yorks LN 21 GP practice identifier: GP Patient demographics Patient name: Richard Smith Preferred name: Richard NHS number: Date of birth: 01/01/1957 Age: 58 yrs Patient sex: Male Ethnicity: White British Patient address: 21 Grove Street, Overtown, W. Yorks LN 21 Relevant contacts: Mrs Smith, Wife Mobile: , mrssmith@mymail.com Admission details Admission method: Emergency Date of admission: 12/02/2015 Discharge details Discharging consultant: Mr J Jones Date of discharge: 16/02/2015 Discharge method: Patient discharged on clinical advice Discharge destination: Usual place of residence Clinical summary 58 year old man with an acute history of cardiac sounding chest pain lasting around 2 hours. Examination unremarkable. Inferior ischaemic changes on ECGs and raised Troponin T. Coronary angiogram demonstrated diseased RCA, drug eluting stent successfully placed. Appropriate secondary prevention medications prescribed and for follow up with Cardiac Rehabilitation team. Diagnosis Cardiac chest pain/acs Page 1 of 2 19 Copyright 2015, Health and Social Care Information Centre.

20 Procedures Coronary angiogram with stent to right coronary artery (RCA) Allergies and adverse reactions Causative agent: Description of the reaction: Penicillin Rash. No swelling/anaphylaxis Plan and requested actions GP please continue secondary preventative medication. Doses will be uptitrated by Cardiac Rehab team. Medication and medical devices Medication Name Dose Medication Frequency Route Ramipril 2.5mg OD oral continue Omeprazole 20mg OD/PRN oral continue Aspirin 75mg OD oral continue Clopidogrel 75mg OD oral 1 year then stop Simvastatin 40mg ON oral continue Medication Recommendations Bisoprolol 5mg OD oral Uptitrate according to BP and HR Investigations and results Investigations Requested FBC Arterial Blood Gases ECG Chest Xray Investigations Results RBC: 5 x /L, WCC: 11.1 x 10 9 /L, Hb: 150 g/dl, neutrophils: 7.0 x 10 9 /L, eosinophils: 0.40 x 10 9 /L, lymphocytes: 3.5x10 9 /L, monocytes: 0.3 x 10 9 /L PH: 7.41, po 2: 13 kpa, pco 2: 6.0kPa, HCO3: 24 meq/l, B.E.:+2 mmol/l Inferior ischaemic changes Normal Distribution list Dr J Orenz, GP, CC: Mrs A Smith, Cardiac Rehab Specialist Nurse Person completing record Name: Role: Grade: Speciality : Dr B Rustel On call Dr SpR Medicine Page 2 of 2 20 Copyright 2015, Health and Social Care Information Centre.

21 13. Appendix D Kings College example mappings for edischarge summary The example mappings from the Kings College edischarge summary have been included for your use when mapping local headings. Example provided by a clinician at Kings College. Document (Example) Ward Consultant Speciality Discharged by Self-discharge GP Hospital number NHS number Patient name DOB Date of admission Method of admission Source of admission Date of discharge Discharge address Usual residence Recommended further action by GP Reason for admission Main diagnosis Other diagnosis Clinical narrative Procedures/operations Operation notes Laboratory Radiology Other diagnosis Discharge status External referral Next appointment Further tests/procedure booked Consultant follow up Allergies Discharge medication AoMRC Top Level Heading Discharge details Discharge details Discharge details Discharge details Admission details GP practice Patient demographics Patient demographics Patient demographics Patient demographics Admission details Admission details Admission details Discharge details Discharge details Patient demographics Plan and requested actions Admission details Diagnoses Diagnoses Clinical summary Procedures Procedures Investigations and results Investigations and results Diagnoses Discharge details Plan and requested actions Plan and requested actions Investigations and results Plan and requested actions Allergies and adverse reaction Medications and medical devices 21 Copyright 2015, Health and Social Care Information Centre.