The Department of Health and Royal College of Physicians will today make a co-ordinated launch of an interactive guide to support professional standards for clinical documentation.
The DH contribution will also launch version 2 of its interoperability toolkit, which aims to provide a framework for the electronic exchange of clinical information using HL7 clinical document architecture.
The DH and RCP will simultaneously issue a new, interactive professional guide to how to compile the content of an electronic discharge summary, in a bid to standardise reporting.
The discharge summary toolkit was developed by the DH Informatics Directorate, based on standards set by the RCP's health informatics unit and endorsed by the Academy of Royal Medical Colleges in 2008.
It will help NHS trusts implement an electronic 24-hour discharge summary and will enable GPs, carers and patients to continue care effectively following a stay in hospital.
It provides professional clinical guidance around the content and format of any discharge summary.
The interactive, web-based toolkit has been tested by five NHS trusts and contains case studies and short video clips from the test sites.
It can be used by any trust, at any stage in their implementation cycle, to introduce the use of the approved national Academy of Medical Royal Colleges standard into their system.
The aim is to move towards enabling all hospitals to transmit electronic discharge summaries to all GPs, who in turn, will be able to integrate the summaries electronically into patient care records.
Currently, many GPs receive hand-written summaries or have to re-enter information manually, even when they receive a discharge summary electronically.
Hospitals that have developed e-discharge summaries face the opposite problem of being able to transmit only to GP practices set up to receive them.
Charles Gutteridge, national clinical director for informatics at the DH said: “This toolkit - building on existing national standards and developed with local trusts - will help NHS organisations produce key patient information delivered to GPs within 24 hours of discharge.
“We now have a discharge summary that is approved by the Academy of Royal Medical Colleges and can be provided by any hospital or clinic.
"[It contains] the information that GPs need to continue care and for patients who need to know which drugs they should take and which procedures they have just had done.
"This information helps patients, it helps healthcare professionals and it makes care better right now and in the future.”
George MacGinnis, ITK programme lead at the DH, told eHealth Insider that the simultaneous launch recognised that technical and professional standards were interlinked.
He said: “This coming together is part of a carefully crafted co-ordinated approach. Everyone can see that this is a real opportunity for the future.”
Keith Naylor, who leads on the technical aspects of ITK, added: “This offers a real opportunity to be a game changer at a local level.
“Instead of local organisations having their own take on a clinical documentation problem, we can now give them something that they can take and use in their specification.”
ITK 2 is wider than just electronic discharge summaries, however. It contains a number of new functionalities developed as a result of feedback from the NHS.
At its core is a web service based on HL7 CDA that contains four functional packages. These are: clinical correspondence; spine mini services; admission, transfer and discharge processes; clinical dashboards.
McGinnis said: “Some of ITK 2 is a roll over from ITK 1, but it has a much more strategic component to it. These are things that are really emerging as important.”
He said the toolkit would support the electronic exchange of information in a number of document formats including CDA, Word, SMS text, pdf and Kettering XML.
It should enable trusts to make better use of existing technology, for example by supporting the transfer of information between a patient administration system and electronic white boards, or by enabling automated communication between an acute trust and a community service about individual patients.
The spine mini services will enable trusts to query the spine about individual patients, without the expense of full accreditation, but with information governance guarantee being maintained.
Naylor gave the example of a hospital patient attending A&E who could not remember the name of their GP. ITK 2 spine mini services would allow a trust to query the spine, find the patient’s GP and automatically send information about the episode to the doctor.
He said: “Having verified the patient, the hospital can then talk to the rest of the NHS world.”
MacGinnis said he was now looking for trusts and vendors to take forward work on proof of concepts. “We are now looking for activity on the ground – what is happening here and now and how we can help in a relatively short time frame.”
Note: this story was updated after its first publication on Monday, 25 July, to correct a misunderstanding about the toolkit. It initially referred to the launch of new professional standards, rather than to a new toolkit for implementing existing standards. EHI apologises for the error and any confusion for readers.
© 2011 EHealth Media.
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