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Health Informatics

NHS Patient Record Standards

Developing and implementing national standards to improve the structure and content of patient records

 In 2000 the President of the Royal College of Physicians (RCP) in London invited JG Williams, Professor at Swansea University since 1992, to set up a Health Informatics Unit within RCP to improve the clinical content of hospital patient records and the quality of information derived from them, and thus to support service delivery, audit and research. Since then Williams has directed that Unit from Swansea, forging a productive collaboration in research and development between RCP and Swansea University.

Initially Williams (in Swansea) and Mann (in London) reviewed the literature on the use of clinical data in patient records to monitor hospital activity through Hospital Episode Statistics (HES). The key findings were that data quality was poor, and could be improved by standardising the structure and content of records, and engaging clinicians in the process of data extraction, coding and validation. In 2004 the Department of Health (DH) and Welsh Government funded the University to undertake a joint project with the RCP to improve clinical engagement in both record-keeping and validation of the coded diagnoses and procedures extracted from records. Williams and Croft set up a virtual ‘information laboratory’ or ‘iLab’ in Swansea with electronic links to RCP; they used this to show individual physicians the potential value of analysing the coded diagnoses, procedures and episodes for patients under their care. We selected half these physicians at random for one-to-one discussions about this information. Overwhelming conclusions from this trial were that the data were not good enough for this purpose, or comparable across the country, confirming the need for national standards for the structure and content of records.

This conclusion reinforced the findings of a study undertaken in Swansea in the late 1990s, in which Williams and Hutchings replicated four small randomised trials using routinely collected data (clinical, administrative and demographic) in place of the designed research data to explore whether clinical trials could be reliably undertaken in this way, but at less cost. The study concluded that this would be possible if the quality of the routinely collected data was improved, but that this would require the implementation of clinical standards for the structure and content of medical records. In 2006 we used this evidence to persuade the Department of Health to commission Williams to develop national standards for hospital patient records based on evidence of good practice or, failing that, consensus amongst medical, nursing and other practitioners. In 2010 Williams and Roberts in Swansea further strengthened the case for this work when they explored the potential usefulness of routinely collected data in monitoring the quality of care through national audits, and concluded that quality of the data being collected was insufficient for this purpose.

The standards developed so far address: the structure and content of records made on admission; communications at handover and discharge, including medication records; referrals to out-patients; letters back to primary care; core headings applicable in the majority of settings; and editorial principles to ensure sustainability of the standards over time. Since 2008 the standards have been available on the website of the Academy of Medical Royal Colleges (AoMRC); they were updated in 2013 (http://www.aomrc.org.uk/publications/reports-a-guidance.html). The standards have been endorsed by numerous statutory bodies and professional organisations, including the Department of Health, NHS England, NHS Litigation Authority, Mid-Staffordshire Inquiry, Care Quality Commission, General Medical Council, Academy of Medical Royal Colleges, and Academy of Medical Sciences.

References

  1. Williams JG, Mann RY. Hospital Episode Statistics: time for clinicians to get involved? Clinical Medicine 2002;2:34-7.
  2. Mann RY, Williams JG. Standards in medical record keeping. Clinical Medicine 2003;3:329-32.
  3. Croft GP, Williams JG. The RCP Information Laboratory (iLab): breaking the cycle of poor data quality. Clinical Medicine 2005;5:47-9.
  4. Williams JG, Cheung WY, 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;7:(26).
  5. Carpenter I, Bridgelal-Ram M, Croft G, Williams J. Medical records and record-keeping standards. Clinical Medicine 2007;7:328-31.
  6. Roberts SE, Williams JG, Cohen DR, Akbari A, Groves S, Button LA. Feasibility of using routinely collected inpatient data to monitor quality and inform choice: a case study using the UK Inflammatory Bowel Disease audit. Frontline Gastroenterology 2011;2:153-9.