Post on 31-Mar-2015
Towards the Single Patient Record: Clinical Documents
Ann Wrightson
Contents
What is a document? Clinical viewpoint Technical viewpoint
Where do documents come from? Federated document stores and patient identity
Clinical viewpoint
What’s a Document?
Content
Header
Record element 1
Record element 2-n
Document header
Document body
A clinical communication describing a care event or episode of care
A collection of clinical information stated at a particular time about a particular patient
A source of information important for patient safety, eg medications, allergies
Document wrapper
Wrapper, header and body
Wrapper Not part of the document itself (may be removed) Specific to a particular use of a document May replicate items from the header or body
Header Patient identity and demographics Administrative information
Body Clinical information
Key elements for patient safety are computable where possible
Priorities for Patient Safety
Core data 1 Medicines
Meds
Core data 2 Diagnoses Procedures Allergies Tests
Diags
Allerg Probs
Tests Proc
Meds
Priorities for Patient Safety
Additional elements Social circumstances Family history Care plan Etc.
Social
Family Care plan
Exam findings
Diags
Allerg Probs
Tests Proc
Meds
Priorities for Patient Safety
Additional elements Blood pressure Head circumference Weight Height Door to needle time Etc.
Social
Family Care plan
Exam findings
Diags
Allerg Probs
Tests Proc
Meds
Priorities for Patient Safety
Technical viewpoint
“The document”
Patient Identity
Recorded demographics
Humanreadable
Header 0123450123
Content
“The” document
Patient Identity
Recorded demographics
Humanreadable
Patient identity as recorded in the document allows the document to “belong” to an individual
Patient demographics as recorded in the document supports patient record administration.
MPI,WDS
?
“The” document
Clinical Classification
Records management
Patient Identity
Recorded demographics
Humanreadable
Classification of this document in some context, e.g. as a clinical event or care plan
Metadata to support records management of the document as an e-record
Processable, computable
clinical information:
“Record Components”
FunctionalMetadata forBusinessProcesses
Clinical Classification
Records management
Patient Identity
Recorded demographics
Humanreadable
Processable, computable
clinical information:
“Record Components”
FunctionalMetadata forBusinessProcesses
Clinical Classification
Records management
Patient Identity
Recorded demographics
Humanreadable
Content
Header
Record element 1
Record element 2-n
Document header
Document body
Processable, computable
clinical information:
“Record Components”
FunctionalMetadata forBusinessProcesses
Clinical Classification
Records management
Patient Identity
Recorded demographics
Humanreadable
Content
Header
Record element 1
Record element 2-n
Envelope/wrapper for transport
Folders may be actual collections, or views constructed using information from the documents
Document participates in business process
Processable, computable
clinical information:
“Record Components”
FunctionalMetadata forBusinessProcesses
Clinical Classification
Records management
Patient Identity
Recorded demographics
Humanreadable
Content
Header
Record element 1
Record element 2-n
Document header
Document body
Document wrapper
Local document store
Scanned paper documents
Document scanning
- Selected pre-electronic medical records- Correspondence
Electronic document store
Header 0123450123
Content
Scanned paper documents
Document scanning
- Selected pre-electronic medical records- Correspondence
Electronic document store
Patient folder
Patient folder
“Born digital” narrative & preformatted documents
Clinical correspondence eg prepared with MS Word templates
Patient folder
Patient folder
Header 0123450123
Content
LIMS
Disease specific systems
Social care
“Born digital” narrative & preformatted documents
Clinical correspondence eg prepared with MS Word templates
Header 0123450123
Content
Content
Header
Record element 1
Record element 2-n
Computable record components appear when they can be safely derived from input data
View documents in WCP
WCP makes documents available in a patient record…and creates them
LIMS
Disease specific systems
Social care
Document scanningWelshClinicalPortalMPI,
WDS
Federated document stores
…one way we might deliver clinical documents in the Single Patient
Record
Each LHB has its own document store(Same technology, separate instances)
Each LHB has its own MPI(Same technology, separate instances)
New LHBs in Wales
Record stores (and PACS) wider integration using eg IHE XDS supporting “pull” requests
Record stores (and PACS) wider integration using eg IHE XDS supporting “pull” requests
MPIs will also work in a federated way
WDS already in place with link to PDS
WDS PDS
End of slide set