joined+up+care
DESCRIPTION
Tim Benson's presentation in August 1999 of the NHS XML-EDI Referrals and discharge communications project (Kettering) at MIE 99 Ljubjana, Slovenia.TRANSCRIPT
Joined up Care
GP SpecialistReferral
Report(Clinic LetterDischarge NoteDischarge Summary)
NHS Information Strategy - Actions
• By the end of 2002 Hospitals and all GPs will be routinely exchanging structured electronic messages for referrals, discharge summaries… (p38)
Proposed Approach
• The quickest route… will be through a national approach to clinical messaging between hospital and GPs… which builds on the “data push” model. This will require the implementation of nationally agreed structured clinical messages for key clinical communications between primary care and hospitals (para 2.84 Information for Health, 1998)
e-Message Benefits
• Speed
• Legibility
• Productivity
• Availability
• Reliability
• Patient care
• Hours not weeks
• Yes!
• GP and Hospital
• Yes!
• Yes!
• Yes!
Volumes
0
5
10
15
20
25
30
Millions pa
Referrals DischargeSummaries
Clinic Letters
Doctors
0
20
40
60 (,000)
GP Hospital + Community
The Many-to-Many Problem
• Each GP refers to many consultants in several hospitals
• Each consultant reports to many GPs using different systems in different ways
• Junior hospital doctors change every 3 months
Clinical Messages
• Referrals are dictated by GP, typed, signed and sent
• Discharge and clinic letters are dictated by consultant or registrar, typed signed and sent
• Immediate discharge documents are written by HO on the ward on 4 or 5-part paper (Patient, GP, Notes, Pharmacy and Coding)
User Needs
• All or nothing - send 100% electronic
• Integration with own system– Analysis– Follow-up actions– Consulting room use– Answer queries
• Ensure reliability and safety - do not lose clinical messages - people may die
Background work
• 1993 CEN TC251 PT3-024 "Messages for Patient Referral and Discharge” ENV12538:1997
• 1995 NHS Version 1 Trial NHS EDIFACT Messages for Communications between General Practitioners Volumes 1, 2 and 3 (E5193,4,5)
• 1996-97 Nuneaton GPPL Trailblazer• 1998 Change Notice 2• 1999 Kettering XML-EDI project
Trailblazer Lessons
• Formatting– EDIFACT has no means of including layout
instructions (not even a blank line!)
• Headings and Codes– Genuine clinical safety concerns
• Clinical Safety– Incorporated into RFA-4+ and RFA-5
regulations for GP systems
Clinical text is ambiguous
Found unconscious in the street. No family history of ischaemic heart disease according to his 12 year old daughter who was injured when trying to stop him falling (small laceration under her right eye - sutures not required). Admitted to intensive care. Attempted to contact wife.
• Who did what?• This text can be understood by a human but
not by a machine
Safety is Paramount
Acknowledgement at both transport and application level
Validation by both sender and the receiver Automatic + manual patient matching Routing to alternate recipient Actions specified and carried out before messages
are moved from task list Deletionless messages; if a user edits a message, a
copy is kept of the original Full audit trail.
Kettering XML/EDI Project
• Aim to provide tested, scrutinised NHS standard messages for national adoption
• Funded by NHS IA
• EMIS at GP end
• EPOC at hospital end
• CIC and CPL prepare XML Schemas
• Clinical Scrutiny by RCGP/ACIG
Why XML?
• Human and Computer readable
• Rigorous structure (easy to program)
• Does what is required
• Massive industry support
XML Syntax
• XML tags for structured data (admin/metadata)
• HTML tags for formatted data (clinical)
• No need for style sheets for the message itself
EDI Principles Apply
• Computer to computer communication with end-to-end integration
• Caldicott (identifiers not person details)
• Patient matching (automatic and manual)
• Reliability (acknowledgement required)
• Security (encryption)
• Safety is paramount
Referrals - Hospital End
e-GP EPOCServer
PAS
DecryptionParsing
Appoint-ments
SecretaryConsultant
MedicalRecords
PAS look-upRegister new patients
PrintPrioritise
O/P Appointments
X.400
Clinic/Discharge LettersDoctor
Dictates
SecretaryTypes
Sign &Correct
Print, file & post e-GP
Paper practice
Uses EPOCTemplate
EPOC Server
StructuredData
Discharge Note
PAS
Patient Record
CodingDept
GP via Patient
GP by post
Discharge Database
EPOCServere-GP
Referral XML Message
• Header
• Patient Information
• Agents Directory
• RequestedService
• PatientAdminInfo
• ClinicalReferral
Discharge/clinic XML Messages
• Header
• Patient Information
• Agents Directory
• RequestedService (Referral)
• MsgRef (Report)
• ReportedService (Report)
• PatientAdminInfo
• ClinicalReferral or Clinical Report
Header
• MessageType• MsgRcptAckRequest• MsgUrgency• MsgStatus• MsgId• MsgIssueDate• MsgSender• MsgRecipient• ServiceRequester• ServiceProvider
Patient ID
• NHSNo• HospitalNo• PracticeNo• PatientSurname• PatientGivenName• PatientMiddleName• PatientTitle• PersonNameType• BirthDate• Sex• PostCode• UnstructAddressLine (5)
Healthcare Agents
• GPId• GPName• PracticeId• PracticeName• SpecialistId• SpecialistName• SpecialtyCode • ProviderId• ProviderName
Patient Admin Info
• FormerName
• CorrespondenceAddress
• Telecom
• RegisteredGP
Referral Data
• ReferralNumber
• TransportInfo
• PaymentCategory
• ServiceEventType
• EventUrgencyStatus
Report Data
• MsgRef (referral reference)• ServiceReportStatus• ServiceEventType• RelDate
– Date of Consultation, – Admission Date, – Discharge Date, – Follow-up Date
• AdministrativeOutcome
Clinical Data
• HTML
• #CDATA within XML tags
• Formatted, not structured
• Full renderable letter sent as HTML
Acknowledgements
• All messages are acknowledged
• Responsibilities– Sender must check that ACK is received– Receiver must report acknowledged messages
that have subsequent problems
Conclusions
• Why it should work (better than before)– Syntax and semantics– Process– Safety, security and reliability
• Results including clinical scrutiny (Autumn 1999) to be presented to Clinical Data Standards Board