Abstract
Background: The Professional Records Standards Body for health and social care (PRSB) was formed in 2013 to develop and assure professional standards for the content and structure of patient records across all care disciplines in the UK. Although the PRSB work is aimed at Electronic Health Record (EHR) adoption and interoperability to support continuity of care, the current technical guidance is limited and ambiguous. Objectives: This project was initiated as a proof-ofconcept to demonstrate whether, and if so, how, conformance methods can be developed based on the professional standards. Methods: An expert group was convened, comprising clinical and technical representatives. A constrained data set was defined for an outpatient letter, using the subset of outpatient headings that are also present in the ep- SOS patient summary. A mind map was produced for the main sections and sub-sections. An openEHR archetype model was produced as the basis for creating HL7 and IHE implementation artefacts. Results: Several issues about data definition and representation were identified when attempting to map the outpatient headings to the epSOS patient summary, partly due to the difference between process and static viewpoints. Mind maps have been a simple and helpful way to visualize the logical information model and expose and resolve disagreements about which headings are purely for human navigation and which, if any, have intrinsic meaning. Conclusions: Conformance testing is feasible but nontrivial. In contrast to traditional standards-development timescales, PRSB needs an agile standards development process with EHR vendor and integrator collaboration to ensure implementability and widespread adoption. This will require significant clinical and technical resources.
Highlights
1.1 Clinical LeadershipHealth and social care information technology projects have typically been technically-led not clinically-led and this has frequently been identified as a significant risk factor [1, 2]
It was recommended that a new group should be formed, provisionally called the "Professional Records Standards Development Body" (PRSDB), to continue and extend the work of developing and assuring professional guidance for patient record content and structure across all care disciplines in the UK
We investigated the feasibility of representing the outpatient letter with PRSB headings in FHIR resources, using the current FHIR Draft Standard for Trial Use (DSTU) as baseline
Summary
1.1 Clinical LeadershipHealth and social care information technology projects have typically been technically-led not clinically-led and this has frequently been identified as a significant risk factor [1, 2]. This work led to a joint project on generic medical record keeping standards commissioned by NHS Connecting for Health and led by the RCP, with involvement throughout from other professional bodies and patients, resulting in the first version of standards for the content and structure of patient records, published in 2008. It was recommended that a new group should be formed, provisionally called the "Professional Records Standards Development Body" (PRSDB), to continue and extend the work of developing and assuring professional guidance for patient record content and structure across all care disciplines in the UK. The Professional Records Standards Body for health and social care (PRSB) was formed in 2013 to develop and assure professional standards for the content and structure of patient records across all care disciplines in the UK. An openEHR archetype model was produced as the basis for creating HL7 and IHE implementation artefacts
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