towards the single patient record: clinical documents ann wrightson
TRANSCRIPT
![Page 1: Towards the Single Patient Record: Clinical Documents Ann Wrightson](https://reader031.vdocuments.site/reader031/viewer/2022012916/551ac29755034656628b5a20/html5/thumbnails/1.jpg)
Towards the Single Patient Record: Clinical Documents
Ann Wrightson
![Page 2: Towards the Single Patient Record: Clinical Documents Ann Wrightson](https://reader031.vdocuments.site/reader031/viewer/2022012916/551ac29755034656628b5a20/html5/thumbnails/2.jpg)
Contents
What is a document? Clinical viewpoint Technical viewpoint
Where do documents come from? Federated document stores and patient identity
![Page 3: Towards the Single Patient Record: Clinical Documents Ann Wrightson](https://reader031.vdocuments.site/reader031/viewer/2022012916/551ac29755034656628b5a20/html5/thumbnails/3.jpg)
Clinical viewpoint
![Page 4: Towards the Single Patient Record: Clinical Documents Ann Wrightson](https://reader031.vdocuments.site/reader031/viewer/2022012916/551ac29755034656628b5a20/html5/thumbnails/4.jpg)
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
![Page 5: Towards the Single Patient Record: Clinical Documents Ann Wrightson](https://reader031.vdocuments.site/reader031/viewer/2022012916/551ac29755034656628b5a20/html5/thumbnails/5.jpg)
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
![Page 6: Towards the Single Patient Record: Clinical Documents Ann Wrightson](https://reader031.vdocuments.site/reader031/viewer/2022012916/551ac29755034656628b5a20/html5/thumbnails/6.jpg)
Priorities for Patient Safety
Core data 1 Medicines
Meds
![Page 7: Towards the Single Patient Record: Clinical Documents Ann Wrightson](https://reader031.vdocuments.site/reader031/viewer/2022012916/551ac29755034656628b5a20/html5/thumbnails/7.jpg)
Core data 2 Diagnoses Procedures Allergies Tests
Diags
Allerg Probs
Tests Proc
Meds
Priorities for Patient Safety
![Page 8: Towards the Single Patient Record: Clinical Documents Ann Wrightson](https://reader031.vdocuments.site/reader031/viewer/2022012916/551ac29755034656628b5a20/html5/thumbnails/8.jpg)
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
![Page 9: Towards the Single Patient Record: Clinical Documents Ann Wrightson](https://reader031.vdocuments.site/reader031/viewer/2022012916/551ac29755034656628b5a20/html5/thumbnails/9.jpg)
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
![Page 10: Towards the Single Patient Record: Clinical Documents Ann Wrightson](https://reader031.vdocuments.site/reader031/viewer/2022012916/551ac29755034656628b5a20/html5/thumbnails/10.jpg)
Technical viewpoint
![Page 11: Towards the Single Patient Record: Clinical Documents Ann Wrightson](https://reader031.vdocuments.site/reader031/viewer/2022012916/551ac29755034656628b5a20/html5/thumbnails/11.jpg)
“The document”
Patient Identity
Recorded demographics
Humanreadable
Header 0123450123
Content
![Page 12: Towards the Single Patient Record: Clinical Documents Ann Wrightson](https://reader031.vdocuments.site/reader031/viewer/2022012916/551ac29755034656628b5a20/html5/thumbnails/12.jpg)
“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
?
![Page 13: Towards the Single Patient Record: Clinical Documents Ann Wrightson](https://reader031.vdocuments.site/reader031/viewer/2022012916/551ac29755034656628b5a20/html5/thumbnails/13.jpg)
“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
![Page 14: Towards the Single Patient Record: Clinical Documents Ann Wrightson](https://reader031.vdocuments.site/reader031/viewer/2022012916/551ac29755034656628b5a20/html5/thumbnails/14.jpg)
Processable, computable
clinical information:
“Record Components”
FunctionalMetadata forBusinessProcesses
Clinical Classification
Records management
Patient Identity
Recorded demographics
Humanreadable
![Page 15: Towards the Single Patient Record: Clinical Documents Ann Wrightson](https://reader031.vdocuments.site/reader031/viewer/2022012916/551ac29755034656628b5a20/html5/thumbnails/15.jpg)
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
![Page 16: Towards the Single Patient Record: Clinical Documents Ann Wrightson](https://reader031.vdocuments.site/reader031/viewer/2022012916/551ac29755034656628b5a20/html5/thumbnails/16.jpg)
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
![Page 17: Towards the Single Patient Record: Clinical Documents Ann Wrightson](https://reader031.vdocuments.site/reader031/viewer/2022012916/551ac29755034656628b5a20/html5/thumbnails/17.jpg)
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
![Page 18: Towards the Single Patient Record: Clinical Documents Ann Wrightson](https://reader031.vdocuments.site/reader031/viewer/2022012916/551ac29755034656628b5a20/html5/thumbnails/18.jpg)
Local document store
![Page 19: Towards the Single Patient Record: Clinical Documents Ann Wrightson](https://reader031.vdocuments.site/reader031/viewer/2022012916/551ac29755034656628b5a20/html5/thumbnails/19.jpg)
Scanned paper documents
Document scanning
- Selected pre-electronic medical records- Correspondence
Electronic document store
Header 0123450123
Content
![Page 20: Towards the Single Patient Record: Clinical Documents Ann Wrightson](https://reader031.vdocuments.site/reader031/viewer/2022012916/551ac29755034656628b5a20/html5/thumbnails/20.jpg)
Scanned paper documents
Document scanning
- Selected pre-electronic medical records- Correspondence
Electronic document store
Patient folder
Patient folder
![Page 21: Towards the Single Patient Record: Clinical Documents Ann Wrightson](https://reader031.vdocuments.site/reader031/viewer/2022012916/551ac29755034656628b5a20/html5/thumbnails/21.jpg)
“Born digital” narrative & preformatted documents
Clinical correspondence eg prepared with MS Word templates
Patient folder
Patient folder
Header 0123450123
Content
![Page 22: Towards the Single Patient Record: Clinical Documents Ann Wrightson](https://reader031.vdocuments.site/reader031/viewer/2022012916/551ac29755034656628b5a20/html5/thumbnails/22.jpg)
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
![Page 23: Towards the Single Patient Record: Clinical Documents Ann Wrightson](https://reader031.vdocuments.site/reader031/viewer/2022012916/551ac29755034656628b5a20/html5/thumbnails/23.jpg)
View documents in WCP
WCP makes documents available in a patient record…and creates them
LIMS
Disease specific systems
Social care
Document scanningWelshClinicalPortalMPI,
WDS
![Page 24: Towards the Single Patient Record: Clinical Documents Ann Wrightson](https://reader031.vdocuments.site/reader031/viewer/2022012916/551ac29755034656628b5a20/html5/thumbnails/24.jpg)
Federated document stores
…one way we might deliver clinical documents in the Single Patient
Record
![Page 25: Towards the Single Patient Record: Clinical Documents Ann Wrightson](https://reader031.vdocuments.site/reader031/viewer/2022012916/551ac29755034656628b5a20/html5/thumbnails/25.jpg)
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
![Page 26: Towards the Single Patient Record: Clinical Documents Ann Wrightson](https://reader031.vdocuments.site/reader031/viewer/2022012916/551ac29755034656628b5a20/html5/thumbnails/26.jpg)
Record stores (and PACS) wider integration using eg IHE XDS supporting “pull” requests
![Page 27: Towards the Single Patient Record: Clinical Documents Ann Wrightson](https://reader031.vdocuments.site/reader031/viewer/2022012916/551ac29755034656628b5a20/html5/thumbnails/27.jpg)
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
![Page 28: Towards the Single Patient Record: Clinical Documents Ann Wrightson](https://reader031.vdocuments.site/reader031/viewer/2022012916/551ac29755034656628b5a20/html5/thumbnails/28.jpg)
End of slide set