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Making electronic care records work for you

...and how you can get involved

Wherever you work, care records are an essential part of the daily routine of every health care professional, and those that cover nursing are often highly complex. It is safe to say that the transition from a paper-based system to a digital one can be challenging, but a recent debate at RCN Congress 2016 demonstrated that many people agree on the benefits of an integrated electronic health system that works for clinicians and patients. 

The aim of the Professional Record Standards Body (PRSB) is to ensure that the structure and content of all electronic health records in health and social care follow widely agreed high quality information standards so there is a single, comprehensive, useable electronic health record (EHR) in whatever setting the person is looked after in. The RCN are founding members of the PRSB as are all of the Medical Royal Colleges. 

Patient-centred care is at the heart of nursing: we know that patients want information about their health to be available wherever they access the health service. You may have heard of John’s Campaign for example (see below). We also know that they do not want to have to repeatedly give their information to health care professionals after their initial contact. That is why it’s so important that nurses are involved, right from the start, in the development of electronic health records that are fit for purpose, and crucially, transferable across health and social care organisations.

John's Campaign

Identifying carers: whilst the support that a carer can provide to a patient with dementia is comparable to that provided by parents when children are admitted to hospital, the identification of carers may be less clear cut. Many people with dementia will be living with a partner, spouse or children; others will have given power of attorney. As progress continues in implementing the Care Act 2014 more carers will be identified on records kept at GPs surgeries, on “This is Me” documents, even within NHS codes. Many hospitals work with their local carer organisations to encourage self-identification.

For more information please see John's Campaign

Get involved

Join our stakeholder advisory group by emailing prsb2@rcn.org.uk

Different location, different system, same information

Different IT systems exist in healthcare settings in the UK. A GP practice in Stirling, a hospital in Swansea, or a care home in Southampton will all capture similar information, but that information is unlikely to be transferable. There are some great examples of systems working in harmony. If you work in Leeds for instance, you are likely to be part of the Leeds Care Record (see the blue box at the side of the page). It provides health and social care professionals access to the most up-to-date information about patients, by sharing appropriate information from medical and care records between health and social care services in Leeds. But as a patient, you may live in Leeds, but your child might become poorly whilst you are visiting friends in Surrey and you would want the GP there to have access to the health history of your child. This can only happen if we have interoperable systems which can “speak” to one another.

Current work

The PRSB develops and helps to implement information standards for the structure and content of care records. These cover, for example, hospital referral letters, handover communications, discharge summaries, and inpatient and outpatient letters. The latest published and approved set of standards are Standards for the clinical structure and content of patient records (2013).

During 2016, they will deliver several projects for new care record standards, including: crisis care and end of life care; ambulance handover to A&E; medication needed for patients being discharged from hospitals to GP care; mental health summaries for people being discharged from inpatient and adult day case care to GP care; and clinical and professional leadership in implementing the care standards. Other projects starting are standards for discharging patients from emergency departments back to GP care; outpatient letters; discharging patients from hospital to care homes; and children’s care information standards.

What can I do?

Visit the PRSB website to find out more about their work. You can join a mailing list to be kept informed about current and future projects. 

If you are an RCN member, we are always looking for people to review draft PRSB documents, respond to surveys or attend workshops. If you would like to help shape PRSB activity by ensuring a strong nursing voice, email us at prsb2@rcn.org.uk.

Do you know who your Chief Clinical Information Officer (CCIO) is? If you work in the NHS, they are likely to be involved in procuring IT solutions. Raising awareness of the work of the PRSB, and why it’s so important to ensure the interoperability of electronic health records across health and social care systems, would be a great way to support the vision of better records for better care.

Matt Butler, RCN eHealth forum steering committee (incoming Chair)
Annette Gilmore, RCN eHealth forum steering committee
Dave O’Carroll, RCN Programme Manager (Information and Resources)

Leeds Care Record

The aims of the Leeds Care Record are

  • better co-ordinated and safer care
  • more time to spend on clinical care
  • less paperwork
  • fewer unnecessary clinical tests
  • more accurate prescriptions
  • better self-management for patients
  • more efficient use of healthcare services.

For more information please see Leeds Care Record