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<br>In recent years the NHS has undergone a raft of reforms under the current government’s modernisation programme. The key to these reforms is the transition towards an increasingly joined up electronic healthcare system, to be achieved in part through the introduction and use of standard clinical and drug terminologies across the NHS.
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<br>Standardisation is crucial for the provision of accurate and well-targeted clinical decision support and is a fundamental part of the National Programme for IT (NPfIT) delivered by NHS Connecting for Health (NHS CfH). To date, standardisation has by no means been achieved, but the transition has certainly begun.
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<br>A legacy of challenges
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<br>Currently, there are few centralised electronic medical records for patients, with islands of information held within disparate clinical systems which do not readily communicate with each other. This lack of clinical system interoperability means that a clinician may not necessarily be in possession of a patient’s complete medical record and may have to make a diagnosis and prescribe treatment without full knowledge of the medical history.
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<br>Individual clinical systems use a mixture of different coding systems including multiple versions of Read Codes, ICD Codes, OPCS, proprietary codes and free text to represent clinical concepts, treatments and medicinal products in patient records.
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<br>Consequences for clinical decision support
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<br>Inconsistent clinical coding has posed a massive challenge to system providers and clinicians in generating effective clinical decision support solutions. At the point of prescribing or dispensing, clinicians are presented with warnings and alerts from their clinical decision support system to flag up potential drug interactions, allergies, contraindications, precautions, warnings and dosage errors.
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<br>The lack of standardisation has meant that alerts are often generated from incomplete patient medical records, with little patient context or poor data quality. This can result in false positive alerts and information overload which can reduce clinicians’ confidence in clinical decision support systems and lead to them switching the alerts off altogether.
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<br>Also, if there is more than one coding scheme in place, a system provider or clinician has to decide which scheme to use. The Department of Health’s Quality and Outcomes Framework (QOF) relies upon Read coded data to calculate payments for GPs. Upon the introduction of QOF, there was a shift from the coding of allergies using proprietary codes in order to drive allergy checking decision support, to the use of Read Allergy codes for QOF. Obviously, it is not in the interests of patient safety for clinicians to have to choose between receiving clinical decision support or receiving payments.
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<br>New terminologies
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<br>In the future, everyone in England will have a centralised patient medical record held on the NHS Care Records Service (NCRS), currently under development by NHS CfH. The NCRS will utilise defined clinical standards including the Systematised Nomenclature of Medicine Clinical Terms (SNOMED CT) for the recording of medical conditions and allergies, and the NHS Dictionary of Medicines and Devices (dm+d) for the consistent identification of medicines and medical devices.
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<br>SNOMED CT is a structured list of terms which can be used to describe the care of patients and covers areas such as diseases, operations, treatments, drugs and healthcare administration. This allows the detailed recording of diagnoses and findings, and the subsequent treatment of them, both within a single episode of care and across the patient's full care record.
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<br>The dm+d provides unique identifiers and descriptions for medicines and devices used in the diagnosis or treatment of patients in the NHS. The dm+d is the UK drug extension of SNOMED CT and will allow safe and reliable exchange of drug information.
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<br>These new terminologies will enable interoperability between diverse clinical systems, facilitating the communication of clear and unambiguous patient information between healthcare professionals.
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<br>Structural advantages
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<br>SNOMED CT offers several structural advantages over Read Codes. A critical improvement for clinical decision support is the capacity for SNOMED CT to allow any coded disorder to 'belong to' more than one class of disorder. For example, in Read Version 2, “bacterial meningitis” is classed as an “inflammatory disease of the central nervous system”, but due to technical constraints within the Read Version 2 coding scheme, it cannot also be classed as a “bacterial disease”. For clinical decisions, the fact that “bacterial meningitis” is, in reality, both a nervous system disease and a bacterial disease cannot be ignored.
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<br>Improved patient context
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<br>The 300,000+ concepts available when coding using SNOMED CT not only offer the facility to provide greater detail about a patient than was present in previous coding schemes, but also allow for additional context information to be coded and associated with the patient.
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<br>For example, if a patient reports a family history of asthma, current clinical systems use varying methods to record this information. Some systems have the context of “family history” embedded into their structure and the “asthma” code is selected and added to this field; some use a specific code of “family history of asthma”; while others apply the context of “family history” to asthma using free text. Multiple methods of representing identical patient information, in particular free text, present immense challenges for clinical decision support.
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<br>The next generation of clinical decision support
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<br>A common structure for patient medical records, standard terminologies and, more importantly, consistent use of both structure and terminology, allow clinical decision support systems to provide improved and more focused alerts and warnings. Ultimately, if a system is presenting alerts which are more appropriate and relevant for each patient, the clinician is less likely to suffer from alert blindness.
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<br>The introduction of healthcare standards such as SNOMED CT and dm+d, together with the NCRS, will provide a firm basis for the future development of enhanced clinical decision support. The concept of common languages and the communication of standard clinical information is a simple one but has so far not been achieved in practice.
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<br>First DataBank Europe is working with NHS CfH, clinical system suppliers and clinicians within the NHS to develop the next generation of clinical decision support, through the adoption of new NHS standards and integration of these into clinical prescribing and dispensing processes and applications. With this infrastructure in place, and with buy-in from clinicians and patients, the NHS can make positive steps towards significantly improving patient safety in a joined up healthcare system.
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发表于 2006-1-25 23:22:16
发表于 2006-1-26 00:42:00