Scotland mandates online patient data dictionary

A new clinical standards dictionary has been set up by NHS Scotland’s National Clinical Dataset Development Programme in an effort to promote the use of approved data standards in Scotland

The web-based Health and Social Care Dictionary (www.datadictionary.scot.nhs.uk) comprises of a full list of national clinical data standards, which will help to support direct patient care, allow professionals to communicate more effectively and support clinical governance.

The dictionary covers all the approved data standards, and allows users to use XML to import the terms onto their own systems. The Scottish health department has made it mandatory that all new systems use these standards.

As well as generic information needed to care for all patients, the dictionary contains specific fields for the relevant hospital departments, such as unscheduled care communications in emergency care and general assessment notes from nurses and midwives.

Dr Lorna Ramsay, clinical lead at the National Clinical Dataset Development Programme (NCDDP) told E-Health Insider: “Linking and standardising patient information so that each professional caring for an individual has accurate, up to date and relevant information at their fingertips is the key to helping create single patient records.”

She said that common standards to support a common record were essential to helping to create a single patient record.

“The National Clinical Dataset Development Programme (NCDDP) is working towards implementing one record for every patient. In order to do this, it is essential that we make all clinical systems fit for clinical purpose, be clinically led and make them interoperable.”

NCDDP actively works with the clinical community in Scotland to ensure that the clinical content of NHS Scotland’s IT systems meet these requirements. Its vision is to support clinicians to develop sets of interoperable national data standards to facilitate the implementation of integrated care records across Scotland.

Dr Ramsay told EHI: “We want to support clinicians to develop national clinical datasets to integrate care records across Scotland. They should be re-usable concepts reducing duplication and available to everyone authorised to access the information.”

She added that the introduction of SNOMED CT will make the risks of different work methods very difficult, and common standards will become commonplace with this new terminology.

“SNOMED codes will not be like Reed codes which clinicians have learnt and can type notes in the terminology format. These are long codes, up to 18 digits in format, so clinicians will have to enter notes in the usual manner, and SNOMED will then convert it into code format themselves.”

Dr Ramsay described some common problems with current systems.

“Context of information isn’t always clear and so with single patient records, not everyone will understand these. Also, there are problems with the way people format text, and the way they write dates, this needs to be nationally agreed so that confusion isn’t a problem anymore – common standards make systems more effective and helps patient safety.”

The NCDPP is now working on addressing a number of key requirements in relation to the sharing of care information across traditional boundaries. These will include interoperability through common standards, explicit clinical definitions and ongoing support.

Dr Ramsay said: “National clinical data standards ensure data collected across cares settings, specialities and professional groups is consistent. This means that key clinical information is recorded exactly the same way, no matter where or when it is collected.”

Links

Scotland Health and Social Care Dictionary