Patients and professionals who provide care are set to benefit from new standards for the drafting of outpatient letters, produced by the Professional Record Standards Body (PRSB).
The standards aim to improve communications between hospitals, other professionals and patients following outpatient appointments.
Outpatient letters are often the main method of communication between outpatient services and a GP surgery. They are sent to the GP practice following appointments at hospital, community hospitals, health centres or online assessments such as Skype.
“The new standards define the content and structure of outpatient letters so that professionals, patients and carers receive consistent, high-quality information”, a PRSB spokeswoman said.
Jonathan Brown, informatics lead for gastroenterology at the Royal College of Physicians and clinical lead on the project, said: “The importance of standardised outpatient letter headings will grow as the number of patients living with long-term conditions increases and they access care in a wider range of settings – including the home.”
“By creating data structure definitions for the content of outpatient letters we can ensure that GPs can focus on the relevant information they need to provide safe and efficient continuity of care.”
Its need comes at a time of importance particularly when West Suffolk Hospitals NHS Foundation Trust recently identified technical problems with its Cerner EPR leading to inaccuracies in discharge letters automatically sent to local GPs.
The trust has launched an on-going investigation into the data errors in discharge letters, which it initially rated as a potentially ‘catastrophic/major harm’ risk.
The trust told Digital Health News at the time that the discharge letter problems stemmed from inaccuracies in information contained within some discharge summary letters issued to GPs, which were created by unspecified technical issues.
During the outpatient letter standards project phase, PRSB consulted with patients and service users, carers, GPs and primary care professionals to ensure that the outpatient letter standards meet the needs of the authors and recipients and are easy for outpatient clinics and vendors to implement in IT systems.
The focus of the project included identifying what information GPs and patients require in outpatient letters and what information it would be preferable to have in a coded form.
It also identifyed what structured (and coded) information it is feasible to include in outpatient letters and how this may change with the implementation of more integrated electronic patient record systems.
The project was conducted according to the editorial principles for the development of record standards, developed by the RCP and adopted by the PRSB.
The PRSB develops standards for digital health and care records, based on research evidence and agreed by professionals and patients. It promotes the use of standards so that people can receive safe, effective care.
How will the outpatient standards benefit professionals and patients?
- Ensure the right information is passed on to the GP in an outpatient letter
- Currently outpatient letters can be varied. Standardising them will mean that GPs always have full access to the right information, improving continuity of care for patients
- The standards have been developed with patients and professionals to ensure outpatient letters meet the needs of those who will be using them to enable their widespread adoption