HIQA publishes national standard for procedures that will support safer better care
The Health Information and Quality Authority (HIQA) has today published the National Standard for a Procedure Dataset including a Clinical Document Architecture specification. This new standard will ensure compliance with best practice in the electronic exchange of clinical documents between healthcare providers.
This standard is part of a suite of standards that HIQA has developed to support national patient summaries. A patient summary is a summarised version of a patient’s medical information that gives healthcare professionals the essential and most relevant information they need in order to provide appropriate care for a patient, for example, current medical conditions, allergies and adverse reactions.
The Director of Health Information at HIQA, Rachel Flynn, said “The standards published today will support the development of eHealth systems, which enhance the quality, accessibility and efficiency across all healthcare services through the secure, timely, accurate and comprehensive exchange of clinical and administrative data. These systems ultimately lead to the provision of safer, better care.”
The national standard for procedures was developed to standardise how procedures such as a hip replacement or an appendectomy are recorded and how this information could be shared between healthcare professionals in order to facilitatesafer better care. Up to now, there has been no standardised national dataset to describe a procedure that can be used in patient summaries. The national eHealth Strategy states that the development of patient summaries is a key priority to support the implementation of eHealth initiatives in Ireland, in particular electronic health records (EHRs).
Ms Flynn continued “The development of standardised patient summaries can increase patient safety as they facilitate effective and accurate exchange of informationand support improved communication between healthcare providers. They can also support continuity of care as patient summariesare intended to help clinicians to access key information when emergency care is being provided.”
Information about procedures is a key section of the patient summary. The purpose of this standard is to define a minimum dataset for a procedure and to define a Clinical Document Architecture (CDA) specification based on the dataset. This is a minimum dataset that could be displayed in a patient summary. The development of this standard can help to standardise how a procedure is recorded in a structured way and can facilitate easier sharing of information within and between health and social care services.
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For further information contact:
Marty Whelan, Head of Communications and Stakeholder Engagement, HIQA, 01 814 7480 / 086 2447 623, mwhelan@hiqa.ie
The National Standard for a Procedure Dataset including a Clinical Document Architecturespecificationcan be found at the link at the bottom.
HIQA is developing Health Information Technical Standards to ensure that there is consistency in capturing and sharing of health information records. The national standard for procedures is part of a suite of standards that HIQA has developed to support the standardisation of national patient summaries, including standards for adverse reactions and diagnosis.
Health Information Technical Standards support the interoperability of systems and the meaningful sharing of data. Interoperability is the ability of health information systems to share and understand data in a structured format. By sharing data in a structured format using predefined standards, health information systems can process and understand data received from other computers.
Interoperability facilitates and enables health information systems to work together within and across organisational boundaries in order to advance the effective delivery of healthcare.
Standards in this area include data definitions, clinical concepts and terminologies, classification and terminology standards, messaging specifications, the Electronic Health Record, and security standards.
A patient summary can consist of medical information such as allergies, adverse reactions, current medical problems (diagnosis), test results and procedures alongside a list of the medication that a patient is currently taking. It also outlines information about the patient summary itself, for example, when and by whom the patient summary was generated or updated by.
As well as during emergency care, patient summaries are used in planned care such as in out-patient departments and when exchanging information within and across different healthcare organisations. Patient summaries can be created and consumed by electronic health record systems. The exchange of standardised electronic documents such as shared patient summaries are key building blocks for interoperability between eHealth systems.
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