Clinical Data Summarisation

Data entry, capture, conversion and encoding are daunting, immense and time-consuming tasks for NHS organisations of all types and sizes"

Over the next ten years, DoH & NHS are aiming to connect more than 100,000 doctors, 380,000 nurses and 50,000 other healthcare professionals by linking over 30,000 GP Surgeries to almost 300 hospitals in England. But this objective can only be achieved by replacing the current patchwork of paper records with Electronic Patient Records (EPR) for each of England's 50 million patients.

What is Clinical Data Summarisation?
Data Summarising is a process whereby specific salient and significant aspects of patient's medical history are extracted from their past medical notes/records to form a precise, succinct document. This provides a safe platform of patient information with comprehensive medical information about a patient to the appropriate and precise use of read codes, medical and insurance forms, hospital consultations, operations details and more.

The patient summary would store patients' essential details such as their address, date of birth, NHS number and their comprehensive health and medical care history, which includes the codes of the items along with all significant aspects of a person's care such as :-

• Major diagnoses and any recent investigation results
  
• Major surgeries/procedures and crucial undergone treatments & therapies
  
• Current and regular prescriptions
  
• Drug allergies & Interactions and adverse reactions
  
• Vaccinations
  
• Family History
  

Why is Clinical Data Summarisation needed?
The Clinical Summarisation process has become increasingly important to medical practice for a number of reasons:

• Emergency or Out-of-Hours access
• Evidencing Disease and Patient Management
• Busier and Over Booked Surgeries
• Patient Demand and Expectations for Better Services
• Increasing Demand of Medical Reports for Insurance and Other Purposes
• New Guidelines and targets issued from DoH and NHS
• The need to Provide Easy Access to Patient Information Anytime and Anywhere

Moreover, patients are likely to be treated by a variety of care professionals in a range of locations throughout their lifetime. Each doctor will keep a separate medical record focusing on the most recent encounter with the patient. Currently, these pieces of vital medical information cannot be shared easily amongst different hospitals, GP surgeries or Social Caretakers nationwide as the computers/networks in different NHS buildings are not inter-connected and hence cannot communicate with each other.

But Electronic Patient Records (EPR) created as part of NHS Care Record Service (NHS CRS) would change all of this, providing solutions to problems/issues that have dogged NHS for ages.

NHS CRS aims to issue electronic NHS Care record to all the NHS patients and put them on a centralised patient record database to enable easy information sharing between GP surgeries and hospitals nationwide. This new NHS setup would effectively link various disparate NHS organisations to create a true national health service.

But this can only be achieved by replacing the current patchwork of paper records with Electronic Patient summaries for each of England's 50 million patients and storing all these medical reports and associated data on a centralised location that can be accessed from anywhere in the UK.

Please read on about how our services can help Primary Care and Secondary Care and assist them to achieve, operate and be complaint with the new patient-centric working environment.

Our Solution

How Can We Help

Data entry, capture, conversion and encoding are daunting, immense and time-consuming tasks for NHS organisations of all types and sizes. MediTech Solutions provides an outsourcing solution that combines the benefits from all the available options.

• We provide a highly reliable, efficient and accurate solution for Data Summarising at highly competitive prices.
  
• We use a team of highly qualified and experienced doctors for Clinical Data Summarisation, resulting in high quality patient summaries.
  
• Since the patient reports are generated by our doctors are precise, accurate and concise, the treating physician can quickly understand the patient’s entire medical history by reading couple of sheets rather than going through the entire patient record with hundreds of source pages. This helps clinicians make better informed decisions regarding the care to be offered. This significantly improves the working lives of all the doctors and staff members by making it safer to operate for medico-legal reasons.
  
• We integrate the patient summaries into your clinical system with appropriate coding (Read or ICD) standards, which can be converted to XML and HL7 messages.
  
• Our outsourcing model helps surgeries reduce their overheads and save fortunes in maintenance and administrative costs.
  
• We can also significantly increase the surgery's revenue under QMAS and help surgeries earn more QOF points, which in turn be exchanged for huge financial rewards.
  
• Our summarisation team works on a 24x7 basis, hence we can complete the summarisation process in matter of weeks rather than in months or years.
  
• Our network solution is highly secure and has been approved by NHS Connecting for Health.
  
• Our unique operational strategy allows us to summarise the patient records in a remote site, causing minimal disruptions to the day-to-day running of the surgery and without needing to physically removing the records from your surgery. So, the GP practice would have access to all the patient records at all times.
  
• Fully Summarised We can help you even if your practice is fully or partially summarised to an acceptable level to maintain those EPRs on an on-going basis.

Please contact us or submit your enquiry to receive a competitive quote for your organisation!!

Methodology

Methodology and fulfillment process

Meditech Solutions provides a seamless and complete outsourcing solution for better control of data output, effective information management, distribution, retrieval and Storage.

Before undertaking the project, MediTech Solutions will have detailed discussion with the organisation to identify their requirements and will conduct a quick review of your clinical systems and of any coding systems being used. We would then setup a protocol for creating patient summaries, which would dictate which information goes into the patient summaries.
We have put together a suite of services to help health organisations such as GP Surgeries, Hospitals, Local Service Providers (LSPs) and GP Consortia, to meet their electronic patient record targets and qualify for additional QOF points, helping to project an efficient image of the organisation. We are aware that different organisations have varying degrees of internal resources dedicate to this strenuous and humongous tasks, therefore we offer a “pick and choose summarisation menu” in order to fit-in with your organisation operational requirements and economical constraints.

Our streamlined process is designed to cause minimal or NO interference in the normal day-to-day running of the surgery. The overall process is as follows:

1. PREPARING THE PATIENT RECORDS

This stage requires organising the paper versions of the patient records, by extracting all the paper sheets from the Lloyd George envelopes or the A4 patients’ file wallets to:

1. Straightening/unfolding the sheets,
2. smoothen the creases out,
3. removing any tags/staple pins/tape and
4. Organising those sheets in the chronological and increasing order of the sheets size so they can be scanned effectively and efficiently.

This is an important process that assists in the summarisation process at a later stage and also helps with the quality control along with the all important checking process to identify if any information may be missing.
The Lloyd George cards along with the rest of the sheets are then repackaged and filed back in the original
wallet/file cover after the scanning process.

2. SCANNING AND UPLOADING THE PATIENT RECORDS

Once all the patient records have been prepped, the documents are scanned in duplex mode to scan both the front and back of all the documents in patient medical record file(s) including both sides of the wallet. These then are uploaded to our fully secure and ISO27001 accredited Datacenter in the UK via a secure, NHS CfH approved data transfer environment.
We hold a full audit history for every record scanned at any stage. For this reason, all medical records would be colour coded to distinguish between records which are prepped, scanned or awaiting scanning. So, even if any of the records are removed off the shelves or taken out of the records storage room and then placed back at a later stage, we can easily detect such records with help of this colour coding mechanism.

We take pride in the high standards of the final output as the scanned image from our system would provide exactly the same readability as the original physical paper copy and even offers advance features such as rotation, inversion, flip, deskew and ability to zoom into specific section of the page etc to further enhance the viewing experience. Also, the scanned images ensure that the GP Practice meets their obligations under legislation such as the Data Protection Act and the Freedom of Information Act. I-Docx conforms to BSI PDC 0008, 0009, 00010 for legal admissibility of documents in a court of law. It also complies with ACCA, ICAEW ,HMRC, FSA, FDA regulations and all of the Caldicott guidelines.

We can also provide an ‘Electronic Data Management’ solution to the surgery that would enable to retrieve and/or review all patient records electronically, providing instant access and information sharing amongst clinical/admin staff. This would not only enable the practice to operate in a ‘paperless’ working environment but also save a fortune in document management, storage and maintenance costs. All patient records in our EDM solution would be indexed on customised parameters that will enable you to search for a patient record on the basis of name (surname/forename), NHS-ID, DOB and much more.

3. SUMMARISATION OF THE PATIENT RECORDS

Once uploaded to our secure servers, our highly qualified and experienced team of doctors, who are well
versed in the art of medical summarising, will summarise the patient records in accordance with the protocols that is pre-agreed with the surgery as part of phase 1
Once summarised and satisfactory Quality Checked, the reports are made available for release back to the
surgery. We will create a customised solution to provide access for as many users as deem necessary by the client to access the patient reports at no extra cost at all. The surgery can then undertake any checks it so desires on the summarised records.

4. ENTERING PATIENT SUMMARIES IN SURGERY CLINICAL SYSTEMS

Once the summarised records have been checked by the surgery, then the next stage is to enter the data from the patient reports into the clinical data management system being used by the surgery. Depending on the system being used by the surgery, this might be either a manual or an automated electronic import process. We use HL7 (v3) messaging protocol/templates for uploading these data summaries into the clinical system.

Clinical Team

Our Human Capital is our biggest asset. This is where we have a cutting advantage over our competitors.

MediTech Solutions uses a team of highly qualified and experienced doctors from all major specialities and facets of medical sciences. Our team is available on 24 x 7 x 365 basis and hence can help you to become 'paperless' in a matter of few weeks rather than months and years.

Medical Data Summarisers
These are the fully qualified doctors who are being trained to perform the task of data summarisation. Coming from the medical background, they are already very well versed with identifying which information would make an impact on the future medical treatment of the patients as they know themselves what medical information they would be looking for when making a critical medical decision. Combined that with our extensive training, our medical summarisers are the masters of the game!!
It is this solid medical/clinical foundation that enables us to address the challenges of clinical summarising by:

• Offering multiple views to the patients’ data.
• Ranking of lab results according to their significance level.
• Preparing a chronological summary of the medical treatment
• Outline of future treatment and/or related impairment.
• Commentary on the causal relationship of diagnoses and/ or treatment to the loss.
• Suggestions for additional investigation and recommendations for further consultations
• Summary of the report and expert clinical opinion relative to research analysis.

Data Quality Managers
These are the highly qualified doctors who have vast experience in clinical data management and summarisation. Hence, they are responsible for monitoring the quality of the data that goes into the practice clinical systems. They audit the batches of patient summaries generated to check the data quality and to ensure that the defined criteria are met. Our quality control measures consist of very strict and stringent policies which our quality managers ensure are implemented and followed.