Developing and implementing national standards to improve the structure and content of patient records
Submitting InstitutionSwansea University
Unit of AssessmentAllied Health Professions, Dentistry, Nursing and Pharmacy
Summary Impact TypePolitical
Research Subject Area(s)
Medical and Health Sciences: Public Health and Health Services
Summary of the impact
Patient records underpin the delivery of healthcare. When the recorded
data are aggregated, they provide information to support service delivery,
audit and research. Research conducted at Swansea University from 2000 to
2011 showed that variations in the structure and content of records across
the NHS limit their quality and utility. To address this, the University
collaborated with the Royal College of Physicians to develop
evidence-based national standards for the structure and content of patient
records. First launched in 2008, the standards have been endorsed by
numerous statutory bodies and professional organisations, including the
Department of Health, NHS England, NHS Litigation Authority,
Mid-Staffordshire Inquiry, Care Quality Commission, General Medical
Council, Academy of Medical Royal Colleges, and Academy of Medical
In 2000 the President of the Royal College of Physicians (RCP) in London
invited JG Williams, Professor at Swansea University since 1992, to set up
a Health Informatics Unit within RCP to improve the clinical content of
hospital patient records and the quality of information derived from them,
and thus to support service delivery, audit and research. Since then
Williams has directed that Unit from Swansea, forging a productive
collaboration in research and development between RCP and Swansea
Initially Williams (in Swansea) and Mann (in London) reviewed the
literature on the use of clinical data in patient records to monitor
hospital activity through Hospital Episode Statistics (HES). The key
findings were that data quality was poor, and could be improved by
standardising the structure and content of records, and engaging
clinicians in the process of data extraction, coding and validation
[R1-2]. In 2004 the Department of Health (DH) and Welsh Government funded
the University to undertake a joint project with the RCP to improve
clinical engagement in both record-keeping and validation of the coded
diagnoses and procedures extracted from records. Williams and Croft set up
a virtual `information laboratory' or `iLab' in Swansea with electronic
links to RCP; they used this to show individual physicians the potential
value of analysing the coded diagnoses, procedures and episodes for
patients under their care. We selected half these physicians at random for
one-to-one discussions about this information. Overwhelming conclusions
from this trial were that the data were not good enough for this purpose,
or comparable across the country, confirming the need for national
standards for the structure and content of records [R3].
This conclusion reinforced the findings of a study undertaken in Swansea
in the late 1990s [R4], in which Williams and Hutchings replicated four
small randomised trials using routinely collected data (clinical,
administrative and demographic) in place of the designed research data to
explore whether clinical trials could be reliably undertaken in this way,
but at less cost. The study concluded that this would be possible if the
quality of the routinely collected data was improved, but that this would
require the implementation of clinical standards for the structure and
content of medical records [R4]. In 2006 we used this evidence to persuade
DH to commission Williams to develop national standards for hospital
patient records based on evidence of good practice or, failing that,
consensus amongst medical, nursing and other practitioners [R5]. In 2010
Williams and Roberts in Swansea further strengthened the case for this
work when they explored the potential usefulness of routinely collected
data in monitoring the quality of care through national audits, and
concluded that quality of the data being collected was insufficient for
this purpose [R6].
The standards developed so far address: the structure and content of
records made on admission; communications at handover and discharge,
including medication records; referrals to out-patients; letters back to
primary care; core headings applicable in the majority of settings; and
editorial principles to ensure sustainability of the standards over time.
Since 2008 the standards have been available on the website of the Academy
of Medical Royal Colleges (AoMRC); they were updated in 2013 (http://www.aomrc.org.uk/publications/reports-a-guidance.html).
Key researchers at Swansea are Williams, HA Hutchings (Senior Lecturer since
2002), SE Roberts (Reader since 2006) and IT Russell (Professor of Clinical
Trials since 2008). Collaborators at the RCP Health Informatics Unit have
included RY Mann (project officer), I Carpenter (associate director) and M
Bridgelal-Ram (programme manager). Three current doctoral students under
Williams's supervision at Swansea University are developing additional
standards based on evidence and consensus - for clinical incident reporting
(A Lewis, since 2012), endoscopy reports (C Hunt, 2010) and patient-focused
summaries (P Rastall, 2012).
References to the research
Authors based at Swansea University during these studies are in bold.
Journal Impact Factors (JIF) are for 2013, and number of citations (cit)
are from Google Scholar.
R1 Williams JG, Mann RY. Hospital Episode Statistics: time for
clinicians to get involved? Clinical Medicine 2002;2:34-7.
doi:10.7861/clinmedicine.2-1-34 (JIF 1.2; cit 66).
R2 Mann RY, Williams JG. Standards in medical record keeping. Clinical
Medicine 2003;3:329-32. doi:10.7861/clinmedicine.3-4-329 (JIF
1.2; cit 65).
R3 Croft GP, Williams JG. The RCP Information Laboratory (iLab):
breaking the cycle of poor data quality. Clinical Medicine 2005;5:47-9.
doi:10.7861/clinmedicine.5-1-47 (JIF 1.2; cit 15).
R4 Williams JG, Cheung WY, Cohen D, Hutchings H, Longo M,
Russell IT. The value of routine data in health technology assessment: can
randomised trials rely on existing electronic data? Health Technology
Assessment 2003;7:(26). doi:10.3310/hta7260 (JIF 4.0; cit 34).
R5 Carpenter I, Bridgelal-Ram M, Croft G, Williams J. Medical
records and record-keeping standards. Clinical Medicine 2007;7:328-31.
doi:10.7861/clinmedicine.7-4-328 (JIF 1.2; cit 24).
R6 Roberts SE, Williams JG, Cohen DR, Akbari A, Groves S,
Button LA. Feasibility of using routinely collected inpatient data
to monitor quality and inform choice: a case study using the UK
Inflammatory Bowel Disease audit. Frontline Gastroenterology
2011;2:153-9. doi:10.1136/fg.2009.000208 (JIF not yet available; cit 4).
Peer-reviewed grants that have supported this work:
1 JG Williams. The value of routine data in health technology
assessment. NHS Research & Development Directorate - Health Technology
Assessment Programme, 1998-2000, £157,625.
2 JG Williams. Development and evaluation of an Information
Laboratory (iLab). Department of Health and Welsh Assembly Government,
3 JG Williams, I Carpenter. Clinical documentation and generic
record standards phases 1 & 2. NHS Connecting for Health, £753,000,
4 SE Roberts, JG Williams. Investigation of the feasibility of
using routine data to monitor quality and inform choice. The Health
Foundation, £80,000, 2007-9.
Details of the impact
The standards were first made publicly available in 2008. They have
received full endorsement from all medical royal colleges in the UK,
AoMRC, Royal College of Nursing, and professional bodies representing the
allied health professions. Uptake of the standards until July 2013 is best
summarised by more than 5000 accessions online and the distribution of
4000 paper versions (cumulative data since 2009 from AoMRC, and since 2012
from RCP). The standards have been widely recommended by the UK
Government, and by professional and statutory bodies; they all believe
national implementation will bring benefits to patient care and safety,
litigation costs, and efficiency of communication; and provide better
evidence for commissioning, audit and research. As the President of the
Academy of Medical Sciences said [C1]:
"Standardising the way clinical data are collected and handled by all
healthcare professionals will ensure data quality and accessibility for
research and clinical use."
There is evidence of early adopters achieving these benefits. In 2011 DH
launched the Discharge Summary Implementation Toolkit [C2] for universal
use in England. This incorporates the record standards and has been
successfully piloted in four NHS Foundation Trusts - Chelsea and
Westminster Hospital; Kent and Medway Hospitals, Newcastle University
Hospitals and South Tees Hospitals - with benefits to efficiency and
patient safety. The Clinical Director for Information Standards Delivery
at the Health & Social Care Information Centre commented [C3]:
"In my present role, and previous role as Director for Clinical Record
Standards in DH, there has been a considerable challenge to design
systems which can obtain coherent and comparable data on health care
activity directly from clinical records. The collaborative work with
Professor Williams and the RCP is the foundation of better records for
the NHS and better data for analysis."
There is also evidence of adoption in Europe, where the standards are
recommended for use in the records of patients with sexually transmitted
infections [C4]. In 2012 the DH Information Strategy recommended that the
NHS collect data in standardised form, and referenced our research
including the standards [C5]. The associated impact assessment recommended
actions necessary to achieve wide implementation [C5]. The rapid
acceptance of our work also led DH to commission a Joint Working Group
(JWG), chaired by the National Clinical Director for Informatics, to
explore how to advance standards. The JWG recommended [C6] that a
self-funded, independent, professional record standards body (PRSB) be
established. This was accepted by DH and NHS England, and supported by
other important stakeholders, including the Academy of Medical Sciences
and many research charities. The PRSB is now working closely with NHS
England and the devolved administrations to oversee the development of
further standards, and achieve universal implementation of record
standards across the NHS (www.theprsb.org.uk).
The standards have the explicit support of statutory bodies including the
NHS Litigation Authority [C7] and Audit Commission [C8]; are
recommended by the General Medical Council [C9]; and have been welcomed by
electronic patient record software suppliers, who previously had to rely
on local consultation to define the structure and content of their
products. The AoMRC has stressed the need for standardised patient-focused
records, and published the standards themselves [C10]. The RCP Commission
on the Future Hospital [C11] and the Mid-Staffordshire Inquiry [C12] also
The NHS Wales Information Service has used the standards in developing
clinical record software since 2009. A major implementation of the
international `Epic' electronic health record system by Cambridge
University Hospitals is incorporating the standards, and NHS Trusts in
England, particularly those supported by the Technology Fund, stipulate a
requirement to conform to the standards in specifications for clinical
information systems [C13].
To stimulate uptake of the standards and thus impact, Williams has since
2008 given invited talks at educational events hosted by RCP, British
Computer Society, King's Fund, NHS Confederation, Nuffield Trust, Royal
Society of Medicine, Association of British Pharmaceutical Industry and
Intellect (the software suppliers' professional association). At RCP in
July 2013 the standards were welcomed by senior leaders from healthcare
and academia [C14] including:
- Chair of the Expert Advisory Group to the Clinical Practice Research
Datalink, the new English NHS observational data and interventional
research service, who stated:
"they provide a platform for the spread of Electronic Patient
Records, improve patient care and save time for clinicians"
- Chair of AoMRC:
"they lay a strong foundation for electronic health records which
will improve not only the patient experience, but also safety and
- Director for Clinical Assurance at the Health & Social Care
"they provide the essential foundation to build an information
landscape that reflects more accurately what is actually happening in
In 2013, the Academy of Medical Sciences endorsed the need for
standardised record keeping to support stratified medicine - a new
therapeutic approach of considerable potential for patients, and
importance to the pharmaceutical industry in the UK [C15]
Sources to corroborate the impact
C1 Williams JG. Diagnosis driven data. International Innovation;
December 2013: 21-23. Bristol: Research Media Ltd; ISSN 2051-8552. (Quote
from President of Academy of Medical Sciences in box on p23)
C2 Health and Social Care Information Centre. Electronic 24-hour
discharge summary implementation. http://systems.hscic.gov.uk/clinrecords/24hour/index_html.
(Swansea University invoked throughout the document and on video, as
C3 Clinical Director for Information Standards Delivery, Health &
Social Care Information Centre, Department of Health.
C4 Radcliffe KW, Flew S, Poder A, Cusini M. European guideline for the
organization of a consultation for sexually transmitted infections. Intl
J STD & AIDS 2012;23:601-12. doi: 10.1258/ijsa.2012.012115.
(Swansea University cited on p6, as accessed 28/5/13)
C5 DH. The power of information: (a) putting us all in control of
information we need. https://www.gov.uk/government/publications/giving-people-control-of-the-health-and-care-information-they-need
(Swansea University cited on p44). (b) impact assessment. London: DH;
2012. (Swansea University invoked in box 8 of table D4 on p29, as accessed
C6 Joint Working Group. Developing Standards for Health and Social Care
Records. Report of Joint Working Group. London: NHS; 2012. http://www.rcplondon.ac.uk/resources/developing-standards-health-and-social-care-record.
(Swansea University invoked on pp 6,9 & 14, as accessed 13/11/13)
C7 NHS Litigation Authority. Risk management standards 2013-14. London:
NHSLA; 2013. http://www.nhsla.com/safety/Documents/NHS%20LA%20Risk%20Management%20Standards%202013-14.pdf
LA Risk Management Standards 2013-14.pdf (Swansea University invoked on
pp50 & 166, as accessed 13/11/13)
C8 NHS Audit Commission. Improving data quality in the NHS London: NHSAC;
(Swansea University cited in para 66 on p29, as accessed 13/11/13)
C9 General Medical Council. Tomorrows Doctors. London: GMC; 2009. http://www.gmc-uk.org/TomorrowsDoctors_2009.pdf_39260971.pdf
(Swansea University invoked in para19 on p24 and appendix 3 on p92, citing
document 43 on Record Standards, all as accessed 28/5/13)
Swansea University invoked in i-care: Information, Communication &
Technology in the NHS, p2, and "Standards for the Clinical Structure and
Content of Patient Records" dated 12/7/2013, both as accessed 13/11/13)
C11 Royal College of Physicians Report from the Future Hospital
Commission: RCP London; 2013 http://www.rcplondon.ac.uk/sites/default/files/future-hospital-commission-report.pdf
(Swansea University invoked in Chapter 9, pp 89-97, paras 9.5, 9.10 &
9.15, as accessed 13/11/13)
C12 Mid-Staffordshire NHS Foundation Trust Public Inquiry. Report.
London: Stationery Office; 2013. www.midstaffspublicinquiry.com/sites/default/files/report.
(Swansea University invoked in recommendation 262 in Executive Summary on
p113, as accessed 28/5/13)
C13 NHS England. The Safer Hospitals, Safer Wards Technology Fund 2013. http://www.england.nhs.uk/ourwork/tsd/sst/tech-fund.
C14 Royal College of Physicians. Press release. http://www.rcplondon.ac.uk/press-releases/stop-reinventing-wheel-standards-clinical-structure-and-content-patient-records-forma.
C15 Academy of Medical Sciences, Realising the potential of stratified
medicine 2013 http://www.acmedsci.ac.uk/index.php?pid=99
(Swansea University invoked on p47, as accessed 13/11/13