1.4 The Core Information Standard (page 6 of 6) in Acknowledgements (chapter 2 of 8) within Core Information Standard: Implementation Guidance

The standard defines a set of information that can potentially be shared between systems in different sites and settings, with professionals and people using services. What information is accessed will differ depending on who is accessing it, for what reason and the wishes of the person the information is about. Access will be based on the national Information Governance Framework being developed by NHS England in parallel with this work.

The core information standard itself is based on the PRSB’s “Standards for the Clinical Structure and Content of Health and Care Records” (PRSB, 2018) which can be found here.

1.4.1 What it is

The core information standard is:

• a core set of information relevant for direct care (across a variety of settings).
• a set of information that could potentially be shared with professionals depending on their role and circumstances.
• a definition of the information professionals and people who use services have told us they want to see in a shared record.
• an information set that is readily translatable across clinical settings e.g. mental health to accident and emergency; acute care to social care etc.
• a blueprint for local implementations to use to draw from for their own local sources depending on local requirements. Local implementers may add to the core information.
• a thoroughly researched and validated definition of the core information standard tested with citizens, patients, carers and health and social care professionals.

1.4.2 What it's not

• a definition of an exhaustive clinical or care record / history.
• a definitive set of information about the person’s current status - no clinical record is ever this and clinical information needs to be understood by the professional reading it as such.
• a prescriptive definition of what must be included – this will be determined ultimately by local projects and specific use cases.
• a logical or physical data model. A logical data model will be developed by NHS Digital. FHIR profiles to support interoperability of the data between systems will be commissioned by NHS England.
• a definition of what information professionals should be able to see or change (which will be set out in NHS England’s Information Governance Framework and Role Based Access Control work).
• a definition of how information should be presented to professionals (what is presented and how much information (history) and how it is viewed/accessed), which should be defined locally.
• a definition of a shared care record.
• a definition of how the content should be sourced, updated, de-duplicated and normalised i.e. the source data and its processing.
• additions or adjustments needed to successfully implement locally which must be defined in local projects.

It is recognised that full interoperability of systems is still some way off in most clinical environments and so what is likely at least at first is a data ‘pull’ from source systems without direct write back into those systems (see clinical safety case).

1.4.3 The approach to the development of the core information standard

The approach to the development of the core information standard is set out in the Final Report which can be found here.