2 Introduction (page 31 of 18) in Clinical Safety Case Report (chapter 3 of 5) within Core Information Standard: Reports

2.1 Purpose of Local Care Records and the PRSB Core Information Standard

The aim of the local health and care records programme is to help local organisations move from today’s position, where each health and care organisation holds separate records for the individuals they care for, to one where an individual’s records are connected up from across the health and care system.

This will help health and care professionals to share information safely and securely as the people they care for move between different parts of the NHS and social care. It also enables individuals to be able to access their own records irrespective of which part of the health and care system that has provided them with their care. The design of such Patient portals is out of scope of this safety review.

The PRSB Local Care Records’ Core Information Standard has been developed following extensive consultation with patients, carers and other citizens, health and care professionals and system vendors. It is intended to be used as a standard set of sections, under which data can be viewed in all local care records, with a clear aim that different LCRs should be interoperable.

The Core Information Standard (CIS) gives one view of the data. A data item should only appear under one section, although this is not a hard and fast rule. It does not show all the relationships of data items. In addition, users may see filtered views of the CIS depending on the setting and situational requirements e.g. views based on the PRSB Care Homes View, About Me, Local Authority Information, Digital Care and Support Plan etc. Electronic health records generally allow the user to view the data in several different ways and these are used to validate and further understand the history of the record subject – the patient/ service user. For instance, a journal or historic view may be compared with a problem orientated view or an encounter or episode orientated view. The logical data model being developed by NHS Digital and PRSB is designed to hold links between the data items and provide the context and provenance of the data. It may be used by the system designers to develop a variety of other views of the data. It is therefore expected that the Core Information Standard will not be the only view available in any shared record system.

The Core Information Standard view of the data is supplementary to the primary clinical systems. It is a way of sharing more data about a record subject and should therefore contribute to improving the quality and safety of care. The addition of this view is over and above and in no way a replacement for existing record systems.

The LCR is for a read only interface initially. This safety case is for a read only record for direct care and if it should become a read/write record and source of original data, the safety case would need to be reviewed.

2.2 Purpose of the Clinical Safety Case Report

This Clinical Safety Case Report (CSCR) for the Local Care Record Core Information Standard (CIS) addresses the requirements of DCB/ ISB 0129 V4.2 Clinical Risk Management: it’s Application in the Manufacture of Health IT Systems [Ref.3].

The full application of DCB0129 cannot be applied, as the professional standard itself is not a manufactured health IT system. However, the guidance within DCB0129 concerning clinical risk management and appropriately governed hazard assessment has been considered. Compliance to requirements from DCB0129 are summarised in section 14.