Clinical information standards define how a patient’s information is recorded, shared and analysed so that every clinician, care provider, NHS organisation and arms-length body (ALB) can be confident in the fidelity of the information they see to the information provided by the treating clinician.
This reduces the risk of mistakes being made between care settings, particularly for patients with multiple or complex conditions, and contributes to the improvement of patient outcomes through more efficient commissioning, better research, and more effective population and public health management and planning.
The NHS standard for clinical data records is SNOMED CT (the ‘Systematized Nomenclature of Medicine – Clinical Terms’). This standard is owned, managed and licensed by SNOMED International on behalf of its 35 country members worldwide, and maintained and distributed in the United Kingdom by NHS Digital. SNOMED CT is already a Data Coordination Board (DCB) published standard for all patient clinical information flows in the NHS. NHS Digital holds a country-member license for use of SNOMED CT in the United Kingdom.
Read more about SNOMED CT, including the requirements specification and implementation guidance here.
The NHS standard for diagnosis based statistical analysis of hospitals is ICD (the ‘International Statistical Classification of Diseases and Health-Related Problems’) to support payment for services and provide diagnosis based statistical analysis for hospitals. This standard is owned, managed and licensed by the World Health Organisation and distributed by NHS Digital in the United Kingdom. The UK has a mandatory obligation to collect and submit ICD morbidity and mortality data to the World Health Organisation for the production of international statistics and epidemiological data.
Read more about ICD here.
Medicines and medical devices should be described using the Dictionary of Medicines and Devices (dm+d).
The NHS Business Services Authority (NHSBSA), in partnership with NHS Digital, maintains dm+d. It is owned by the Department of Health and Social Care, and distributed by NHS Digital. It includes the vast majority of medicines and devices currently available, as well as those discontinued, in clinical trial, or imported along with the tariffs used in primary care. The NHS dm+d standard has influenced the design of the SNOMED International drugs model, and is strongly aligned to it. This standard brings together the UK clinical product reference source (UKCPRS), the primary care drug dictionary (PCDD), the secondary care drug dictionary (SCDD) and the medical device dictionary (MDD).
Read more about dm+d, including the requirements specification and implementation guidance here.
The current NHS standard for procedure based statistical analysis of hospitals (OPCS) will be changing.
The OPCS (Office of Population Censuses and Surveys - a forerunner of the Office of National Statistics) Classification of Interventions and Procedures is a Crown Copyright classification and published standard used to support payments and also to derive procedure based hospital statistical analysis. Currently OPCS enables interventions and surgical procedures performed on patients to be coded consistently for use in analyses. OPCS is managed, maintained and distributed by NHS Digital.
In the future OPCS will be replaced by a new DCB published standard for procedure based classifications, to complement the richness of ICD, and to provide better integration with SNOMED CT.
Read more about OPCS, including the requirements specification and implementation guidance.
The NHS standard for describing clinical tests and test results will be Unified Test List (UTL) which is an NHS-owned and developed standard, currently in development, with a first version due to be published in 2019. The UTL will describe the medical tests and results used across the NHS, with the first version covering haematology and clinical chemistry. The UTL will be managed and published by NHS Digital, and will become a DCB published standard.
Read here for a more detailed overview of the vision for NHS Clinical Information Standards.