Professional standards for digital care records are a fundamental element of delivering successful IT enabled care and interoperability between services. In 2013, the Academy of Medical Royal Colleges (AoMRC) published Standards for the Clinical Structure and Content of Patient Records in an effort to define a set of generic clinical headings.
Adoption of these standards were supported via the NHS Standard Contract, and early examples of AoMRC clinical headings usage for discharges can be found in the Papworth case study and the Oxleas case study.
The Professional Record Standards Body (PRSB) has developed and broadened the AoMRC work and have now produced many individual standards that reflect current professional practice. The PRSB work includes new and changed structured content for inpatient and daycase discharge, emergency care discharge and outpatient letters.
This has been achieved by working closely with its membership which incorporates clinicians, professional bodies, patient/carer groups and vendors. The PRSB standards reflect what information is essential to share to provide high-quality care efficiently that is well-coordinated and meets an individual’s needs.
NHS Digital have utilised the information models produced by the PRSB, at a fixed point, to create the Transfer of Care technical specifications. Subsequent adjustment and publication of the PRSB standards as part of their maintenance activities would not automatically drive a change to the APIs.
The merits and drawbacks of any API adjustment would need to be considered as part of a benefits analysis embracing changes to all layers. The timing of any evaluation is most likely after much wider adoption of the APIs.