Electronic IT system for Clinical Letters—Defining the Requirements (v.5)
Introduction: There is a National Target to improve communications between primary and
secondary Care. The aim is to reduce the time from clinic appoint to delivery of clinic letter to
GPs down to 24hours.
There are 2 fundamental requirements to achieve this
1. Improve the speed of letter production—Use of digital dictation (Voice Recognition for
those who may want to consider it)
2. Electronic letter creation and transmission to and from GP surgeries
3 systems need to be seamlessly integrated together which will make this possible. These
systems are:
1. Digital Dictation ( with Voice Recognition as an option)
2. Document Management System (for creating, storing letters sent and received from GPs
and other hospital consultants)
3. Clinical Letter Delivery system (for electronic delivery of clinical letters into GP Systems)
A. Digital Dictation System- Specifications
1. Must integrate seamlessly with the chosen Document management system (proof of
integration with other systems must be provided)—via messaging of the clinic episode
number from the document management system
2. Must have the option of users to use Voice recognition, (if they should choose to).
3. Must be hardware independent. It should be able to work with standard off-the-shelf
hardware like Phillips Speech mike, foot-pedals etc. Trust must be able to buy its own
hardware in the competitive market
4. Should be able to integrate with Microsoft outlook with voice recognition
5. Authentication of users must be via windows log-in (extra-log-ins should not be required) or
should link with Single sign-on from Imprivata
6. Future integration with other clinical/non-clinical systems must be supported
7. Trust-wide availability of digital dictation
8. Support for CCOW (discussed in Appendix 1) standard for context integration with future
clinical systems is desirable.
9. There must be a means of dictating other letters (not just clinical letters) using digital
dictation workflow- must clarify
B. Document Management System –
a. Specifications for letter creation in clinics:
1. Clinic/dictation Worklist—Ability to create clinic worklist for dictating letters based
2.
on list of patients booked into their clinic (Integration with PAS is a must for
demographic and clinic bookings)
Multiple doctors should be able to work off a single clinic worklist. However,
when an individual starts dictation the patient should be locked (so that other
doctors are unable to take it up)
3. Synchronised status of the clinic episode with PAS (depending on what status is
supported by PAS),
a. Letter received
b. Appointment arranged
c. Attended
d. Cancelled
e. Changed/re-arranged
f. dictated
g. unverified/unauthorised
h. verified/authorised.
i. Amended
j. DNA
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
Must also be able to update status messaging to PAS
Must Integrate with chosen digital dictation
User definable abilty to create worklists which can be filtered against many criteria
a. any of the above status,
b. clinic code,
c. consultant code,
d. date-range,
e. specialty,
all messages from PAS.
Secretarial (transcription) Worklist: ability to create for typing worklist based on
author/consultant code/clinic list (worklist creation should be flexible and user
definable) with integrated voice files from digital dictation
There should be no need for them to type the name of the doctor as this should be
automatic from log-on from the dictation event.
Authorization Worklist for doctor to be able to draw up a list of all letters dictated by
them to sign off electronically. There should be ability for other doctor to
authorize/sign off letters (if the author goes on leave etc)
Once authorized/verified a copy must be retained. Robust audit trails for amending
lettes with original retained as record.
Electronic Letter Delivery to GPs: Once the letter is electronically signed off the
letter will go electronically to the GP surgery (and also a copy printed for filing in
notes)—should integrate with the Electronic delivery system chosen by the Trust
doctors should be able to create additional letters
a. additional letters for the same clinical episode
b. letters without a clinic episode
Ability to add informal notes with a clinic episode is required.
Ability to scan documents and images to the clinic episode.
Ability to send attached documents/images with the letter to GPs
Use of Soundex—Patients with same or similar sounding names will be highlighted
on the clinic worklist
b. Specification for Receiving Letters
1. Received Letter Worklist is created for all letters received under a consultant code.
This is particularly useful for internal referrals, as they will be already available on the
system.
2. Electronic letters received from GP/other clinicians/other Trusts--can also be
attached (Inbound letter delivery is vital as well)
3. Paper letters received can be attached via scanning
4. a. Ability to allocate functions for received letters: print for inclusion in notes, book
into clinic( which will be picked up by admin staff) etc—customizable
b. Ability to allocate multiple functions
5. A booking worklist for admin staff to pick up the patients that need booking into
clinic on PAS
6. Ability to attached received letters from Choose and Book service
c. Searching for a patient on the Clinical Letter/Document Management System—
a. On searching for a patient the systems should display a list all letters for that
patient
b. Should be able to filter letters based on specialty/consultant code (mapping
from PAS)
d. General Specifications for Clinical Letter/Document Management system
1. Authentication---Single sign-on with windows log-in—No further log-ins or passwords
should be required.
2. Should adopt CCOW as standard for context integration as future integration with
Ordercomms, PACS, and other systems are required (a software developers kit SDK
for CCOW is free) for patient safety.
3. Logs are created for letter access, dictation, signature and delivery. These logs need
to easily viewable. This will allow for consultants to be aware if juniors are aware of a
clinical letter pertaining to a patient.
4. Management Reports can be created for clinics by consultant code, author of letter
(doctor), typist etc.
5. Must be able to easily generate reports for times from (so as to compare with
national standards)
a. clinic attendance to digital dictation
b. DD to transcription.
c. Transcription to authorization
d. Authorization to delivery
e. etc
3. Defining the Requirements for Delivery to GPs
1. The system should get the letters delivered directly into the document management
system at the GP end (on the GP system).
2. If no document management system is present, then a robust workflow must be
provided by the system at the GP end
3. Ability to deliver other data forms—pathology and radiology reports etc
4. Ability to receive delivery and read receipts
APPENDIX -1
Adoption of CCOW as a standard within the organization is vital
a. Healthcare providers require more than 1 clinical application to fulfill a
clinical task (single clinic visit for a patient will require access to
Clinical Letters System, Ordercomms system, PACS, endoscopy
system, cardiology system etc)
b. Searching for the same patient on multiple different clinical systems-as
above has clinical risk of associating patients and reports for different
patients with the same name. This is also time consuming and
inefficient.
c. With CCOW adoption all applications will be automatically
synchronized to the same patient
d. CCOW adoption is vital for patient safety and avoiding patient mismatch in a world of multiple clinical systems
e. CCOW increases efficiency due to automatic synchronization between
applications
CCOW from Wikipedia:
“CCOW is the primary standard protocol in healthcare to facilitate a process called
"Context Management." Context Management is the process of using particular
"subjects" of interest (e.g., user, patient, clinical encounter, charge item, etc.) to
'virtually' link disparate applications so that the end-user sees them operate in a
unified, cohesive way. The CCOW standard exists to facilitate a more robust, and
near "plug-and-play" interoperability across disparate applications.
Context Management augments this by then enabling the user to identify subjects
once (e.g., a patient) and have all disparate systems into which the user is granted
access to "tune" to this patient simultaneously. As the user further identifies particular
"subjects" of interest (e.g., a particular visit), those applications containing
information about the selected subject will then automatically and seamlessly to the
user "tune" to that information as well. The end result for the user is an aggregated
view of all patient information across disparate applications.
CCOW works for both client-server and web-based applications.”
APPENDIX-2
HARDWARE REQUIREMENTS for the Project
1. Assumption is made that all clinics now have PCs within them due to PACS
deployment
2. As part of the business case the Trust will need to buy hardware like Speech mikes
(about 400-500) and foot-pedals for secretaries (about 200)
Author:
Neelam Dugar
Consultant radiologist
Clinical PACS Lead for DBH
Contributions;
Members of the Communications group at DBH
Date: 9/3/09