‘Consultation on Information Requirements of Community Nurses
and Health Visitors for a Primary Care EPR’ – Interim Stage Report.
Executive Summary February 2003
This paper summarises the Interim Stage Report on the ‘Consultation on Information
Requirements of Community Nurses and Health Visitors for a Primary Care EPR’.
The electronic Community Health Information Project (eCHIP) channelled this
consultation, through the Community Nursing Network (CNN)1 a Scottish Reference
group for Community Nursing IM&T. A full copy of the report can be obtained
through the eCHIP Project Manager2
The Response
Responses were returned from 12 CNNlink people representing 12 out of 17
PCT/Island Boards (71%). Additional individual responses were also returned. In total
279 community nurses were involved in this round of the consultation. The response
process findings are helpful in starting to identify issues that support and restrict
‘grass roots’ access to, and involvement in, national projects. Further work on this
theme will be taken forward within the fifth stream of eCHIP: Supporting the
infrastructure: underpinning people issues.
Information requirements
There is general consensus that health record information can be grouped at three
levels:
 Core information,
 Summary information,
 Specialist information, with
management information being a selective anonymised by-product aggregation of
data from the other groups.
‘Specialist information’ within operational clinical systems and accessed by HCPs of
the same discipline or within the same “functional” multidisciplinary team
‘Summary information’ should provide other HCPs with enough detail to allow
contact to be made with named person for further information to be shared.
‘Core information’ is seen as being basic to clinical practice and is required by all
HCPs as well as social care colleagues
Some 83% of responses said that current ‘management information ‘does not
accurately reflect clinical practice and we should be striving towards this.
A number of responses highlighted the link between management information and
clinical governance.
The area of highest priority is around access to information from other systems that
enables community nurses to deliver effective clinical care and reduce duplication of
work.
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All respondents (100%) felt the concept of care programme and evidence based
planned care is valid for ‘Summary Information’ although 75% said some care is
‘one off’ or isn’t ‘neatly’ a care programme. Further work on clarification of concepts,
terms and definitions will be done within Stage Two.
EPR Core Dataset
The criteria for a core dataset for the purpose of electronic patient records are:
 It supports direct patient care
 It supports continuity of care
 It supports communications processes for the patient journey
This however does not mean that all HCPs have to always collect this data. Some
could be maintained by Board/Trust level systems integrating with local systems.
Could be maintained at Board/PCT level
CHI/patient identifier
Surname
Forename
Date of Birth
Sex
Address
Postcode
Telephone
Ethnicity
GP Practice No
GP Practice Postcode
Allergies (optional if none)
Care Programme
Care Programme Start date
Key worker/case holder discipline
Significant factors socio-environmental(optional if
none)
Significant factors medical(optional if none)
Care Programme end date(only at end of specific care)
Discharge reason/outcome(only at end of specific care)
Encounter/contact date
Type of encounter/contact
HCP making encounter/contact
Location of encounter/contact
Interventions
Problem/health issue/symptom (Optional if not explicit target
Alerts (optional if none)
Care Programme)
Table 4: Proposed EPR Core Dataset (this does not mean that all HCPs have to always collect this data
some can be maintained by Board/Trust level systems integrating with local systems)
Management Core Dataset
The criteria for a core dataset for the purpose of management, service planning,
monitoring and development are:
 It is truly a by-product of a clinical dataset
 It validly reflects patient care
 It reflects care planned and delivered by competent professionals
 It focuses on professional best practice standards rather than on ‘tasks’
 It supports professionally validated outcome measures
 Must be appropriately anonymised
 Must contribute to the knowledge base on health service delivery and
health improvement.
Date of Birth
Sex
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Postcode
GP Practice No
Care Programme
Start date
End date
Discharge reason/outcome
Key worker Discipline
Significant factors socio-environmental
Significant factors medical
Table 5: Management core dataset
General Issues
Many questions were raised in relation to:

Data protection, patient confidentiality and consent.

Sharing information and access controls

Lack of integration of systems and much duplication of work and data
entry

What to do with the paper records

Management information has to be anonymous and there was general
concern that patients may refuse to give information because of fear
about ‘government agencies’

Mobile technology- needed most in patient’s home
Related findings
Some issues were raised in this consultation and although there is some overlap here,
these will be covered within other streams of PTI.
Next steps
Stage two
Stage two integrates with the project plan of eCHIP Stream 3: Practice Team
Information (PTI) and aligns the the above datasets with the PTI dataset for a further
short round of consultation. The Clinical data development team within ISD will
facilitate clarification and definition of concepts within the datasets. This work links
with UK wide and international informatics work.
Stage two aims to measure what functionality existing clinical information systems
provide and identify with three levels priorities for extended functionality. The
findings from this will inform an analysis of the impact of introducing standardised
dataset and information standards to support clinical practice.
1
2
www.cnnet.org.uk
Kathy.Dallest@scotland.gsi.gov.uk tel:0131-244-2279
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