Dr Steven Moore Consultant in Emergency Medicine, Countess of Chester Hospital, UK.
Health informatics – the discipline that brings clinicians and information technologists together – has an important role to play in almost all aspects of surgical care. Its value in day case surgery lies in supporting processes to ensure clinical safety and efficiency within the framework of high caseload wherein might lie unanticipated clinical risk. In preoperative assessment, it is important for practitioners to be able to access reliable medical data such as contemporaneous medication records, allergies and comorbidities. This can be achieved through systems such as the National Summary Care Record or more bespoke local solutions such as the Cheshire Care Record, providing more detailed records concerning other care providers. New tools are being developed to facilitate effective informed consent with web based systems allowing patients more time to digest and understand treatment options. Clinical documentation, as the NHS looks to a digital future, will be subject to various internationally recognised coding systems, such as SNOMED CT, ICD-10 and OPCS v4.x Such coded data will support business and clinical intelligence systems in analysing outcomes as well as developing more accurate costing data allowing more accurate remuneration. Informatics work can also support new ways of working with particular regard to patient and equipment tracking. A number of suppliers are now offering tools to follow patients, equipment and prostheses using standardised bar codes and RFID technology. Clinical correspondence can be supported by all the above if data is collected and stored in formats that allow export into Primary care systems without the need for further data entry. The delivery of informatics supported process change requires clinical leadership – the appointment of a Chief Clinical Information Officer within each health care organisation will enable clinical engagement in new systems development from the outset, to ensure that benefits are properly realised in the clinical workplace. The Wachter Report has set out the infrastructure required to develop a cohort of clinicians in this role.
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