Clinicians must improve the quality and value of their hospital data, a report says.
The report, by the NHS Information Centre, urges consultants to take responsibility for their clinical data, both in the way that notes are recorded and the accuracy with which patient data is coded.
A lack of clinical engagement over the accuracy of hospital data is a major concern for royal medical colleges and directors of trusts, it says.
Hospital Episode Statistics: improving the quality and value of hospital data accuses doctors of having little knowledge of the large Secondary Uses Service database into which trusts submit data from their Patient Administration Systems, or of the Hospital Episode Statistics database which stores data for monitoring the quality of healthcare and shows health trends.
It says: “Since the first national set of data was collected in 1989 there has been considerable evidence that the majority of clinicians have not engaged in the process.
“They have not been concerned about the accuracy of the data, the many ways that it is used, nor have they used the data to support their own clinical practice or service developments.”
The report, which is endorsed by the Academy of Medical Royal Colleges, claims that improvements in the collection and use of hospital data by clinicians would improve patient outcomes and inform patient choice.
It must be “urgently addressed” because national data is increasingly being used to assess the quality of clinical services and will be available in a patient-anonymised format on pubic websites such as NHS Choices.
“Metrics and indicators of clinical quality will increasingly be published for individual, named consultants, in line with government policies on patient choice of consultant-led teams and ‘transparency’ of detailed data on public services,” it says.
Appraisal and revalidation will also require statistical evidence of good clinical practice, it adds.
The report calls on trusts and colleges to discuss how data input and use can be improved.
“The weaknesses in the current processes for collection of HES data cannot be fully rectified without radical change,” it says.
“These weaknesses include the limitations of the data collected from a clinical perspective, the use of statistical classifications for coding rather than a clinical terminology, and the very fact that a parallel process is used to extract data from non-standardised, largely unstructured paper records.”
The AMRC is calling for a review of this process and a migration towards the collection of data directly from standardised, patient-focused electronic records in which the data items are recorded at the point of care.
Consultants are being urged to teach juniors good note keeping and the importance of clinical coding.
Read the full report.
