Medical records and record-keeping standards.

The structure of medical records becomes ever more critical with the advent of electronic records. The Health Informatics Unit (HIU) of the Royal College of Physicians has two work streams in this area. The Records Standards programme is developing generic standards for all entries into medical notes and standards for the content of admission, handover and discharge records. The Information Laboratory (iLab) focuses on hospital episode statistics and their use for monitoring clinician performance. Clinician endorsement of the work is achieved through extensive consultations. Generic medical record-keeping standards are now available.

Can hospital episode statistics support appraisal and revalidation? Randomised study of physician attitudes.

Hospital episode statistics were originally designed to monitor activity and allocate resources in the NHS. Recently their uses have widened to include analysis of individuals' activity, to inform appraisal and revalidation, and monitor performance. This study investigated physician attitudes to the validity and usefulness of these data for such purposes, and the effect of supporting individuals in data interpretation. A randomised study was conducted with consultant physicians in England, Wales and Scotland. The intervention group was supported by a clinician and an information analyst in obtaining and analysing their own data. The control group was unsupported. Attitudes to the data and confidence in their ability to reflect clinical practice were examined before and after the intervention. It was concluded that hospital episode statistics are not presently fit for monitoring the performance of individual physicians. A more comprehensive description of activity is required for these purposes. Improvements in the quality of existing data through clinical engagement at a local level, however, are possible.

The RCP Information Laboratory (iLab): breaking the cycle of poor data quality.

A review of data quality in the NHS by the Audit Commission cited a lack of clinician involvement in the validation and use of centrally held activity data as one of the key issues to resolve. The perception that hospital episode statistics cannot support the needs of the individual clinician results in mistrust and disinterest. This in turn leads to under-development of such data from a clinical perspective, and the cycle continues. The RCP Information Laboratory (iLab) aims to address this problem by accessing, analysing and presenting information from these central repositories concerning the activity of visiting individual consultant physicians. With support from iLab staff--an information analyst and a clinician--local data quality issues are highlighted and local solutions sought. The information obtained can be used as an objective measure of activity to support the processes of appraisal and revalidation.