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On the eve of the Institute’s national conference for health informatics - HC2012 (2/3 May), the two organisations are calling for hospital doctors not only to take on specific leadership roles such as Chief Clinical Information Officers, but also to take the lead in improving healthcare records in their own areas of practice to ensure that patients benefit from the highest standards of record-keeping.

Professor John Williams, director of the RCP’s Health Informatics Unit (HIU), said:

Accurate information derived from data captured at the point of care is fundamentally important to ensure high quality, safe management of individual patients and evidence-based development and management of clinical services. Clinical leadership is essential to ensure that the processes of data capture in patient records are fit for purpose and the aggregate information derived is relevant, valid and useful to patients, professionals and the NHS.

Poor clinical record keeping leads to mistakes in communication and subsequent patient care, particularly in the key areas of admission, handover and discharge.  Implementing the clinical records standards, produced by the RCP and agreed by the Academy of Medical Royal Colleges, would reduce errors and could be incorporated into clinical professional training in a structured way.

Implementation could be supported by three tiers of leadership:

• a Professional Record Standards Development Body (PRSDB) that would lead the development and professional assurance of clinical record standards across all specialties and clinical disciplines; the standards will provide the foundation upon which to base the collection, storage, communication, aggregation and reuse of structured clinical information across organisational boundaries throughout health and social care
• chief clinical information officer posts in every hospital to lead on implementation of national standards
• every healthcare professional to ensure the standards are implemented in their own practice, as they would for evidence-based clinical guidelines and care pathways.

Professor John Williams, director and Professor Iain Carpenter, deputy director of the RCP’s Health Informatics Unit, will be speaking and presenting fringe sessions at HC2012 where they will expand on these themes and discuss both the generic records standards and the recent report of the Joint Working Group on the establishment of a Professional Record Standards Development Body (PRSDB).

Professor Iain Carpenter, deputy director of the RCP’s Health Informatics Unit (HIU), said:

It’s time for healthcare professionals to implement medical records standards in the same way they implement evidence-based clinical guidelines – by improving health records we can improve patient care.

Mike Sinclair, BCS Health vice-chair for professionalism, said:

These initiatives powerfully reinforce and strengthen the increasing importance of clinicians, and the information that they routinely collect and use, in the quality, effectiveness and safety of care across the NHS. The use of information and information systems must now become an even more fundamental and integral part of the professional development and conduct of clinicians across all health and social care services and sectors.