1. Professional terminology: unleashing the potential of digital care records
Mandy Sainty, Research and Development Manager, Royal College of Occupational Therapists
Louise Middlewood, Occupational Therapist, First Community Health and Care
19th June 2017

2. Seminar content Setting the scene Digital – is it meaningful?
Professional terminology: a pilot project
The First Community Health and Care Experience
Key messages
Discussion: your thoughts….

3. Seminar objectives
To increase understanding of professional terminology within electronic records, its contribution to service user care, and its potential to contribute to demonstrating the value of occupational therapy.
To gain insights into how occupational therapists can engage with, and contribute to, the digital record agenda.

4. UK eHealth: four policies
Shared vision:
Interoperability of systems
Uptake
Summary records
Data protection & security
Research and innovation
eHealth Strategy
eHealth and Care Strategy
Personalised Health and Care 2020
Informed Health and Care
England (2014) Personalised Health and Care Using data and technology to transform outcomes for patients and citizens. A framework for action.
Northern Ireland eHealth and Care Strategy for Northern Ireland.
Scotland (2015) eHealth Strategy
Wales (2015) Informed Health and Care. A digital health and social care strategy for Wales.

5. Getting the full picture
An integrated health and social care system cannot provide good care without a joined-up, coherent, record keeping system. Digital care records offer a solution and are a reality... (PRSB 2016)

6. Making digital meaningful
’Louise died in a Bristol A and E in plain view of everyone because the information for her end of life care plan wasn’t at hand to me, or the paramedics, or her GP or consultant. I live every day with the guilt of not helping her to die a good death for lack of that information.’
Roberta Lovick Mother of Louise, 28

7. Why keep records?
HCPC and Professional body professional standards and codes of ethics and conduct
Primary rationale: to facilitate the care and support of a service user
Secondary rationale: to provide information and data about the nature of service provision

8. Digital care records
Transition is in place from paper to digital care or electronic care records
There are many drivers, but the pace of implementation will be influenced by local priorities and resources
The digital environment in which occupational therapists are working can vary significantly

9. Professional terminology
Is needed to:
Facilitate the use of both coded common terms and free text detail
Adequately reflect the nature of the practitioner’s contribution to the service user’s health and social care
Reflect in records the nature of occupational therapy with service users

10. Coded language SNOMED CT is an example of a coded language
In England, SNOMED CT has been mandated as the single clinical terminology to support direct management of care in the NHS (Great Britain. National Information Board 2014)
Visit to find out more

11. Occupational therapy terminology
Subsets:
Assessment
Problems
Findings
Goals
Interventions

12. RCOT Pilot Project
To establish whether the occupational therapy subsets can be deployed live effectively
To identify any changes required to ensure the subsets are fit for purpose and have sufficient stability
Volunteers sought by the Royal College of Occupational Therapists in 2016

13. Subset evaluation criteria
Frequency of use of key terms
Relevance of terms available
Benefits for practitioners
Benefits for reporting on service activity

14. Vision: ‘Rejuvenating the wellbeing of our community’
Who we are
Vision: ‘Rejuvenating the wellbeing of our community’ 14

15. Community Neuro Rehabilitation Team
Inclusion criteria:
East Surrey GPs
Aged over 18 years
Confirmed neurological diagnosis
Experiencing functional difficulties as a result of their condition
Medically stable with clear rehabilitation goals or management needs

16. Community Neuro Rehabilitation Team
Commissioned to provide up to 12 weeks intervention
Aim of service: to maximise independence and well-being, promote self management and minimise long-term disability
Provide a patient centred, goal led, multi- disciplinary team approach although uni- disciplinary intervention available

17. Our digital care records
Change of patient record system (EMIS)
Mobile working
Paper light
Tailoring the system to suit
Maximising potential

18. SNOMED: the potential Data capture Data analysis Reporting Internally
Externally

19. Putting theory into practice

20. Progressing the pilot: the barriers
Limited code access
Priority for system provider with GP implementation of SNOMED CT
Reduced priority for commissioners

21. What does the future hold?

22. Key messages
Review what occupational therapy coded terms are available to you
Engage with your IT / information support team
Projections and planning
Commissioning drivers: individual KPIs and service quality

23. Act now…
… and unlock the potential of digital records for your service users and the profession

24. Time for your thoughts...

25. Bibliography
College of Occupational Therapists (2015) Code of ethics and professional conduct. London: COT.
College of Occupational Therapists (2017) Professional standards for occupational therapy practice. London: COT.
Health and Care Professions Council (2016) Standards of conduct, performance and ethics. London: HCPC.
College of Occupational Therapists (2015) Managing information: implementation plan London: COT.
Great Britain. National Information Board (2014) Personalised health and care 2020: using data and technology to transform outcomes for patients and citizens: a framework for action. Leeds: National Information Board.  
Professional Record Standards Body (2016) Clinical and professional leadership in adoption of standards and the digital arena. London: PRSB.
Contact: