In pathology, different providers and vendors use a variety of coding systems, which are all useful and safe in their own settings. However, it can be hard to consolidate all the information from different laboratories.

We know that diagnostic information is vital for supporting good healthcare outcomes and that’s why we are working with NHS Digital to standardise pathology coding. This will help to make accurate and comparable information about test results accessible for those who need it. In 2019/20 we hope to build on the good foundations put in place in the last year.

People are increasingly turning to app and online symptom checkers for advice about common conditions, minor ailments and injuries, without necessarily needing to see a doctor. Next year the PRSB strategy includes plans to develop an accreditation service to provide formal approval to accredited suppliers. PRSB is exploring accrediting an online service that offers pre-primary care advice, as part of our expansion into accreditation services. This will be done following consultation with members and stakeholders, as well as formal endorsement by relevant members.

Classification codes are used extensively within hospitals for clinical audits, health surveillance, service development, performance measures, contracting or research. OPCS-4 and ICD-10 are two examples of clinical classifications standards. OPCS-4 is used to classify interventions and surgical procedures, ICD-10 is used to classify diseases and other health conditions for morbidity and mortality statistics. NHS Digital has commissioned the Professional Record Standards Body (PRSB) to carry out an investigation into how they are used elsewhere, gaps and potential wider uses.

The way medical diagnoses and GP problem lists are recorded and the culture for recording information in primary and secondary care are different. In 2019-20 PRSB, in collaboration with the Royal College of Physicians, will complete guidance for the recording of medical diagnoses and problem lists in a structured form in patient records that enables standardisation and uniformity across primary and secondary care.

The guidance will define exactly what is meant by a problem, symptom and diagnosis. It will also clarify how all of information will be recorded. There is need for a wider programme of work on diagnosis recording beyond this project, e.g. defining the attributes of diagnosis and the educational support required to implement guidance on recording diagnosis. This report identifies the further work needed.

In order to provide a fully digitised GP service, Lloyd George records in general practice should be scanned and stored digitally. Although these patient records are no longer updated, they are needed to understand patients’ medical histories and provide patients with online access to their medical information.

The NHS has reviewed the process and has recommended a full digitisation of Lloyd George records with a complete upload to general practice clinical systems. PRSB will be consulting relevant professionals, patients and the public about the options and NECS’ recommended process, with a view to assuring it.

At the moment hospitals must decide when it’s safe to discharge a patient and handover care to other services. Part of that decision-making process requires hospital staff to determine whether a care and support assessment is required before the patient leaves hospital care, so that appropriate social care can be put in place to support them.

If hospital staff believe an assessment is required, they must notify the local authority’s social services team. The PRSB has been asked to assure NHS Digital standards for assessment, discharge and withdrawal notices, so that the information can be shared safely and securely.

The single most important factor in successful digital change is engaging the end users. In 2019-20 PRSB in collaboration with the Academy of Medical Royal Colleges is launching the Doctors Download consultation with the medical profession to drive that change. PRSB and the Academy will be engaging doctors in an online conversation about their daily experience and aspirations for using digital systems to do their jobs well.

The consultation

We will be asking questions about the benefit and challenges that doctors currently have with the different technology and systems they are using, how systems are currently affecting them, and what doctors hope to see change in the future. Commissioned by Health Education England, the body which is responsible for training doctors and conducted by Clever Together, the study will give UK doctors a say in the way digital healthcare can have the greatest impact.