READ codes are used in primary care and feature as one of the standards that are applicable to the NHS interoperability framework. Before discussing READ codes in more detail, i’ll just explain what the interoperability framework means.
Patient records are central to the delivery of healthcare and serve a number of functions including the recording of clinical assessments and interventions. Aggregated data is also utilised at a local and national level to inform commissioning.
Electronic Patient Records
The digitisation of patient records offers a number of advantages over paper based records. These advantages include automated backup of records, reduced use of physical storage space (since paper based notes are switched to servers), off-site access to records using mobile devices and the potential to develop analytical clinical support tools which use computers to process clinical data to help improve clinical decisions. Not all healthcare services have electronic patient records but most providers are moving in this direction.
Getting Electronic Patient Records to Talk to Each Other
When patients move between healthcare providers – for instance between primary care and the hospital – they may find that one provider does not have information that the other provider has. There are many providers and many electronic paper record systems. For two systems to talk to each other they have to solve a number of problems. When these problems are solved a patient can move between providers and healthcare information can be accessed by the different providers. A key solution to this problem of health information gaps is the Health Information Exchange (HIE).
The Health Information Exchange
There are many definitions of what a Health Information Exchange is. (Hersh et al, 2015) define a HIE as follows:
‘Health information exchange (HIE), the electronic sharing of clinical information across the boundaries of health care organizations’
Whilst this definition is simple, the process of sharing clinical information between healthcare organisations is technically complex and encompasses a range of software, hardware and governance issues. The process of helping systems to talk to each other is helped by the development of standards. A set of standards is outlined in the NHS interoperability framework.
The Interoperability Framework
A digital copy of the Interoperability Handbook can be found at the NHS England website (NHS England, 2017). The handbook explains how an interoperability framework can support an interoperability strategy. The interoperability framework has three layers – a governance layer, an exchange layer and an interpretation layer.
The Standards Applicable to the Interoperability Framework
Appendix A in the Interoperability Handbook shows how various standards map onto the Interoperability Framework (NHS England, 2017).
The READ codes
Amongst the standards that map onto the Interoperability Framework are the READ codes. The NHS Digital website details how the READ codes are divided into READ version 2 and READ version 3. READ version 3 is also referred to as CTV3. The NHS Digital website describes the READ codes as a ‘coded thesaurus of clinical terms’. The READ codes are being retired in 2018 according to the site and will be replaced by SNOMED CT® which I have covered elsewhere.
https://digital.nhs.uk/article/1104/Read-Codes, accessed 8.4.17
Links to Other Posts in the Health Information Exchange Series
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