SHORT FORMS Purpose The purpose of this paper is

							                                    ‘SHORT FORMS’

Purpose
The purpose of this paper is to introduce the Programme Board to the subject of
short forms. Short forms are abbreviations, acronyms, initialisations and any other
form of text reduction, which may be presented to patients and NHS staffs, but
particularly clinicians and social care professionals. The attached paper sets out the
detail of the subject.

Recommendations
1.  The National Programme Board is asked to agree that there is a gap in the
    current information standards portfolio with reference to short forms.

2.   The National Programme Board is asked to agree that this gap is
     remedied by a specific NHS Short Form Information Standard.

3.   The list of official NHS short forms, their logical and dictionary definitions
     and their attributes should be designed, developed, tested and released
     through the Connecting for Health Common User Interface Project.

4.   The Information Standards Board for Health and Social Care (ISB HaSC)
     should assure and publish the NHS dictionary of short forms either
     directly or through the technology office of NHS Connecting for Health.

5.   Serious consideration should be given to highlighting one or more
     ‘Directories of Short Forms’ such that suppliers could use these
     resources to create interfaces to speed up data entry and create fun and
     innovation around data entry for example ‘extreme keying’. [ISB HaSC
     would like to stress these short forms would generate full forms which
     would be committed to the record].

6.   Should none of these recommendations meet Programme Board approval
     ISB would like to seek advice on the method by which the Board would
     like to see dangerous short forms dealt with?




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SHORT FORMS: AN INFORMATION STANDARDS BOARD FOR HEALTH
AND SOCIAL CARE PAPER FOR THE NATIONAL PROGRAMME BOARD
FOR NPfIT

Purpose
To assess the current position with regard to NHS information standards and short
forms [abbreviations, acronyms, initialisations etc].
To make recommendations to the National Programme Board for the National
Programme for IT based on that assessment.

Context
Why is this subject important?
There are four main reasons why this subject is important:

1.     Professional Competence and Effectiveness
The regulators of health and social care professions have a duty to make sure
professional standards protect the public. Professional standards do not only cover
the practice itself but also how it is recorded and communicated. The use of short
forms [or not] in records and communication are part of professional competence and
are highlighted in the practice guidelines from regulators.

2.       Patient Safety
Another clinician may misinterpret short forms recorded by one clinician and the
resultant action could damage a patient. Such occurrences have been identified in
the literature, insurance enterprises and within the patient safety community. Many of
these organisations advise against the use of short forms from a patient safety
perspective

3.      Technical [computer] Design Constraints
When computer systems are originally designed there is typically a clear requirement
that leads to specific field lengths being decided on. Over time the drivers for these
field lengths do change and the systems begin to place constraints on the new
requirements for recording and display of data. This has forced clinicians to adopt
short forms and truncations to fit into existing system constraints. The determination
of short form standards has a profound effect on system design but equally design
can create short forms when the field length is not sufficient for the characters
needing representation

4.      Clinical Efficiency
In the world of health and social care whether we like it or not the use of short forms
abound for example the NHS, SHA’s, PCT’s etc. It is wise to consider why because
clearly there are some behavioural advantages to using short forms otherwise they
would not be used! One use is clearly to exclude people who cannot recognise the
short form and to increase the ‘power’ of the user by the use of this special language
or jargon. This is clearly an unacceptable use case for the care of citizens in a team
based care environment in which the patient is a partner. A far more pragmatic use
case is to increase the efficiency of creating records. For example a clinician will
write ‘ERCP’ instead of Endoscopic Retrograde Cholangio- Pancreatography’ and
one can see why! This driver will exist in the computerised environment as much as it
does in the paper environment however there is no reason why in the computer
environment that we should not separate the data input tools and the data storage
and presentation formats. Short forms have a behavioural advantage when
completing records in terms of reducing the time spent in creation



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What is the current situation?

1.      Professional Competence and Effectiveness
It is worth remembering that: “Under the Public Record Act all NHS employees have
a degree of responsibility for any records that they create or use. Thus any records
created by an employee of the NHS are public records and may be subject to both
legal and professional obligations”. 1

Quoting from the recent ISB publication “Health Record and Communication Practice
Standards for Team Based Care” (Dec 2004) - a consensus based list of minimum
standards for health care professions to adhere to:

      “3.2 Communication of Information: You must ensure that the information you
      give to patients/clients is presented in a way they can understand.”

This an agreed statement from a range of professional regulatory bodies, but some
do further qualify this in their own professional guidance to practitioners, e.g. the
Nursing and Midwifery Council:

Patient and client records should not “include short forms, jargon, meaningless
phrases, irrelevant speculation and offensive subjective statements” 2

Whilst others do not go into detail, e.g General Social Care Council of Great Britain:

      “Communicating in an appropriate, open, accurate and straightforward way”…
      “Maintaining clear and accurate records as required by procedures established
      for your work” 3

Professional body advice is less dogmatic for example the section on data entry in
the Good Practice Guidelines for General Practice Electronic Patient Records [2005]
states:

      ‘Data entry in paper records is relatively straightforward and usually consists of
      unstructured or semi-structured narrative, abbreviations and perhaps a
      diagram’

In addition for many the de-facto standard for prescribing is the British National
Formulary, which is collaboration between a regulator [the Royal Pharmaceutical
Society of Great Britain] and a trade union [the British Medical Association]. Its
guidance on prescription writing on one hand supports the avoidance of short forms
but in other parts actively enables them as shown below:

      ‘In general, titles of drugs and preparations should be written in full. Unofficial
      abbreviations should not be used as they may be misinterpreted’

      ‘Quantities of 1 gram or more should be written as 1g etc’
      ‘Although directions should preferably be in English without abbreviation some
      Latin abbreviations are used (for details see back cover of British National
      Formulary)’


1
  Records Management NHS Code of Practice (DH, 30 June 2005)
2
  Guidelines for records and record keeping p7 (NMC, Jan 2005)
3
  Codes of Practice for General Social Care Workers and Employers (GSCC, 2002)


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2.      Patient Safety
Within the Department of Health report “An Organisation with a Memory” a fatal
consequence of acronym use /misuse is given, “An organisational accident
chronology in health care - death of a patient from maladministration of an anti-
cancer drug”. One of the events leading to the failure was a junior doctor abbreviating
the route of administration instead of using the full term. 4

The Medical Protection Society also highlights patient safety issues with
abbreviations:

      ‘Using abbreviations saves time, but can lead to problems. It is important that
      abbreviations are unambiguous and universally understandable – do not rely on
      the context to give the meaning. This is particularly true in general practice,
      where a patient may have unrelated conditions with shared abbreviations. For
      example, PID can mean pelvic inflammatory disease or prolapsed intervertebral
      disc.’

[Since sharing this paper two more examples of this initialisation have come to the
authors attention to a microbiologist this could mean Protist Image Data whilst in the
laboratories generally it might refer to Proportional-Integral-Derivative used for
controlling equipment unless, that is, they have picked up on PRINCE2 in which case
it means Project Initiation Document!]

Internationally short forms are known to be a serious risk to patient safety. The most
advanced work in this are was published on 3rd November 2003 from the United
States Joint Commission on Accreditation of Healthcare Organizations
(JCAHO). JCAHO has developed, and approved, a list of dangerous abbreviations,
acronyms and symbols. Beginning January 1, 2004, these dangerous abbreviations,
acronyms and symbols must be included on each accredited organization's "Do not
use" list. JCAHO accredited organizations must achieve 100 percent compliance by
the end of 2004. JCAHO has stated that these dangerous abbreviations, acronyms
and symbols should be eliminated from all heath care documentation (which would
include the electronic health care record).

      ‘Certain abbreviations are unacceptable, such as coded expressions of
      sarcasm. Humorous abbreviations to describe a patient’s condition have no
      place in modern medicine.’
                              GP Registrar, Issue 6, Spring 2004 - Medical Records


3.      Technical [computer] Design Constraints
There are two separate perspectives on this issue that need to be considered. The
first concerns the design of the application and has two sub-component parts
namely:

•       The field length is too short for data entry i.e. it does not enable the full clinical
        expression to be entered or;
•       Even worse the field length for presentation is too short i.e. it does not enable
        the full record entry to be displayed during routine clinical use.
In the first sub-component issue either the application needs modification or there
should be a standard way a short form can be used. In the second sub-component
issue one has an unacceptable technical and clinical situation, which has to be

4
 An Organisation with a Memory – Report of an expert group on learning from adverse events in the
NHS, chaired by the Chief Medical Officer (DH, 2000)


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immediately remedied. These ‘system generated short forms’ may occur at the point
of data entry and/or at the point of data viewing i.e. presentation. These short forms
will be totally unexpected by the clinician and generally unknown to the service. The
prevalence of these short forms is unknown and there is no method by which they
will be highlighted until there is an adverse event or events. This is not a systemically
desirable feature for computer applications in the NHS.

The second perspective is when the technical experts act as passive conduits to the
NHS and build into their systems, in good faith, short forms, which do not have a
formal universal acceptance or official support. At present technical system builders
have nowhere to go for reference on short form information standards.

4.      Clinical Efficiency
As already stated short forms abound in health and social care practice at
http://www.pharma-lexicon.com is a dictionary of over 200,000 medical,
pharmaceutical, biomedical, and healthcare acronyms and abbreviations! This
behaviour will not stop by the simple introduction of computers into the NHS. Indeed
the ability to use short forms for data entry may be an extremely attractive attribute of
a computer application that promotes health and social care professional uptake.
What is not however acceptable is that the use of short forms for finding concepts to
enter into an electronic record is synonymous with the entry of those short forms into
the database and being the presentation format to professionals processing data in
or from that record. It is clear what is entered into the record and what is presented to
the next health or social care professional or indeed the patient them self is an
unambiguous term. If then short forms are too be allowed for data entry what must be
presented to the health and social care professional at the user interface is one or
more unambiguous data items to which that short form refers and it is the fully
expressed unambiguous concept that is stored and subsequently presented. For
example PID data entry short form would produce an on screen choice for the user of
pelvic inflammatory disease or prolapsed intervertebral disc. The chosen one of
these unambiguous terms would be stored within the system and displayed on
screen. There is ONE EXCEPTION to this rule which is when the short form is an
accepted national information standard and published as such.

Short forms for data entry would NOT be part of any information standard, only short
forms which are acceptable for display should be within the standard as learning
hundreds and thousands of short forms is neither systemically desirable or practically
feasible and as they will never be displayed they should not be part of any standard.
The mechanism whereby short forms get proposed and tested then becomes the
major issue, given short forms by definition will be presented to the user throughout
the NHS they will be part of the NHS Connecting for Health Common User Interface.

Suggested ISB Conclusions
•   The current position of the NHS and its partners on the management of short
    forms is inconsistent and lacking in focus.
•   There is sound evidence that short forms are positively discouraged by
    Regulators of the professions.
•   There are practical empiric examples that short forms are explicitly accepted by
    professional and authoritative bodies.
•   Short forms should never be used for sarcasm and pseudo-humorous
    expressions to describe a patients condition.
•   The evidence implies there should be a point of reference for short forms that
    determine whether a short form is ‘official’ or ‘universally accepted’ in the NHS.




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•    There is no point of reference for acceptable or official health and social care
     short forms i.e. there is no information standard.
•    Limitations in functionality of computer applications have the potential to create
     ‘system generated short’ forms. The prevalence of these is unknown.
•    System generated short forms are a source of concern and should be avoided.
     Any system generated short forms should be reported and discussed with the
     NHS Connecting for Health Safety Committee with the intention of their removal
     as soon as possible.
•    Clinical and social concepts presented to clinicians in a computer environment
     for storage and presentation must be unambiguous.
•    Short forms which are presented to health and social care professionals and
     patients accessing and using record data should be stored as the short form
     and be part of any formal NHS Short Form Standard.
•    Short forms which are intended to become NHS Information Standards should
     be designed, developed, tested and implemented as part of a mainstream
     programme of work.

Recommended Actions
1.  The National Programme Board is asked to agree that there is a gap in the
    current information standards portfolio with reference to short forms.
2.  The National Programme Board is asked to agree that this gap is
    remedied by a specific NHS Short Form Information Standard.
3.  The list of official NHS short forms, their data and dictionary definitions
    and their attributes should be designed, developed, tested and released
    through the Connecting for Health Common User Interface Project.
4.  The Information Standards Board for Health and Social Care should
    assure and publish the NHS dictionary of short forms either directly or
    through the technology office of NHS Connecting for Health.
5.  Serious consideration should be given to highlighting one or more
    ‘Directories of Short Forms’ that suppliers could use to speed up data
    entry and create fun and innovation around data entry for example
    ‘extreme keying’.




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