Standards explained

Every time we interact with health or social care services, people make a record of what happens. Over a lifetime, this information forms our health and care history.

These pages explain why we need standards to record our health and care information in a consistent way so that it can be made available whenever it is needed such as when we visit our GP, attend a hospital appointment or order medication from the pharmacy. 

Why do we need information standards?

Our health and care information isn’t all recorded in a single system but in many different systems. When we go to hospital or to a GP surgery, a record of the conversation between the person and clinician is made, including any decisions and actions taken. Records are created in other settings too, such as care homes. A care and support plan agreed between the resident and care home staff is recorded in a care home record system.

The fact is that people access care in many more settings today than they ever did before, and for professionals and people themselves to have a complete picture of a person’s health and care, we need to join all these many records together so information follows the person whenever and wherever care is provided.

Recording information consistently

For information to flow between systems, it needs to be organised and recorded in the same way every time.

Agreed national standards and definitions must be used so that any computer can reproduce it with the same meaning. 

Right place, right time

When information standards are implemented by care providers and their computer system suppliers, information will be recorded consistently across different settings. 

This enables meaningful information to be made available to the right professionals at the right time, so it can be used to inform decisions about the care of the person. 

Information tailored for different needs

Not everyone we interact with needs to see all the information in all these records to advise us on what tests we might need, or diagnose a condition, or meet our care and support needs, but they might need to see some information from more than one record. 

Different types of information standards

Different types of information standards are needed for information to flow between computer systems. Below are all types of information standards.

Information record standards

Information record standards define the information needed in a person’s health and care record, such as their allergies, vaccinations and medications. They also include information that is important to the person, such as how best to communicate with them, how to help them feel at ease or details about how they like to take their medication.

PRSB standards are information record standards. 

They standardise the recording of health and care information for a given situation or use case, so that everyone has the same understanding, and the information can be shared safely between digital systems with no loss of meaning to support safe, high quality care.

Data and terminology standards

Data definitions and terminology define formats, data types and values, so that information can be consistently recorded in systems. Record standards are mapped to data and terminology standards to set out how information should be recorded.

Terminology standards include SNOMED CT, a clinical vocabulary used for capturing clinical terms for example for clinical findings, diagnoses and treatments in electronic patient records. Find out more about SNOMED CT and how it is used.

The NHS data model and data dictionary is a data standard that sets out how information should be formatted such as birth date YY-MM-DDDD and what values (or codes) can be used; for example, Ethnic Categories, A (White – British) or M (Black or Black British – Caribbean).

Technical standards and specifications

Technical standards specify how information defined in a record standards is to be held or moved between systems. 

These can be based on Fast Healthcare Interoperability Resources (FHIR) but do not need to be. NHS Digital now uses HL7’s FHIR standard in the development of technical standards as it is the global industry standard for passing healthcare data between systems.

Application Programming Interfaces (APIs) are examples of technical standards that enable communication between two systems. These can be developed using FHIR. Examples include FHIR UK Core APIs, Transfer of Care Inpatient Discharge – FHIR API (API catalogue – NHS Digital)