Electronic patient record system within Cardiff and Vale University Health Board

Provision of an electronic patient record system to record information about a range of patients with different diseases linked to clinical services and research together with diagnostic and outcome information.

Record patient encounters, both face to face and virtual, that are not currently captured on PMS (e.g. when patients telephone into the department asking for advice, referrals received) – to include outcomes, durations and individuals involved.

Generate proformas for various clinics so that patient entries can be made efficiently and admin time minimised. These proformas to be easily converted into letter format to send to GP, referrers, patient etc.

The system needs to be accessible from any welsh NHS computer. Information needs to be shared between professionals of teams in different hospital sites and the system needs to include an internal messaging system and ability to set actions.

Integration requirements:

• NHS Wales Active Directory (NADEX) for user management and login
• Cardiff and Vale PAS (PMS)
• Aneurin Bevan PAS (WelshPAS)
• NHS Wales enterprise master patient index (eMPI)
• Document repositories (Cardiff and Vale, NHS Wales WCRS – WCP documents)
• Links to open imaging in local PACS

Outcome measures and data:

• Graphical charting of all outcomes over time
• Addenbrookes’ cognitive assessment
• EDSS, EDSS-FS
• Weight, height
• Lung functions including blood gases and spirometry
• ICARS and SARA ataxia rating scales
• Berg balance scale
• Bedside swallow assessment
• MND structured symptoms recording
• Hospital anxiety and depression score
• Mini-mental state examination score
• Haemophilia joint health score
• Motor-UPDRS
• Walking status
• Neurology higher training curriculum map
• MS relapse and disease course form
• SOAP
• ALSFRS-R
• EQ5D
• RODS for CIDP
• 9 hole PEG
• Timed walk assessment
• Snellen visual acuity
• LogMAR visual acuity
• Generic procedure form (SNOMED-CT procedures)
• Botulinum toxin injection form; outcome form
• ADRT
• Seizure frequence form
• Symbol digit modality test
• Valproate annual risk assessment form
• Rehabilitation assessment form
• MND phenotype form
• Ambulation assessment form
• Use of services questionnaire
• MSIS-29 form
• Ishihara results
• Smoking history
• Routine observations (p/BP etc) form
• Presenting complaints/problems form
• MS DMT assessment form
• Hoehn and Yahr form
• Non-motor symptoms in PD form
• MOCA form
• Core patient data - from local PAS and national systems
• Recording of diagnoses/co-morbidities including problems via SNOMED CT.
• Recording of drug/medication usage over time using UK dm+d
• Recording of diagnostic results, including synoptic reporting of MRI scans of brain for different disease states (e.g. structured reports of brain for MS)

Ability to pull reports – e.g. for audit purposes for job planning for clinicians and to inform and evolve service provision. Automated wizard to fetch lists of patients for a specific clinic.

Must have access to existing PatientCare records.

Online consent forms, with electronic consent-form builder with versioning and lifecycle management. Upload of scanned signed consent forms to meet regulatory standards.

Application monitoring, servicing and maintenance (12 hours per month)

a) Review of application log files, identification of recurrent system or application problems and fixes

b) Monitoring of backup reports

c) Monitoring of the secure messaging service for feature requests and queries by end-users

d) Application housekeeping tasks including database checks

Regular software upgrades, normally more than one per month (4-6 hours per month) comprising:

a) Fixes for any identified problems or software bugs

b) Implementation of new features (duration dependent on features) Additional information: This Pin will run to the 18th March. If no interest is shown a contract will be awarded to the current supplier