The Adult Social Care Record (MODS) for adult social care aims to provide interoperable building blocks that can be brought together to form a digital social care record. Although each “building block” can be brought together in a specific view and/or collected as part of a specific form, the “building blocks” should be stored against the overarching conceptual model. For example, a need is one of the building blocks within a digital social care record, and is directly associated with a person - however, a need could be observed whilst completing an assessment form or within the care plan or during the provision of care activities.
Current release
The current release of the Minimum Operational Dataset (MODS) is 0.1.0 and is in beta.
MODS 0.1.0 has been developed following a discovery phase of work and the subsequent development of a MODS alpha. The focus of the beta and the next phase of work is to make sure that the MODS works as well as possible. The team will continue to gather user research and feedback and iterate the MODS based on what we learn.
Our Approach
DiSC are proposing to develop standards in a consultative and open manner with a focus on publishing early and iterating specifications. Our methodology will integrate a top-down approach, with “bottom-up” activities to inform, develop and test concepts.
Top Down:
the team are endorsing an International Standard for Health and Social Care (ISO13606) as an overarching framework for the development of the new standard
conceptual framework will be mapped to and based on concepts from ContSys
development of a conceptual model that described the key entities and relationships
development of a minimal operational dataset for adult social care
development of a MODS data glossary and terminology for adult social care data
data dictionary of preferred definitions for adult social care data
development of reference sets and coding standards
This approach allows us to create concepts with the subject matter expert within a consistent standards based framework.
Bottom Up:
landscape assessment of the standards currently in use within the adult social care data community (see related standards section)
data standards
national data collections
terminologies / glossaries / synonyms
forms / questions
identification of common concepts, similarities and differences across existing data landscape
publication of standards of use through the data catalogue
This approach allows us map the data concepts created against real-world processes and data.
Iteration:
We will follow an iterative cycle where concepts are created using a top-down approach and then mapped to existing data discovered through the bottom-up exercises. These can then be modified, iterated and reviewed.
Publication will be based GDS Guidelines on phases of an agile project: https://www.gov.uk/service-manual/agile-delivery
Related Standards and Programmes of Work:
ISO13606:
“ISO 13606 is a standard from the International Standardization Organization (ISO), originally designed by the European Committee for Standardization (CEN).
The overall objective of the ISO 13606 standard is to define a rigorous and stable information architecture for communicating part or all of the electronic health record (EHR) of a single subject of care (patient) between EHR systems, or between EHR systems and a centralized EHR data repository. It may also be used for EHR communication between an EHR system and clinical applications or middleware components (such as decision support components) that need to access EHR data, or as the representation of EHR data within a distributed (federated) record system.”
Classes of information about the person within the MODS will fall into one of the following categories:
EHR_EXTRACT: The top-level container of part or all of the health and social care record of a single subject of care, for communication between an EHR Provider system and an EHR Recipient.
FOLDER: The high level organisation within a health and social care record, dividing it into compartments relating to care provided for a single condition, by a clinical team or institution, or over a fixed time period such as an episode of care. Examples of FOLDER are Diabetes care, Schizophrenia, Cholecystectomy, Paediatrics, St Mungo’s Hospital, GP Folder, Episodes 2000-2001, Italy.
COMPOSITION: The set of information committed to one health and social care record as a result of a clinical encounter or a record documentation session. Examples of COMPOSITION are Progress note, Laboratory test result form, Radiology report, Referral letter, Clinic visit, Clinic letter, Discharge summary, Functional health assessment, Diabetes review.
SECTION: EHR data within a COMPOSITION that belongs under one care heading, usually reflecting the flow of information gathering during a care encounter, or structured for the benefit of future human readership. Examples of SECTION are Reason for encounter, Past history, Family History, Allergy information, Subjective symptoms, Objective findings, Analysis, Plan, Treatment, Diet, Posture, Abdominal examination, Retinal examination.
ENTRY: The information recorded in a health and social care record as a result of one clinical action, one observation, one clinical interpretation, or an intention. This is also known as a clinical statement. Examples of ENTRY are a symptom, an observation, one test result, a prescribed drug, an allergy reaction, a diagnosis, a differential diagnosis, a differential white cell count, blood pressure measurement.
CLUSTER: The means of organising nested multi-part data structures such as time series, list or tables. Examples of CLUSTER are Audiogram results, electro-encephalogram interpretation, weighted differential diagnoses.
ELEMENT: The leaf node of the health and social care record hierarchy, containing a single data value. Each ELEMENT contains data of a particular Data Type. Examples of ELEMENT are Systolic blood pressure, heart rate, drug name, symptom, body weight.
For more information on that standards please see http://www.en13606.org/information.html