Table 2

Suggested roles of major stakeholders in improving the recording of problems and diagnoses in the NHS

StakeholderSuggested role(s)
Professional Record Standards BodyLiaise with healthcare professional organisations to build consensus on professional requirements for problem and diagnosis recording.
Faculty of Clinical InformaticsAdvocate and develop models to improve the recording and sharing of problems and diagnoses, and ensure it is embedded in undergraduate and postgraduate medical training.
Academy of Medical Royal CollegesEnsure that accurate recording of diagnoses is a high priority in all medical specialties, endorse guidance for healthcare professionals, and encourage the use of standardised, routine data for national clinical audits.
Specialist societiesAlign requirements for clinical diagnosis and audit with information models for problems and diagnoses.
OpenEHR communityDevelop models for healthcare information (archetypes) that enable details of problems and diagnoses to be recorded and shared.
INTEROPenDevelop interoperability profiles which accommodate diagnosis information models, and encourage vendors to adopt them.
NHSX, NHS Digital and other central NHS organisationsDevelop core informatics infrastructure and a programme of work for standardised recording of problems and diagnoses, including disease archetypes and terminology subsets.
NHS TrustsProvide user-friendly EHRs that enable problems and diagnoses to be recorded in a standardised way, and support clinicians in using them.
Health Data Research UK and research fundersFund work on data standards and improving usability of EHR systems, in order to improve the quality of data and its utility for medical research.
Medical schools and postgraduate deaneriesEnsure that medical students and doctors in training understand how to use problem lists and terminologies, and appreciate the need for accurate recording of diagnoses.

  • EHR, electronic health record; NHS, National Health Service.