Digitising your patient records efficiently

The new five-year GP contract in England indicates that practices should be offering new patients online access to their prospective records, and from next year all patients online access to their full records, as part of a wider drive to offer patients more digital services.

It is important to understand the requirements and how to go about digitising patient records efficiently while protecting patient confidentiality.

Going paperless

The UK has a long-standing reputation for leading the development of IT in general practice. The first ‘paperless’ practice and printed scripts were developed here, back in 1975.

The emphasis on digitising of patient records is now shifting so that practices are required to create and maintain records for use by other services and patients, rather than solely for their own use.

As such, records are no longer used only as an aide memoire for the patient’s GP, but also increasingly for performance management, risk stratification, planning services, medical research and crucially for medico-legal purposes.

Patient access

In line with this, practices are now being encouraged to enable patients to access their own records. In the future, complete digitisation and the ability of patients to access their own full records will supersede the need for practices to provide copies of records for SARs.

However, this requires GP medical records to be digitised completely and accurately. This process involves ensuring that all prospective information and communications are added to the electronic record, and that the back catalogue of legacy paper records is scanned. Wherever possible, all entries should be coded.

Contractual requirements

The new 2019 GP contract builds on previous IT requirements for general practices. Key requirements on digital records are listed below and full requirements regarding IT can be found on the BMA website.

• Provide all patients with online access to their full record, including the ability to add their own information, from April 2020.
• Provide patients newly registering from April 2019 with full online access to prospective data.

Implementing these requirements will be dependent upon NHS England providing resources including upgraded IT infrastructure and functionality.

NHS England allocated £1.8 billion for making the NHS paperless over five years, until 2020. As part of this the current GP System of Choice scheme for general practice IT will be replaced by GP IT Futures which is currently under development.

Many of the deadlines should at this stage be considered to be aspirational as there will need to be changes in clinical computer systems as well as additional financial investment, especially for scanning of legacy records.  Gain advice from your Local Medical Committee before agreeing to be part of any pilot scheme.

Practices should ensure they are planning how to implement these changes, but unless they have a imperative to do so, should delay doing so until the resources and IT tools are in place.

Next steps

Every practice is at a different point on the journey to full digitalisation of records, and in preparation should take stock of where they are now. Practices should ensure that they have the following in place or develop a plan to do so:

• Everyone adding to the record – GPs, other clinicians and admin staff – should understand that data must be accurate and wherever possible coded so that records can be easily searched, and appropriate information extracted. Symptom codes should be used until a definite diagnosis has been reached.
• Everyone who adds to the record must be aware how to suppress entries and attachments with third party data, so these are not visible to online access.
• Practices should have a process for scanning, coding and adding to a workflow any communications which are received in hard copy.
• Practices should highlight to their CCG and LMC any communications which are regularly received in hard copy and ask for the plan to convert these to electronic messages.
• Consider training administrative staff to code and triage communications so that only items requiring action are added to clinicians’ workflows.
• Staff and clinicians should be aware of the relevant changes due to General Data Protection Regulations and the Data Protection Act 2018.
• Ensure that records received by GP2GP are processed in a timely manner (normally within three working days) including coding and summarising.

Key changes for practices under the GDPR and the Data Protection Act 2018

1. The practice must have a Data Protection Officer (CCGs must offer to provide these).
2. Data Privacy Notices must be displayed, and kept up to date.
3. No charge can be made for a patient to access their record, nor for appropriate access to records of deceased patients.
4. Ensure the process for gaining consent is updated. The age of consent for access to records is now 13.
5. Ensure no data is ever shared without a GDPR lawful basis. A Data Protection Impact Assessment must be undertaken where there is a ‘high risk to the rights and freedoms of individuals’. This will include most occasions where data is not being shared as a SAR, under the Access to Healthcare Records Act 1990 or for direct patient care.

Scanning Lloyd-George notes

There are different options for digitising the back catalogue of the contents of Lloyd George envelopes. Ideally, they should be scanned into the document management system that the practice already uses, then coded. If scanning multi-page documents separately, for example though a commercial scanning company, the preferred format is Tag Image File Format (TIFF) Version 6.

Prior to scanning, the contents should be trimmed of any documents which no longer have relevance.

There is no requirement for the Lloyd George envelope to be kept once the contents have been summarised and scanned.

Protecting third-party data

There is much confusion about third party data. In essence, if the data has been provided by, or is known by, the patient (data subject) it does not need to removed.

The only exception can be where data is shared by the patient and a third party, which should not be shared with another. For example, if one parent is asking for a child’s record, the other parent’s address, contact details and details of relatives should be redacted.

Accepting external additions to records

Other parties adding data to general practice records can sometimes, but not always, be beneficial. Practices where other agencies already add to records will have experienced the downsides – for example, excessive entries may make the record cumbersome to use, and inaccurate entries may distort QOF and other audits, and can affect patient safety. Changing these entries normally requires contacting the originator and asking them to alter it. Ensure that your practice considers all the advantages as well as disadvantages before accepting other bodies adding to the practice’s record.

Patient additions to records

Many of these changes are still in development. My view is that entries by patients should sit beside, but not within, the electronic record with the ability to accept the information into the main record if appropriate. Online and video consulting should be integrated into the practice software and in line with common practice for telephone consultations recorded.

Summary

The development of a complete electronic record, transferred by GP2GP, will have many benefits for practices, although the issue of patients moving between England and other parts of the UK still requires an urgent solution.

Practices should ensure they are planning how to implement these changes, but unless they have an imperative to do so, should delay doing so until the resources and IT tools are in place.

Dr Grant Ingrams is former chair of GPC GP IT Subcommittee, Co-Chair Joint GP IT Committee and Fellow of the Faculty of Clinical Informatics