Promoting Excellence in Family Medicine Enabling Patients to Access Electronic Health Records Guidance for Health Professionals

Enabling Patients to Access Electronic Health Records Guidance for Health Professionals Patient Access to Electronic Records

Access to paper records is already well established. The Guidance has been written to facilitate direct access to electronic patient records by patients. The Guidance will be applicable to all aspects of NHS activity (e.g. primary care, secondary care etc.) and all health disciplines although it has been specifically developed for primary care. Patient Access to Electronic Records

Benefits for patients – understanding, compliance, self care, decision making, accuracy, quality Benefits for clinicians – shared care, trust, better care Guidance - ready for publication to stakeholders Backing of key patient, regulatory and professional bodies Approval of NHS CFH Clinical Reference Panel Literature - review of publications Patient Access to Electronic Records

Legal background Security and authentication Guidance for clinicians Guidance for patients Third party data Mental health Children

NHS Connecting for Health (NHS CFH) has commissioned the Royal College of General Practitioners (RCGP) Informatics Group to: Consult key stakeholders Refine the Guidance as necessary Gain endorsement from key bodies for the Guidance prior to formal publication. Patient Access to Electronic Records

To enable health professionals to use and implement patient record access safely and with confidence. To support a “ partnership of trust ” between the patient and the health professional / organisation To offer a set of good practice guidance for health professionals in England Through examples, make clear what the limitations on access are and demonstrate how to deal with these limitations Patient Access to Electronic Records Aims of the Guidance

To offer relevant advice about the design of systems that offer record access To describe how to proactively write a record and make attachments to it so that it can be legally and safely accessed by the patient To enable patients accessing records to experience a more consistent service To maximise the safety of record access and minimise risks. Patient Access to Electronic Records Aims of the Guidance

Project preliminary results: Patient groups and voluntary groups supportive in general Professional bodies approving in principle but concerns around detail – approach too quick - workload - patient understanding of context - lack of definition of purpose of medical records Patient Access to Electronic Records

Summary The main aims of the project are to quality assure the Guidance and consult with key stakeholders so that the Guidance is endorsed and adopted by relevant bodies (who ideally will promote it to their members). Produce recommendations for initial publication, future ownership and maintenance of the Guidance. Patient Access to Electronic Records

What next? Publication and endorsement plans

Patient Access to Electronic Records

The Consultation Section A: your details Section B: Responses to the Principles Section C: Your responses to other statements Section D: Your priorities Section E: General questions about the draft document Section F: Any other comments Patient Access to Electronic Records

Principles 1-4: Patients should be given appropriate information and opportunities to exercise the degree of control they choose over the health care decisions that affect them. Giving patients direct electronic access to their health records is an appropriate method of sharing relevant information with them to help them make informed decisions about their health care. Wherever feasible, patients should be able to gain direct electronic access to their health records at no cost. Health organisations should strive to enable direct record access by patients and when available, inform patients of the facility and how to use it. Patient Access to Electronic Records

Principles 5-9: Health professionals should encourage patients to access their records, withholding information only in exceptional cases. Record sharing is likely to improve the care and the safety of patients. Computer systems suppliers should develop tools to facilitate direct electronic access to records by patients. Patients should be encouraged to access their own health records and use them to improve their health and care. Health care professionals must take reasonable steps to withhold confidential third party information. Patient Access to Electronic Records

Other statements: It is essential that patients are registered for record access so that the correct patient is given access to the correct electronic record. Access to medical records may be most effective when accompanied by appropriate information such as leaflets or electronic links to improve patients’ understanding and use of the data contained within their record. Clinical information with serious implications should always be communicated by a health professional before the results are available to the patient through record access Patient Access to Electronic Records

Other statements If a patient and a health professional agree beforehand, clinical information with serious implications can be made available to a patient through record access without prior discussion with the health professional Patients are entitled to confidentiality and should be able to exclude specific parts of their record from view, having been informed about possible consequences. Patients should be provided with a mechanism to add comments or suggest amendments to their health records. Knowledge, skills and attitudes for sharing records should be included in medical, nursing and allied health professional curricula and continuing professional development. Patient Access to Electronic Records

Items to Prioritise Ordering repeat prescriptions Making appointments Accessing laboratory results (including clinical interpretation) Clinical summary Seeing list of current repeat prescriptions Seeing recent acute prescriptions Seeing drug allergies/adverse drug reactions Feel free to add your own priorities below, including them in your ranking Patient Access to Electronic Records

General Questions about the Draft Guidelines The content of the draft document is about right. The tone of the draft document is about right. The length of the draft document is acceptable. The language in the document is about right. The draft document will be helpful and valuable. The draft document contains practical advice and will be useable. Patient Access to Electronic Records