Revised Good Practice Guidelines due later this year will advise GPs on sharing and maintaining records. Their editor, Dr Alan Hassey, outlines the key points
GPs are increasingly likely to share their record systems with other health professionals and patients. Modern electronic records may have multiple contributors over time. Interoperability of the records and the data they contain will therefore be the central theme of the revised Good Practice Guidelines for electronic patient records (version 4), with the aim of ensuring records are fit for sharing. There is also emphasis on obtaining appropriate consent and informing patients how data may be used. The GPGv4 guidance is still in draft form and won’t be published until the end of this year, but here are a few interim tips.
Make records fit for sharing
This will require health professionals to think in new ways about clinical record-keeping and create genuinely interoperable electronic records that can be safely shared with health professionals and patients. Examples include:
• uploads to the Summary Care Record in England or the Emergency Care Summary in Scotland
• shared detailed health records across different care settings as provided by EmisWeb and SystmOne.
Develop governance rules
Any community using a shared electronic record, such as TPP SystmOne, needs governance rules ensuring clear allocation of responsibility and defining rules by which responsibility can be transferred. The responsible prescriber for each item in the record should be clear, and mechanisms should exist to allow another competent prescriber to take over responsibility for items in defined circumstances, such as during hospital admission.
Double-check all data disclosures
There is growing demand in the NHS and beyond for practices to disclose clinical information from patient records to support clinical care, audit, planning and research. GPs should ensure they review data before it leaves the practice to check it:
• is accurate and complete
• is the minimum required for the purpose
• contains no third-party data
• contains no information the patient has asked you not to share
• contains no free-text extract linked to coded terms where the meaning and context is unclear.
Take care with GP2GP
More than two-thirds of English practices now have GP2GP record transfer enabled. But some incoming data may be incomplete and particular care is needed with:
• medication information
• allergy information
• some business-specific information such as call/recall dates
• the general record view – which may not obey the same rules on the receiving system in terms of appearance, layout or ordering.
Take a consistent approach to record-keeping
All clinicians using a system must adhere to the same coding approach. Consider using a template or protocol in specific circumstances, such as call/recall, immunisations and QOF data. Many systems allow free text to be associated with coded concepts. Never add free text that alters the meaning of the coded concept.
Don’t forget attachments
Any attachment to an electronic record should be regarded as having equal medico-legal weight as a note within the system and should be accorded the same stringencies on audit trail and backup. It should be possible to extract these attachments and send them to the requesting practice either electronically or as a printout.
Wherever possible all attached data should be stored on the clinical server and not on a separate server.
Ensure completeness of all record summaries
Care records are designed to assist in management of patients in unscheduled settings. Each is populated by selective extracts from the GP record, with the core extract consisting of all current medication and allergies identified in the source record. Ensure completeness and accuracy by:
• engaging in timely medication reviews
• entering handwritten prescriptions in the electronic record
• entering medication prescribed and dispensed in another care setting
• entering regular over-the-counter medication where possible.
Provide information for expert patients
The internet provides opportunities for clinicians to direct patients to appropriate resources to encourage self-management. GPs might consider developing an electronic library of trusted links for patients, such as www.patient.co.uk and www.expertpatients.co.uk.
Prepare for system failure
Where the network fails, or the server develops problems, you may find your practice abruptly and unexpectedly without access to the clinical system. This is never easy and how you manage will depend on your practice’s circumstances. Consider the following:
• delegate the task of contacting IT support and have this done immediately
• have staff trained to handle patient requests and contacts without the computer system, for example reverting to manual systems for prescription and home visit requests
• it may be reasonable to move to ‘emergencies only’ working until systems are back up – it may be unsafe to do routine prescribing and consulting without access to the clinical record
• inform patients of reasons for delays and contingency plans
• consider how handwritten data will later be entered onto the system.
Implement education and training
Maintaining competence in use of modern GP clinical systems requires ongoing education and training. All clinicians need to:
• know the technical aspects of which codes to use
• understand how contextual factors shape the meaning of records
• know how to use electronic records in a safe, effective and reliable way to communicate with other health professionals and patients.
Dr Alan Hassey is the editor of the GPGv4 guidance, a member of the RCGP’s Informatics Group and clinical adviser to NHS Connecting for Health
Click here to read the rest of our special issue on IT and information governance. Guest editor Making sure your electronic records are up to scratch