The Government has shown admirable diplomacy and collaboration in moving towards record access for all patients who want it by 2015 – that is, until last month.
Opposition to patient record access remains strong – despite the evidence for benefit to patients and practices and the technical arrangements that protect practices from third party breaches. The Government has made the deadline clear. In an inspiring move, it has also delegated the difficult work of discussion, negotiation and implementation to the RCGP, in combination with key players in the field (most notably the BMA, practice staff, suppliers and patient groups). Behind the scenes, discussion has been vigorous and detailed – and has been proceeding so far with mutual respect and thoughtfulness.
Now the Government has threatened the process it began. It wants to fund the development of record access and an e-suite of services for patients – that is good. But not only will it offer no new money, but it appears happy to impose QOF changes to make this happen – that is seriously bad. The Government also appears to have chucked in the idea of secure messaging between patient and practice. This appears to come out of the blue with no discussion that I know of.
In the first year of the DES 2013/4 :
- online booking of appointments with a GP
- online ordering of repeat prescriptions
- identifying and making available selected test results to patients online.
In the second year of the DES2014/5, their demands are as above, plus
- identifying and making available further test results to patients online
- secure electronic communication with the practice; and
- online access to medical records.
And we all thought we were heading into a time of no top down. But what has slowed us down in the online service stakes?
Appointment booking and ordering of repeat prescriptions are pretty uncontroversial. Although there is no hard evidence, experience suggests that they save the practice time and reduce DNAs. They are pretty easy to put into practice. Despite this, only about 60% of practices offer these services.
Patient record access (RA) is currently, only EMIS offers this service comprehensively. There are two tiers:
- full access to more or less everything that the practice holds on the patient
- access to coded data only: problem titles, test results, imms and allergies. No letters and no free text are viewable. Although this restricts what the patient can see, it does protect the practice, with no extra work, against unnoticed breaches of third party data and thoughtless comments from the past.
Evidence is good that record access:
- improves relationships
- improves the accuracy of the record
- supports self-care and shared decision-making
- is safer, offering much needed data-sharing and transparency where it is really needed – through with and by the patient
Two studies from the US and UK showing that record access reduces appointments and telephone calls although admittedly one from the US that suggests it increases them.
The BMA are concerned that RA will result in breaches of the Data Protection Act; that patients will be put at risk by insurance companies demanding information; that patients in coercive situations will be at risk; and that RA will result in more work for practices. All these issues are being discussed in the RCGP process. In my opinion, the issue of coercion is the main outstanding problem – and that can, to some extent, be mitigated.
The Government has also targeted e-messaging between practice and patient as a key future service – but where did this idea come from? The technology has been available for years and is an EMIS standard: secure messaging, not e-mails which are not recommended because they are insecure. Almost no practices offer it because we are concerned about the workload implications. And we are right to be concerned. In Denmark, the government has paid GPs more for e-consultations because they are more efficient. The evidence, such as it is, from Kaiser in the US is that secure messaging does indeed initially save appointments and telephone calls. But eventually, traffic builds up and begins to destabilise workload.
We need more evidence about workload and relationship implications before this is mandated. This should not be difficult – there are likely to be a number of practices who would be willing to trial the functionality, and we could have good data in a couple of years. I am particularly anxious about the workload of e-messaging and so I would want research done before we took this on, so that we could have a handle on what the resource implications are.
For patients, it’s a no-brainer – they would be the main beneficiaries of the introduction of these services. They would save patients a lot of time, and – probably – be a lot safer.
But for GPs, these e-ideas challenge established practice and need time to be ‘tried and tested’. To impose their implementation on the profession will set progress back substantially.
Dr Brian Fisher is a GP in Lewisham and the clinical lead of Patient Access to Electronic Records (PAERS).
This story was updated on 7 January, with changes to the headline and standfirst to reflect the fact that records access is part of proposals for new DES, not new QOF indicators as initially stated.