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    NHS Digital announces patient de-identification software partnership

    Thursday, 05 July 2018 16:48
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    Over half of acute trusts are now using GP e-Referral Service

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  • NHS launches National Data Opt-Out facility

    NHS launches National Data Opt-Out facility

    Thursday, 31 May 2018 09:01
  • ePACT to be decommissioned on June 8 as ePACT2 takes over

    ePACT to be decommissioned on June 8 as ePACT2 takes over

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online-patitent-recordsApril 22 2015

GPs need to ensure the confidentiality and accuracy of medical records which are being uploaded for patients to access online, says the Medical Defence Union.

Following the introduction of the contractual requirement to offer patients in England online access to summary information from their medical records, the MDU is advising that practice staff be trained in this area.

“Those involved in creating the medical record will need to be aware that the record can be viewed by patients, and think carefully about the purpose of the records, and the impact they may have on patients reading them,” says the MDU. “Training could highlight potential issues surrounding third party data, cover the need to ensure data accuracy and minimise the use of abbreviations.

“When registering patients for online access, staff will need to understand the registration process, and be able to explain to patients the importance of keeping their information secure.

“Patients will need to understand that they may see information that they do not understand, or may find upsetting and that they can discuss their records with a GP if this happens.”

The MDU says a number of GPs have contacted it over the new contractual requirement. Dr Beverley Ward, MDU medico-legal adviser, commented: “Making confidential information about patients available online has logistical difficulties, and practices will need to consider how to allow patients to access information securely, while being sensitive to any information which may cause distress.”

Dr Ward pointed out that there is a range of guidance available for practices and for patients “but there are likely to be more queries about the accuracy and contents of records once patients begin to sign up for online access.

“For example, GPs may need to explain any abbreviations the records contain and will need to ensure test results are reviewed and discussed with the patient before they are uploaded to the online record.”

The issue of consent also needs to be considered, for example when a parent requests access to their child’s record. “For children over 16, GPs should usually get their consent before granting access to someone with parental responsibility, but for under-16s the situation is more complicated,” says Dr Ward.

“The RCGP suggests that full access for those with parental responsibility should be automatically switched off at age 11 and a discussion arranged with the child and parents to consider the extent of ongoing access. However, the age at which a child becomes competent will vary and it will be important to keep any access by parents under regular review.”

Other points GPs need to consider include:

•    how patients’ ID will be verified and how the practice will record patients with online records access
•    the need to educate patients about keeping their information or log in details secure and the implications if they share these details with others
•    how practices will identify third party information which will need to be withheld
•    the importance of giving patients the opportunity to correct inaccurate or incomplete records, but not amend content simply because they find it upsetting.

Links:

MDE announcement    

MDU FAQs on online access to patient records    

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