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Better information better care

22 Feb

The NHS is upgrading its information systems: patient sharing data is going live from April 2014 onwards. This is an opportunity for each of us to help the NHS provide high quality care for all.
Summary care recordYou can choose to have a Summary Care Record.

  • If you would like one, you won’t need to do anything. It will happen automatically.
  • You can choose not to have a Summary Care Record. Let your GP surgery know by filling in and returning an opt-out form.
  • If you opt out, you can rejoin the scheme at any time. An opt-out form is included with your letter.

You’ll be informed by letter when it’s time for your local primary Commissioning Care Group (CCG) to introduce Summary Care Records. The letter will contain details about your choices and how to opt out of the scheme.

More information about Summary Care Records is available at http://www.nhscarerecords.nhs.uk.

Why are Summary Care Records being created.

Medical recordsToday, records are kept in all the places where you receive care. These places can usually only share information from your records by letter, email, fax or phone. At times, this can slow down treatment and sometimes make it hard to access information.
Summary Care Records are being introduced to improve the safety and quality of patient care. Because the Summary Care Record is an electronic record, it will give healthcare staff faster, easier access to essential information about you, and help to give you safe treatment during an emergency or when your GP surgery is closed.

For example, a person who lives in London is on holiday in Brighton. One evening, they’re knocked unconscious in a car accident and taken to an accident and emergency (A&E) department. Under the current system of storing health records, it would be difficult for A&E staff to find out whether there are any important factors to consider when treating the person (such as any serious allergies to medications), especially as their GP surgery is likely to be closed. If healthcare staff cannot get the relevant health information quickly, some patients may be at risk.

A Summary Care Record is an electronic record that’s stored at a central location. As the name suggests, the record will not contain detailed information about your medical history, but will only contain important health information, such as:

  • whether you’re taking any prescription medication
  • whether you have any allergies
  • whether you’ve previously had a bad reaction to any medication

Access to your Summary Care Record will be strictly controlled. The only people who can see the information will be healthcare staff directly involved in your care who have a special smartcard and access number (like a chip-and-pin credit card). These are currently used in the surgery by all staff but only to obtain information about patients registered at the practice.
Healthcare staff will ask your permission every time they need to look at your Summary Care Record. If they cannot ask you, e.g. because you’re unconscious, healthcare staff may look at your record without asking you. If they have to do this, they will make a note on your record.

ABOUT HEALTH RECORDS

When I see patients in a different setting eg in an Urgent Care Centre or Walk in centre patients are often surprised that I do not know anything about them ie their present medication or ongoing illnesses not appreciating that there is no electronic connection between different medical centres and especially those people who have complex problems it would be a great advantage to have that connection.

Health records play an important role in modern healthcare. They have two main functions, which are described as either primary or secondary.

Primary function of health records

The primary function of healthcare records is to record important clinical information, which may need to be accessed by the healthcare professionals involved in your care.
Information contained in health records includes:

  • the treatments you have received,
  • whether you have any allergies,
  • whether you’re currently taking medication,
  • whether you have previously had any adverse reactions to certain medications
  • whether you have any chronic (long-lasting) health conditions, such as diabetes or asthma,
  • the results of any health tests you have had, such as blood pressure tests,
    any lifestyle information that may be clinically relevant, such as whether you smoke, and
    personal information, such as your age and address.

Secondary function of health records

Health records can be used to improve public health and the services provided by the NHS, such as treatments for cancer or diabetes. Health records can also be used:
to determine how well a particular hospital or specialist unit is performing,
to track the spread of, or risk factors for, a particular disease (epidemiology), and
in clinical research, to determine whether certain treatments are more effective than others.
When health records are used in this way, your personal details are not given to the people who are carrying out the research. Only the relevant clinical data is given, for example the number of people who were admitted to hospital every year due to a heart attack.

Types of health record

Health records take many forms and can be on paper or electronic. Different types of health record include:

    • consultation notes, which your GP takes during an appointment,
    • hospital admission records, including the reason you were admitted to hospital,
      the treatment you will receive and any other relevant clinical and personal information,
    • hospital discharge records, which will include the results of treatment and whether any follow-up appointments or care are required,
      test results,X-rays,photographs, and image slides, such as those produced by a magnetic resonance imaging (MRI) or computerised tomography (CT) scanner.

Confidentiality

There are strict laws and regulations to ensure that your health records are kept confidential and can only be accessed by health professionals directly involved in your care.
There are a number of different laws that relate to health records. The two most important laws are:

  • Data Protection Act (1998)
    Under the terms of the Data Protection Act (1998), organisations such as the NHS must ensure that any personal information it gathers in the course of its work is:
    only used for the stated purpose of gathering the information (which in this case would be to ensure that you receive a good standard of healthcare), and
    kept secure.
    It is a criminal offence to breach the Data Protection Act (1998) and doing so can result in imprisonment.
  • Human Rights Act (1998).
    The Human Rights Act (1998) also states that everyone has the right to have their private life respected. This includes the right to keep your health records confidential.

imageFor further information – the Health and Social Care Information Centre is a public body which have been appointed to ensure a high quality information is used appropriately to improve patient care and have published the following document to address questions patients may ask:-
http://www.nhs.uk/NHSEngland/thenhs/records/healthrecords/Documents/Care.data%20patient%20FAQs%20V3%2019022014.pdf

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Posted by on February 22, 2014 in Training and Advice

 

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