Abstract
Introduction
In this chapter, we look at how to manage the vast amount of information that practices handle.
Patient records
These are increasingly shared across multiple organisations (e.g. community nursing, walk-in centres, etc.) with the patient’s consent. There is also a national committment to make all of your records accessible to all patients all the time. This will increase the level of scrutiny you should expect with your record keeping. The majority of primary care systems are now electronic patient medical records. Good medical notes are the keystone of modern general practice for reasons outlined in Table 12.1.
Reasons to keep good patient notes.
Making medical notes
When making medical notes be factual, consistent, accurate, unambiguous, legible and concise. The General Medical Council (GMC) guidance (2013) is clear on the expectations for all doctors. Clinical records should include:
relevant clinical findings
the decisions made and actions agreed, and who is making the decisions and agreeing the actions
the information given to patients
any drugs prescribed or other investigation or treatment
who is making the record and when (http://www.gmc-uk.org/guidance/good_medical_practice/record_work.asp)
write records as soon as possible after an event/encounter has occurred
ensure a logical sequence
use standard coding techniques if using an electronic record (remembering that clinical computer suppliers may amend these from time to time)
wherever possible write notes openly, whilst patients/carers are present, in terms they can understand
date, time and sign (or otherwise identify yourself) on all entries. For locums, ensure each employee has a unique identifier so that it is possible to identify exactly who made the notes long after the event – an electronic tag of ‘locum’ is not sufficient.
Include: information you have on which to base your decisions: — problems presented to you by the patient — relevant aspects of past and family history — examination findings and test results you already have — allergies your impression of the situation: how you see the problem – may include diagnosis, differential diagnosis, prognosis plan of action: as negotiated between patient and health professional – may include tests requested, prescriptions given, referrals made information shared and advice given: — relevant worries or concerns voiced by the patient — information provided to the patient — advice given – especially contingency plans if things don’t go to plan and review/ follow-up arrangements other essential information, e.g. correspondence to and from other agencies; whether a sickness certificate was issued, and if so for how long and the reason stated on the certificate; if consent for disclosure of information or treatment/examination was given.
Don’t include: abbreviations – especially unconventional ones jargon personal views about behaviour or temperament unless they have bearing on management.
Notes of telephone and video consultations
Most practices deal with hundreds of telephone calls per day. Record keeping must include a system to accommodate these calls. Telephone calls should be logged on the computer appointment system screen where appropriate, e.g. time and date of the message, the person taking the call and the person who has dealt with the message is one way of dealing with calls to practice receptionists. In particular, receptionists are advised to detail conversations regarding results given over the telephone, any medical advice however minor, and any difficulties encountered during the conversation. This helps provide a history to anyone who may encounter the patient in the future. Telephone consultations with medical staff should be recorded in the patient notes in the same way as any consultations undertaken in the surgery or as home visits.
Tape or digital recording of telephone conversations
There is a central move to offer video consultations. This has been happening in many pilot areas across the country over the last few years. The demand is growing and requires an approach not too dissimilar to the method of telephone consultations but with the added benefit of seeing your patient. In order to have a good experience there are many software providers who ensure you can have multiple functions like ‘waiting rooms’ that make the process more like what happens in practice. It’s important the lighting and camera quality as well as the Internet connection is robust for a good experience for the patient too. Recording notes is usually in the same system you normally use and currently the majority are not being recorded. However, it can be easily envisaged that in future this may be an ask.
Recording telephone conversations has a number of advantages – messages can be replayed if there is confusion over names or addresses, and recorded conversations can settle disputes about what was said, when, and by whom.
Any practice using a telephone is subject to conditions imposed by their telephone provider. These require you to make a reasonable effort to inform patients that the call may be recorded and to keep a record of how callers are informed. The GMC reinforce this in their guidance for doctors updated in 2011 (http://www.gmc-uk.org/guidance/ethical_guidance 2013). With the use of many handheld devices such as mobile phones, the GMC guidance includes all forms of recordings (http://www.gmc-uk.org/static/documents/content/Making_and_using_visual_and_audio_recordings_of_patients.pdf) ‘Recordings’ in this guidance means originals or copies of audio recordings, photographs, and other visual images of patients that may be made using any recording device, including mobile phones. It does not cover copies of written records.
Many businesses use a simple recorded warning before the caller is connected informing them that the conversation will be taped, and this system works well in general practice too. Possible wording might be:
In the interests of patient safety, incoming calls to this practice are recorded. These recordings are strictly confidential and dealt with in the same way as patient medical records.
Additionally, patients should be informed about call recording through practice leaflets, surgery notices and websites.
Tape recordings made for clinical purposes form part of the medical record and should be treated in the same way as any other part of the patient medical record. It is therefore subject to the same rules of disclosure and confidentiality and must be kept for the same duration as any other part of the medical record.
Organisation of notes
It is the responsibility of the doctors in a practice to take leadership in the organisation of notes, often in consultation with the practice manager and other team members who use the notes, e.g. practice nurses. It is essential that all those using the notes reach agreement on these matters and abide by the agreement. One team member recording information in an individualistic way can greatly hamper communication and information retrieval. Decisions should be made on:
what structure the patient’s record will take, e.g. manual record or computerised record, and how the manual and computerised record are integrated
the system for summarising and computerising existing notes
the systems for managing the notes of new patients
the system for updating notes
the systems for returning notes requested by the PCO
the system for storing notes.
Structure of the patient record: manual and computerised records
Over the years fax machines are becoming obsolete, with all communication, including pathology, directly linked or emailed. This is expected to result in completely paperless record transfers and entries.
Pragmatically, paper and electronic records should work in concert. Organisational processes should make optimal use of both. There are very few practices that are ‘paper only’ and probably none that are truly ‘paperless’. The vast majority of practices have travelled some way on the journey towards ‘paperlight’ patient records.
Removing obsolete or duplicated data: There are legal problems about discarding any medical information and this must always be borne in mind when pruning paper notes. However, many sets of notes have a lot of redundant paper that can easily be discarded, making them easier to store and information easier to retrieve from them, e.g.
scraps of paper with handwritten pathology results – especially if the official result is available, blank continuation cards, unused scripts and all duplicated information can be safely discarded
multiple pathology results or immunisation records could be transcribed to the appropriate card and then thrown away.
Discarding other information is more contentious. Each practice should decide its own policy and medical defence organisations can advise.
Storage of paper patient notes: The majority of practices will have had a Care Quality Commission (CQC) visit and security of notes storage is a common check. It is important to have a good storage system for all records. Notes may be filed in filing cabinets, open carousels or on shelving. The choice of filing system will probably be dictated by the space available and the design of the building. Receptionists spend a good deal of time pulling and re-filing notes. Most receptionists become adept at knowing exactly where to find a set of notes. However, large amounts of time can be wasted searching for lost or misfiled notes. Most systems have common features:
Store files closed and in a logical order (e.g. alphabetical or by family groupings). Colour coding can help identify misfiled notes – coloured tape is applied to the same place on the spine of 20 or so consecutive notes. The next 20 notes have a different coloured tape on the spine at a different level. A misfiled set of notes can be easily identified as its identity tape will not match its neighbours.
Use a tracking system (e.g. coloured cards or tracer cards marked with the destination of the notes) to monitor the whereabouts of files and return them as soon as they are no longer required.
Difficulties can arise with patients of the same or similar names – these should be clearly marked with a warning to this effect or a differentiation mark.
Difficulties can arise with ethnic names – see pages 8-09–8-11.
Filing outside the medical notes In some cases, it may be better to file some papers outside the medical notes. For example, reports for life insurance must be kept for 6 months by law, but can then be discarded. If these reports are filed separately, it is much easier to identify which reports can be discarded. However, it is often advisable to keep the most recent report, even if it is more than 6 months old, as it is useful if another report is requested and may help future summarisers.
Storing notes off-site As the remit of GPs expands, it is important to consider maximising space within the practice. Some practices have chosen to dispense with the storage of their medical records and have engaged commercial storage companies to provide off-site storage for them. This approach can be costly, but can release vital space to enable expansion of medical services, for example. Practices considering this approach should ensure that they research their chosen storage company extensively and ensure that the requirements of information governance are adhered to. Off-site storage would benefit practices that have most of their medical records summarised to reduce the transportation of records from storage site to practice.
Major software systems currently in use and approved by NHS Digital that links with the Calculating Quality Reporting Service (CQRS), the payment verification system for the quality and outcomes framework. (the payment verification system for the Quality and Outcomes Framework (QOF)). Note this list may not be exhaustive and that each provider may supply a variety of systems, e.g. EMIS currently offers, EMIS web.
Note: Prior to any upgrade or system change, it is essential that practices consult NHS England and their CCG for advice on funding and how their proposed changes fit in with the national programme.
Read codes: Read codes are the system that has been used to code general practice in the UK to date. They can code history, examination, investigations, social data and family history, diagnosis, interventions, administrative tasks and many other aspects of patient care.
Accessibility, capacity and storage: Practices need to ensure that they have an adequate number of workstations at each point within the organisation. The system must have adequate data storage capacity to meet likely current and medium-term future needs for storing their electronic patient records and supporting applications securely.
System for summarising and computerising paper notes
Transferring the information from paper notes to the computer is a huge task for any practice and one that should be done in a step-wise fashion:
Step 1: Record demographic (registration) data for all patients. This can be done using GP/PCO registration links and recording all standard demographic details and their changes on the computer as they are received. All receptionists should be trained to do this.
Step 2: Data download from other pre-existing systems, e.g. cervical screening or childhood immunisations.
Step 3: Active use of the computer with all clinicians entering their own data directly onto the computer at the time of the encounter for routine consultations in the surgery, clinic-based chronic disease management, and acute and repeat prescribing.
Step 4: Adding to disease/problem registers from incoming reports (e.g. letters, discharge summaries).
Step 5: Summarise historical paper records in electronic format.
Consultation entries: This is probably the area in the clinical side of the practice that causes the most difficulty when considering computerisation. Patients’ paper records go back over years and doctors wonder how on earth they are going to manage without them.
The use of templated entries for conditions has allowed for accuracy in recording coded data for recall around disease conditions. However, the explosion in templates for a number of staff has equally turned a few off from using them and effort needs to be put into training staff.
Locums and registrars: When computer data entry during the consultation is the norm, it is important to train locums and registrars in the use of the practice system before they start consulting. A locum needs to be able to access all clinical information as a minimum requirement. Prescriptions can be handwritten, but this means there will be no record kept. If the locum makes handwritten notes, these will need to be entered onto the computer by a member of the practice. All locums should have a unique identification tag on the computer to enable the responsible doctor to be traced years after any entry for medicolegal purposes – ‘Locum’ is not sufficient.
The registrar must become fully conversant with both the entry and retrieval of data. It could be considered an essential part of every registrar’s education.
Other members of the primary healthcare team (PHCT): A strong coordinated PHCT should endeavour to share clinical records. Each professional person needs their own records, but there are advantages both for fellow professionals and their patients if all members have access to these. Shared notes improve the ability to audit and generate material to help with health-needs planning. However, we do not live in an ideal world, and for many practices this may be a difficult situation to achieve. Most PCO computer systems are not compatible with those in primary care. In addition, PCOs require data from their community staff who are not directly relevant to primary care. Added to this is the problem that some attached staff do not actually work in the same building as the rest of the PHCT, and a unified record may not be possible.
On the positive side, all attached staff can be trained to access patients’ records in the practice system. If it is impossible to negotiate with attached staff to use the practice system completely, it may be possible to ask attached staff to record contacts with patients, health promotion data collected, immunisations given, etc.
Visits: Once the practice is comfortable with the use of the computer for consultations, the next step is to computerise the notes for visits. The following are a few ways in which this can be achieved:
Laptop computers now have large storage facilities, and with the advent of web-based electronic record systems they can be accessed securely over the Internet with the right security access. A doctor could use his laptop in his/her consulting room for both clinical and non-clinical purposes, networked into the practice system. When he/she goes on home visits it can be unplugged to accompany him/her, thus providing access to all patients’ notes. Using a laptop has the advantage that the computerised clinical system can move with the doctor, as well as offering the flexibility its other systems offer, e.g. the ability to take notes at a meeting directly onto a word processor. The cost may be prohibitive for many practices. However, if a practice is considering buying PCs rather than dumb terminals for the practice system, laptop computers may be an option. (A dumb terminal is a terminal that feeds into a main computer processor.)
Systems are being developed to download clinical data onto mobile devices such as iPads. This has the advantage of combining computer access to patients’ notes with size and portability. The downside to portable devices is that they typically do not ‘mirror’ the full version for ease of functionality, which makes the experience different. For example if templates are used these are often difficult to recreate in a mobile format. They are also much cheaper than a laptop and do have some word-processing facilities.
Paper summaries can be printed from the computer for all visits. The summary could include the medical summary, current drugs being prescribed and details of the most recent consultation. The consultation can be entered onto the computer when the doctor returns to the surgery. There is the added difficulty of making sure you are disposing of the printouts securely and not left in a public place.
Lists of visit requests can be generated on the computer for each doctor in the same way that appointments for surgeries are generated.
Referral letters and other letters out: Referral letters may be stored as templates, and once completed, linked into the patient notes for computer-linked filing.
Repeat prescriptions: Prescribing is usually one of the first systems to be computerised. When a practice becomes paperless, very few changes will need to be made to the established system. The practice will still need a system to accept repeat prescription requests. Most practices only accept written requests for repeat prescriptions. This reduces the margin for error. If requests are made on a repeat card or the tear-off half of a prescription, the same system can continue. Some patients prefer to fax or email requests, which has the advantage that they can be dealt with at the practice’s convenience. Some clinical software systems allow direct requests to be made via a password-protected link to the patient’s medical record.
The advent of electronic prescription service (EPS) http://systems.digital.nhs.uk/eps has made the ease of access to ordering scripts simple. This allows patients to request online, and as long as you have smartcard secure access to your patients’ notes, the ability to prescribe with the ‘click of a button’. The script is then electronically registered with the nominated pharmacy of the patient’s choice. This allows the patient to have a good experience and limits the chance of losing the prescription.
Hospital and other correspondence in: There are various options for dealing with incoming correspondence:
Incoming correspondence could be reviewed by clinicians, and clinicians could code the relevant parts of the document for further action. The letters should then be scanned and filed.
Software packages such as Docman will enable areas of scanned letters to be directly coded by clinicians from within the GP Consultation Software systems (e.g. EMIS/VISION). Most systems such as EMIS now have their own readers, as electronic transfer of letters and pathology results are becoming commonplace for hospital communications back to a practice.
Alternatively, admin staff could type the whole or part of the content of the letter onto the computer. If only part of the letter is to be transcribed, a doctor will need to highlight the relevant parts for the secretary. This will be time-consuming for the secretary.
If documents are ‘Read’ coded in the clinical notes, it should be possible to cross-reference all incoming letters. This will have the advantage that letters can be filed and searched according to subject or speciality (or even consultant if Read codes are developed for these). Letters can be searched for according to subject, etc. at a later date rather than scanned by their date of entry. Many enhanced schemes are now predicated on these scanned letters being coded correctly, so effort into developing a good process in your practice is essential.
Scanners can read documents either as a photograph or text. It is preferable to buy a scanner that reads as text because then the letter can be amended just like any other word-processed document. Documents scanned as pictures take up a lot of disc space. It is beyond the scope of the authors to advise on the different types of scanner, and practices will need to take advice from the software or computer supplier to establish which systems will be compatible.
Some practices also email referral letters electronically straight into the practice system via the NHSnet and indeed receive letters in the same way, which will remove the need to scan.
Summarising notes: Practices must decide what information is to be included in a summary and where this is to be recorded. Most practices use a problem-oriented approach, so that medical and non-medical data can be stored side by side. For example, it may be considered equally as important to record that a patient lives alone or has had a negative barium enema as to record that they have had an appendectomy. Some practices keep a single problem list, others divide the problems into active (current) – e.g. diabetes mellitus, active rheumatoid arthritis, and inactive (past) problems – e.g. hernia repair or ‘burnt out’ rheumatoid arthritis. The second system requires problems to be re-classified when they become inactive.
The following information should be considered for each summary:
operations (other than minor ones)
major illnesses and continuing medical problems (whether diagnosed or undiagnosed)
important investigations
family history
social history
allergies
immunisations
prevention data (blood pressure, weight, alcohol, smoking, cervical smear, etc)
current medication.
Note: It is important when summarising and updating records that there is consistency in Read coding to enable accurate patient call and recall, audit and payment through the QOF.
Much of the work involved in summarising notes can be delegated to specially trained staff. Training should involve a doctor and have a reliable quality control system including random checks of summaries to ensure data is being entered correctly.
Migrating from one computer system to another: Software development continues to move forward at an alarming pace. Therefore, from time to time it will be necessary to update the practice software. When migrating to a new software system, practices should ensure that at least one responsible member of staff has a thorough understanding of any consequences of coding migration, any consequences for the management of routine business of the practice (such as call–recall schemes and data collection) and any consequences from the change in patient record architecture (e.g. the way in which problems are classified). It is also important that all personnel using the system receive adequate training before it is implemented and that at least one member of staff is trained to a higher level in order to enable him/her to guide others through the initial teething stages. Practices should formally review all prescribing decisions after software system migration and not assume that all such information will have been carried forward reliably.
Note: Currently audit trails are not transferable between different clinical systems. For medicolegal purposes, it is advisable to create and maintain a verified backup of the clinical data from the old system in case of retrospective claims (see Keeping medical patient, page 12–13).
Systems for managing the notes of new patients
Even if a practice’s notes are well organised, it is unlikely that the notes of new patients will be received in a format that matches the practice’s own notes. It is important that a practice devises a system for sorting and summarising new sets of notes along the lines of the system used for computerising notes.
A number of system providers now are facilitating electronic notes transfers such as EMIS GP2GP. They help reduce the burden on the receiving practice coding data, but have the added complication that it does not replace the need for the paper copies of records to be posted out to the practice, reviewed and stored. It is expected that as the web-based systems improve transfers will be made easier as well as more complete.
A practice using the EMIS computer software as its clinical system became concerned that its audits were made difficult because each doctor used different codes for certain conditions.
The computer produced a list of the 200 most frequently used codes. Scrutiny of these codes showed problems in a number of areas, where different codes were being used for the same diagnosis. The following areas were particularly problematic:
— Viral illnesses coded as ‘upper respiratory tract infection’, ‘acute naso-pharyngitis’ and ‘coryza’
— Sinusitis labelled both as ‘sinusitis’ and ‘upper respiratory tract infection’
— Lower urinary tract infection labelled as ‘UTI NOS’ and ‘acute cystitis’
— Depression has a number of codes, both as a diagnosis and as a symptom
— Hospital referrals were coded in a variety of ways, e.g. ‘emergency admission’ and ‘admit medical emergency’.
At one of their regular audit meetings, the GPs and practice nurses discussed this problem. They developed a unified list that they all agreed to use for given conditions. The list was produced as an aide memoire for all those consulting the codes. The practice found that the list made searches for these conditions much simpler. It also, of course, brought a number of new conditions into the ‘top 200 codes’, some of which were also duplicates!
Systems for updating existing notes
You may have worked hard to get summaries of all notes on your computer system, but summaries must be kept tidy and up to date. You will be surprised how quickly diagnoses achieve multiple entries and how many minor diagnoses are recorded as major.
Have a protocol for entering new relevant data and a system for checking, tidying and linking summaries regularly. Try to ensure Read codes are used consistently as this makes data retrieval much easier.
Make sure you are now linking all new and reinstated prescription items to a diagnosis. There are QOF points for this and it also helps greatly for audit purposes and when patients see different GPs.
Encourage the use of templates for disease management wherever possible, for accuracy, protection and uniformity. They must be designed to be Read code accurate (i.e. use QOF codes) to enable data gathering, be user friendly and, vitally, be kept up to date. Commercially developed templates are available or templates can be developed in-house to meet the needs of the practice.
Over the last 10 years, much of the data entry into computer systems has been done manually, with laboratory and radiology results and edited highlights from correspondence laboriously copied by hand onto computers. Over the last few years, new developments have revolutionised the way in which data can be added to the patient record. These include:
pathology messaging (electronic data interchange)
radiology messaging (electronic data interchange)
scanning of incoming letters stored as attachments to the record or integrated within the clinical record
production of electronic reports for referrals and insurance companies
attachment of pictures to the clinical record, e.g. ECG traces or pictures of dermatological lesions
electronic prescription transmission to pharmacies
electronic hospital discharge letters
electronic GP to GP records transmission
online appointment booking/referrals.
These developments generally save time and make the system more efficient. However, they do have their pitfalls – for example it is easy to click a button and miss an abnormal pathology result. Ensure all those who will be using the system know how it works and that adequate checking mechanisms are in place before instituting any new system.
Pathology and X-ray reports
Links with pathology departments are well established in many practices. A secure electronic link with the pathology department enables results to be downloaded every day, directly into the practice’s computer system. This system should now be available for most practices from their PCO.
Once the results are in the system, they need to be filed in the patient’s notes, and the practice will need to develop a new system to cope with this. A typical system is as follows:
Each partner is responsible for looking at and filing his/her own patients’ results. Someone must cover for doctors who are away or for tests ordered by a locum. Larger practices may adopt a buddy system to cover this.
One doctor, possibly the duty doctor, is responsible for filing all results. It is sometimes difficult to comment on the results of a test when you do not know why it was ordered. The doctor doing the filing will need to liaise with the patient’s doctor if there is uncertainty or if the test result is abnormal.
With the advent of large partnerships or groupings of practices there has been an explosion in these tasks being taken off the ‘regular’ clinician who requested the test with a back office function undertaken by pharmacists, nurses and other health professionals carrying these tasks with some training. Owing to workload issues this seems to be increasing in popularity, and time will tell whether this will become the norm with external companies offering a service to practices. A method is also required to ensure that the patient is informed of the result. For example, the practice may ask patients to telephone or call for results, but actively informs all patients whose result is abnormal or requires action. In order to be able to do this, it is important to inform the receptionist or secretary what to tell the patient when they contact the surgery. For example, a message can be filed in the patient’s notes with the relevant information. For most results, these messages could be standardised statements stored in the computer (e.g. ‘See the doctor’, ‘Thyroid test normal’, etc.) to save the need to type out a message each time.
Some laboratories and X-ray departments will not be computerised and these results will need to be filed electronically by one of the methods outlined previously in the section on ‘Hospital and other correspondence in’. Many computer systems now enable the use of text messaging information to patients who have a mobile phone number. A number of systems are being used for appointment reminders, recalling patients and informing them where appropriate about test results too.
In the Church Road practice, the duty doctor was responsible for filing all pathology results that had been downloaded overnight at 9.00 a.m. The results were filed in the patient’s clinical record. A message was recorded on a message pad in the computer, which automatically duplicated the message into the patient’s computer clinical record. When a patient telephoned for the result, the receptionist looked in the patient’s clinical record for the message that was communicated to the patient. The receptionist knew immediately whether the result had been received, thus saving hours of searching through piles of pathology result slips. Once the patient had rung, the message was erased by the receptionist.
The process was speeded up by providing the doctor doing the filing with a list of possible messages to the patient – ‘normal thyroid test’, ‘not anaemia’, ‘discuss blood test result with doctor by phone’, ‘cholesterol high, discuss diet with nurse’, etc. This meant that most messages did not have to be typed out in full each time.
At the end of every month, a receptionist erased all messages that had not been collected by the patient and were at least 4 weeks out of date. This prevented a backlog of uncollected messages, of which there were several each month. The actual result was obviously still available in the patient’s computer clinical record. If a test result needed action, the patient’s own GP was informed by sending him a computer message. This ensured that action was taken even if the patient did not ring for the result.
Systems for returning notes to the PCO
PCOs request the notes of patients no longer registered with the practice at regular intervals – for example patients who have died or have moved to other practices. Ensure a system is present to check the list received for accuracy. Most practices using computerised notes print off a copy or summary of the computer notes and include it with the manual notes returned to the PCO. In the future, electronic transfer of the computerised record will become the norm. If the patient has computerised notes, the record should not be deleted when the patient is no longer registered with the practice but kept on the system with a note to the effect that the patient is no longer registered.
Computerised appointment systems
Computerised appointment systems offer a number of advantages:
it is easy to check a patient’s appointment time as a search can be made by patient name – even if the patient has forgotten the date of the appointment
it is easy for a receptionist to see whether a doctor is running late
it is easy to add messages for each appointment, highlight overdue pill reviews, etc.
it is easy to get an overview of all appointments, such as who is available today, and when Dr Smith’s next free appointment is
the numbers of patients seen can be audited
audit of appointment availability and waiting times can be undertaken
a number of systems allow patients to log in to their practice to book an appointment directly, change or cancel.
The appointment system can also offer additional flexibility:
visits and telephone calls can be listed for each doctor, either at the end of surgery or as a separate list
notes can inform the doctor what the problem is for a visit or the reason for a telephone call
messages can be left on appointment screens for urgent visits and telephone calls
visiting lists can also be generated for health visitors and community nurses, enabling receptionists to know their location when they are away from the surgery.
Keeping patient records
The duration for which medical notes should be kept is explained in depth in Records Management, NHS Code of Practice Part 2 (2nd edition) (http://systems.digital.nhs.uk/infogov/links/recordscop2.pdf). A summary is included in Table 12.3.
Minimum duration for which medical notes should be kept.
In most practices, all paper notes are kept as long as the patient is registered with the practice, and then returned to the PCO.
PCOs must make arrangements for secure preservation of records for the prescribed time in respect of patients no longer registered with a GP. In particular, the accommodation must be secure, with proper environmental controls and adequate protection against fire and flood.
Disposal of medical notes
Practices will still need to keep paper records until it is legally acknowledged that they can be substituted by an electronic record. Until such time, it is advisable to continue to prune redundant and obsolete material from notes and file them in an orderly fashion. Disposal of paper medical records or items from them (e.g. redundant material) must be done carefully, ideally by shredding or, failing this, careful incineration.
Information governance
Information governance ‘provides a framework for handling personal information in a confidential and secure manner to appropriate ethical and quality standards in a modern health service’ (http://systems.digital.nhs.uk/infogov). NHS organisations, in general, and primary care teams, in particular, are increasingly expected to work in close collaboration with other organisations both within and outside the NHS. Information governance covers confidentiality of patient records, security of records and rights of access.
Confidentiality
The Human Rights Act (1998) establishes a right to ‘respect for private and family life’ and creates a general requirement to protect the privacy of individuals and preserve confidentiality of their health records. Respect for confidentiality is also an essential requirement for the preservation of trust between patient and doctor.
Everyone who works in a medical practice must understand the utmost need for confidentiality. Any information gained about a patient during the course of work must never be discussed with a third party, either within or outside the practice. These issues must be discussed at the first training session with new staff, and staff must understand that any breach of confidence will lead to instant dismissal. A paragraph to this effect can be added to staff contracts. Doctors must understand that failure to comply with standards can lead to disciplinary proceedings and even restriction/cessation of practice.There is a requirement for all NHS organisations to complete the Information Governance Toolkit. The Information Governance Toolkit is an assurance process developed and updated by the Health and Social Care Information Centre (HSCIC). It helpfully combines the legal rules and policy guidance into a single standard as a set of information governance requirements. GP practices are required to carry out self-assessments of their compliance against the Information Governance (IG) requirements. Typically, most practices are aware of the need through Care Quality Commission (CQC) inspections, but it is should be seen as essential safeguard for patients’ records for all staff who use the practice computer.
The Caldicott Review 2016
Dame Fiona Caldicott has undertaken a number of reviews and the most recent constitutes ‘Caldicott 3’. Each review served a purpose and stretched policy decisions. The first dates back to 1997, when the initial six ‘Caldicott’ principles were set out to protect confidentiality. The consequence of protection led to difficulty for integration moves such as those for health and social data integration. This led to a second review in 2013 adding a seventh principle of a duty to share being as important as to protect, where the circumstances deemed so. Moving with a concern around public trust over data security and the limited uptake following the second review, a third was embarked on. The most current review looks at the concept of patients opting out with confidence that their wishes will be rightfully upheld by the systems in place. Each review has built on their predecessor adding more detail.
Professional standards and good practice: All processing of such data must be lawful. There are four legal bases for processing personal confidential data which meet the common law duty of confidentiality. These are described below in this chapter, in the ‘Data processing’ section.
Caldicott Principles (Caldicott Review: Review of data security, consent and opt-outs, 2016).
Principle 1: Justify the purpose(s)
Every proposed use or transfer of personal confidential data within or from an organisation should be clearly defined, scrutinised and documented, with continuing uses regularly reviewed, by an appropriate guardian.
Principle 2: Don’t use personal confidential data unless it is absolutely necessary
Personal confidential data should not be included unless it is essential for the specified purpose(s) of that flow. The need for patients to be identified should be considered at each stage of satisfying the purpose(s).
Principle 3: Use the minimum necessary personal confidential data
Where use of personal confidential data is considered to be essential, the inclusion of each individual item of data should be considered and justified so that the minimum amount of personal confidential data is transferred or accessible as is necessary for a given function to be carried out.
Principle 4: Access to personal confidential data should be on a strict need-to-know basis
Only those individuals who need access to personal confidential data should have access to it, and they should only have access to the data items that they need to see. This may mean introducing access controls or splitting data flows where one data flow is used for several purposes.
Principle 5: Everyone with access to personal confidential data should be aware of their responsibilities
Action should be taken to ensure that those handling personal confidential data – both clinical and non-clinical staff – are made fully aware of their responsibilities and obligations to respect patient confidentiality.
Principle 6: Comply with the law
Every use of personal confidential data must be lawful. Someone in each organisation handling personal confidential data should be responsible for ensuring that the organisation complies with legal requirements.
Principle 7: The duty to share information can be as important as the duty to protect patient confidentiality
Health and social care professionals should have the confidence to share information in the best interests of their patients within the framework set out by these principles. They should be supported by the policies of their employers, regulators and professional bodies.
Special circumstances
Children: Disclosure of personal medical information can be authorised by a person with parental responsibility. Young people mature enough to understand the implications can make their own decisions and have a right to refuse parental access to their health record.
Mentally incapacitated adults: Capacity must be judged in relation to the decision to be made. People with a mental disability can authorise or prohibit sharing of information concerning themselves if they broadly understand its implications. If a patient lacks the ability to understand, decisions must be based on an evaluation of the person’s best interests and reflect the individual’s expressed wishes and values. A third party appointed by a court may authorise disclosure.
The deceased: Legislation covering records made since 1 November 1991 permits limited disclosure in order to satisfy a claim arising from death. Where there is no claim, there is no legal right of access to information.
Data processing
This is an extract taken from Caldicott 2 (Box 12.2) looking at the laws that apply. All processing of such data must be lawful. There are four legal bases for processing personal confidential data which meet the common law duty of confidentiality. These are:
Caldicott review 2 (Caldicott review: information governance in the health and care system, 2013).
with the consent of the individual concerned. Details concerning consent for direct care are fully explored in section 3;
through statute, such as the powers to collect confidential data in section 251 of the NHS Act 2006 (see section 6.25) and the powers given to the Information Centre in the Health and Social Care Act 2012 (see section 6.12);
through a court order, where a judge has ordered that specific and relevant information should be disclosed and to whom; and
when the processing can be shown to meet the ‘public interest test’, meaning the benefit to the public of processing the information outweighs the public good of maintaining trust in the confidentiality of services and the rights to privacy for the individual concerned. In addition to having one of these legal bases the processing must also meet the requirements of the Data Protection Act and pass the additional tests in the Human Rights Act. Any processing of personal confidential data that is not compliant with these laws, even if otherwise compliant with the Data Protection Act, is a data breach, and must be dealt with as such.
Summary of relevant legislation
See Table 12.4 for a summary.
Summary of relevant legislation relating to confidentiality and access to patient records.
Further information: Information Commissioner’s Office: https://ico.org.uk/
Difficult situations
Telephone information: Telephone information should only be given to the patient the information concerns, unless the patient has previously consented to the information being given to a third person. Messages containing medical information should not be left on answerphones. Receptionists should beware of relatives or employers trying to obtain information on behalf of a patient. It may not be appropriate to give certain information by telephone, even to the patient it concerns – positive pregnancy results, abnormal cervical smear results or the results of tests for venereal disease are best given by a medical member of staff who can answer the questions that may arise.
Staff and their relatives: Staff and their relatives who are registered with the practice present special difficulties regarding confidentiality. Staff and their families can be encouraged to register with a neighbouring practice. Alternatively, staff notes could be locked in a separate filing cabinet with access to doctors only.
Reception areas: These can present problems. Conversations and telephone calls can be overheard by other patients, and notes or results left on open counters may be viewed by other patients. Diligence and awareness is necessary at all times. Background music can muffle conversations, but confidential conversations or telephone calls should ideally be held in soundproof areas of the reception area or, preferably, in another room.
Prescriptions and medication: These should only be given to the patient or someone who is known to be their representative.
Access to medical records
Under the Data Protection Act 1998, patients have a right of access to health records that:
are about them and from which they can be identified
consist of information relating to their health or condition
have been made in connection with their care.
Most records made by doctors and other members of the PHCT are included, regardless of when they were made.
Who can seek access?
Any competent person may seek access to their own health records, including competent children.
Any person with parental responsibility may apply for access to records of a child (under 18 years, or under 16 years in Scotland). Where more than one person has parental responsibility, each may apply independently without consent of the other parent.
Where the patient is incapable of managing his/her affairs, a person appointed by a court may access records necessary for the appointee to carry out his/her functions.
A third party authorised by a competent person (such as an employer) may seek access to that person’s records – but proof must be provided that permission has been given. Usually a written application for information is required, together with signed consent from the patient. If there is any doubt, contact the patient to verify consent has been given.
Requests for access
Nothing prevents doctors from giving patients access to their records on an informal basis provided there is no reason for preventing disclosure. Information must not be disclosed if it:
is likely to cause serious physical or mental harm, or
relates to a third party who has not given consent for disclosure (where that third party is not a health professional who has cared for the patient).
If unsure, take advice from the BMA or your medical defence organisation.
Formal applications for access must be in writing. No fee can be charged for giving access to health records unless none of the information was recorded after the beginning of a period 40 days immediately preceding the date of application. In this case, the maximum fee chargeable is the same as that for Data Protection Subject Access Requests which is currently £10. Patients are entitled to a permanent copy of information (e.g. photocopy, print out), which must be accompanied by an explanation of any unintelligible terms. Any reasonable costs of copying or postage may also be charged to the patient. Access must be given within 40 days of receipt of the request and any fee.
Mrs Smith visited her doctor, and the following week she asked to see her medical records. The practice did not charge a fee.
Mrs Jones went to see her doctor on 1 October. The consultation was routine, and no follow-up necessary. On 2 January of the following year she asked to see her medical records. As there had been no entries for 40 days preceding her request, Mrs. Jones was charged a fee of £10.00.
Teaching practices
Teaching practices should inform their patients that doctors outside the practice may look at their notes and patients must be given the opportunity to object to this. The following notice could be displayed in the practice leaflet and the waiting room: This practice is a teaching practice. The approval process to become a teaching practice involves the inspection of patients’ medical records at intervals by visiting teams from outside the practice. They treat the contents of these records as strictly confidential. If for any reason, you object to your own records being viewed in this way, please inform the receptionist.
Access to identify subjects for research projects
General practices are frequently asked to help identify patients to participate in research studies. There are several ways in which this can be done, such as the following examples:
Self-selecting population: a notice is placed in the practice asking patients to volunteer to take part in the study. This tends to lead to a skewed population for the researcher.
Asking GPs to recruit patients directly during the course of their work – the patient is given details of the study and then can opt to take part or not without any breach of confidentiality.
The researcher may request that a practice run a computer search to generate a list of patients with a particular condition under study. From these data, the researcher can generate a sample of patients who meet the study criteria. The researcher can notify the practice of the unique patient identifiers that the practice translates back into patient identity. The GP can then write to the patients on behalf of the researcher, inviting them to participate in a research study. The patient retains control and confidentiality is not breached.
Caldicott 3 now stipulates that any research requiring larger practice population access has to offer ‘opt out’. For further details see the information section on confidentiality with the Caldicott update.
Security of records
To maintain patient confidentiality and trust, it is essential that patient records are kept securely. As a general principle, think about security at all times:
Do not leave records (electronic or manual) unattended in easily accessible areas.
When not in use, ideally, store all files and portable equipment under lock and key.
Query the status of strangers.
Highlight any concerns to the practice/security manager.
Do not reveal to anyone how security systems operate.
Electronic records
Do not leave a terminal unattended and logged-in.
Do not share logins or reveal your password to others.
Change passwords regularly and avoid using short or obvious ones.
Always clear the screen of a previous patient’s information before seeing another.
Use a password-protected screensaver to prevent casual viewing of patient information by others.
Access to patient records can be determined by differential access codes, for example, allowing lay staff access to registration details only. However, practices may decide that differential codes are not necessary on the grounds that all staff should understand the rules of confidentiality for all situations.
Ensure that the practice system has an up-to-date anti-virus software and is protected by a functioning firewall at all times.
When communicating electronically with other NHS sectors, ensure appropriate mechanisms are in place to maintain the privacy of any patient-identifiable data concerned, and that there is some form of accreditation or conformance testing of the technical mechanisms to be used that is designed to preserve the integrity of the data being exchanged.
Review incoming electronic data not just for its impact on patient care, but also to ensure as far as possible that it is not corrupted in some obvious way – reject it if it appears so.
Highly sensitive information
This can cause problems, for example concerning patients who are HIV positive or hepatitis B carriers. It can be argued that, as all information should be confidential, highly sensitive information should not be treated any differently; also, this sort of information has implications for all clinical staff and should be readily available. Against this view is the cost of a breach of confidentiality for sensitive information, which is so very high, and the stigma that is attached to these diagnoses. Good clinical practice demands that precautions should be taken with all patients for procedures involving body fluids, not just those who are high risk. There are ways in which the risk of disclosure of highly sensitive information can be minimised – for example special codes on the computer that mean that a diagnosis will not appear on a problem list – but instead a symbol indicating to the clinician that a ‘sensitive’ diagnosis is present, enabling the clinician to access the information as needed. Each PHCT must decide how they will deal with such situations.
Paperless accreditation
Many practices have chosen to go paperless through the increased use of scanners in practice. However, many practices still use some manual recording system in addition. ‘Paperless (or paper light) accreditation’ is obtained from the PCO, who base their criteria on the Good Practice Guidelines for Electronic Records endorsed by the Department of Health, the General Practitioners Committee (GPC) and the Royal College of General Practitioners.
These guidelines suggest that for practices applying for accreditation:
it should be possible to download demographic information into the clinical system
data should be recorded in a manner that is complete, accurate, relevant, accessible and timely
all clinicians should participate in data recording and enter their own data directly into the clinical system, including that from home visits
the practice should consider what data are not recorded at all (or not consistently) on computer by some, or all, clinicians
data from other PHCT members, such as community and practice nurses, locums and registrars, should be captured
data from new patients should be captured on the system
protocols of care and/or diagnostic criteria (where available) should be used consistently and made acceptable to the practice as a whole
the individuals who will design, develop and implement templates or protocols should be identified.
data from external providers (e.g. hospital discharge letters, pathology and radiology results) should be captured
a protocol for managing system failure should be established
data quality should be monitored
training for general practitioners and other practice staff involved in data capture should be considered
a practice IT lead should be identified
a baseline assessment should be carried out to enable the practice to understand what changes need to be made.
Fax machines
Fax machines are potential sources of breaches of confidentiality. Information transmitted by fax should only be sent if confidentiality can be guaranteed at the other end. It is expected that fax machines will become obsolete and a relic of history as all communication moves to electronic mail.
Further information:
Access to health records by patients
Confidentiality and people under 16
GMC: Guidance on good practice – confidentiality. http://www.gmc-uk.org
Information Commissioner’s Office: http://www.ico.gov.uk/
The Good Practice Guidelines for GP electronic patient records v4, Department of Health/Royal College of General Practitioners/British Medical Association (2011)
Electronic secondary care appointment booking
The first key system to go live under the Information for Health Strategy was the electronic booking service from primary care to secondary care. This was known as Choose and Book and is now known as the NHS e-referral service. The service allows patients to effectively (where possible) choose the hospital that they would like to be treated in. The NHS has invested heavily NHS e-referral and it has not been without its faults, nor without manipulation. However, in general, patients tend to like the system and enjoy having some say in when and where their appointments will be. Once referral has been decided upon and a unique booking reference number has been created by the GP surgery, a patient can then make their own hospital appointment through the NHS e-referral service either over the phone or via the NHS e-referral website (https://www.ebs.ncrs.nhs.uk/) as described below.
The benefits of the NHS e-referral service are as follows:
The patient can choose any hospital in England that is funded by the NHS (including many independent hospitals).
The patient can choose the date and time of their appointment, fitting it around their own schedules.
The patient can check the status of their referral and amend or cancel appointments as they choose.
Electronic Prescription Service (EPS)
The programme for the electronic transfer of prescriptions between GPs, community pharmacists and NHS prescription services is in place. The roll-out has been a phased approach and many GP practices are enabled to use it. The theory is that prescribers will be able to send prescriptions electronically to the dispenser (usually a local pharmacist), which can be of the patient’s choosing. The security of this process for the prescriber is through smartcard access to create the necessary two step user authentication security process (login followed by smartcard login). This is dependent on patients choosing their preferred pharmacy and once set can have all scripts issued to them with the prescriber only using a ‘pin’ code, rather than signing, as the authorisation of scripts. There is a lot of ease with this. Many practices have linked this to allow patients to request prescriptions online too. From a practice perspective there is a huge burden of printing, storing and patients collecting that has now moved away from the front desk. It is more convenient. However, it is more cumbersome to recall once issued.
NHS care records service
NHS Digital (http://content.digital.nhs.uk/) is the name for the organisation formerly known as the Health and Social Care Information Centre (HSCIC). It holds all the information that was in predecessor entities, including the outputs from the historic national programme for IT. The first phase of NHS care records service (NCRS) contains basic functions that include personal details, any medication that has been prescribed, any known allergies or any bad reactions to medicines that the patient may have suffered. This first phase is known as the summary care record (SCR).
The summary care record (SCR)
Initially this was due to be the single summary record. With the advent of ‘care planning’ which comes in different guises, the SCR is a brief synopsis with details now residing in other parts of the system. The ambition was for universal roll-out access across the system. An attempt through ‘care.data’ in 2016 led to public concern about the use of health data. This was one reason for triggering the third Caldicott review. Currently, whilst access is being built the opt out mechanism has been made more robust.
NHSnet
NHSnet is a network connecting NHS organisations, which is protected from the Internet by a firewall. This enables NHS users to access the Internet, but outside users cannot access NHS websites (though they can send emails to NHS users). All GP practices in the UK have been connected to the NHSnet, enabling email, Internet access, electronic exchange of information about appointments and test results, shared learning resources, computer-based training packages, discussion forums and many other benefits. Many practices now receive all laboratory results back electronically and this is likely to extend to clinic appointment letters in the near future. The current political ambition is to start communicating electronically with patients too. A number of pilots are taking place at present with a move to support greater online and remote access.
NHS directory
This comprises lists of NHS organisations, departments and personnel together with biographical details. The NHS directory will be used to authenticate individuals using the system in order to control access to restricted areas of the NHSnet and ensure confidential data are not transferred into the wrong hands – an essential factor in the development of national electronic records systems for both staff and patients. It will also be used together with the NHSmail system to aid communication between NHS staff.
Use of email in the surgery
The majority of the UK population now has access to email, and its use is increasing rapidly worldwide. National surveys show that patients increasingly want to be able to communicate with healthcare professionals by email, but email has been used relatively little to date in healthcare settings due to concerns over quality of email content, confidentiality and liability. This has changed, and now there is a move to all communication being electronic. That offers a benefit in respect of being a single channel of communication to check. However, the downside is that it requires more efficient processes to triage the messages as to what is urgent for review that practices now need to incorporate into the usual daily workings of a practice akin to how phone calls are treated.
E-consulting
See page 12-03.
Use of the Internet and telemedicine
See page 12-03.
Further information: NHS Digital: http://content.digital.nhs.uk/
Non-clinical uses of computers in the surgery
There are several areas of practice management that lend themselves naturally to computerisation; these are the repetitive, time-consuming tasks that require more administrative than managerial skills. The key to successful transfer from a manual to an electronic system is clear evaluation and aims. Many people make the mistake of allowing the technological tail to wag the dog – in other words, they manufacture tasks to fit the facilities of the computer software. To remain in control of computerisation, it is essential for managers to be definite about the things they wish to achieve and then research the correct software package to deliver the objectives.
Before embarking on any form of computerisation, a manager, or any other member of the team, is well-advised to analyse how their time is spent. (See the ‘Time management’ section, 7-36.) It is often the mundane jobs that occupy the majority of available time, not necessarily the major projects or current priorities. This type of analysis will focus upon the areas that are desirable to be dealt with electronically and that will free valuable time to be redeployed more productively.
Much of the partnership’s business that is suitable for computerisation is highly confidential, e.g. practice accounts. For this reason, the manager should have a PC rather than a networked terminal. Access can be restricted and sensitive data stored on external devices that can be removed from the premises to safeguard the data. As with the clinical system, a comprehensive back-up routine is essential. To enter confidential data on a networked system that can be accessed by any user may leave the manager guilty of a breach of confidentiality, even if this is unintentional.
In this section, there will be many parallels with the disciplines and guidelines that apply to the electronic storage of clinical data. For this reason, the chapter should be read in its entirety.
Internal communication
Meetings, minutes and agendas
The business and policy meetings held in the partnership must be properly recorded and the minutes circulated promptly. This is a routine task and often the partners will wish to clarify a previous decision. Computerised records can be interrogated in a variety of ways, e.g. using key words or dates, to produce the answers. A laptop will allow the minutes to be taken during the meeting and eliminate the need to take notes and transcribe them after the meeting.
Internal messaging
There are many occasions when a manager or receptionist needs an urgent signature from a doctor – this often involves hovering outside the consulting room door to catch the doctor between patients. Time wasted in this way can add up to hours during the course of the week. Many of the clinical systems allow messages to be flagged on specific screens, allowing any team member to contact a doctor in their consulting room without disturbing the consultation. Examples of its use may be a message about a cancelled appointment, an urgent phone call or visit, or an urgent cheque or letter to be signed. Whatever the reason, it makes much better use of everyone’s time. Practices can become quite innovative in the way these message screens can be used. With the advent of EPS and messaging on the computer systems more options are available now.
Diaries
Many practice managers use shared electronic diaries so that everyone’s diary can be accessed. This makes the arrangement of meetings much quicker, removing the need to consult each individual about their whereabouts at any given time.
Practice intranets
These can be useful to aid communication within the practice as information on the intranet can be accessed from every networked terminal. Restrictions on access can be included so that different information can be accessed dependent on who is looking. Examples of information which could be included on a practice intranet are names and photos of staff including attached and visiting staff (very useful for people who work irregularly in large practices); practice protocols; ‘good locum guide’; templates of all locally-used referral forms; headed paper; computer trouble-shooting tips; links to useful websites such as local hospital sites or the British National Formulary (BNF). Some of the existing clinical systems have intranet facilities and modules incorporated within them.
Correspondence
There are numerous letters used in general practice which can be standardised. Nowadays standard referral letters, recall letters, letters informing patients of results and patient questionnaires, for example, can all be embedded within clinical systems.
If other letters are being dictated frequently in the practice, it can save hassle to install digital microphones on each PC, enabling dictation directly into the PC. The digital record can then be transferred electronically to a secretary for typing. Alternatively, there are several speech recognition, voice recognition or voice dictation software packages which automatically transfer letters dictated into them into a word-processing package – without the need to type at all.
Address books
Some software packages offer a specific filing system that equates to a card index, into which names, addresses and telephone numbers can be entered. This type of computerised address book is easy to amend and has the advantage of producing address labels via the printer. Alternatively, a spreadsheet package or standard database can be used to create your own address book.
Desktop publishing
Most of the leading word-processing packages offer a variety of typefaces, which, combined with a high quality printer, make it possible for a practice to produce their own headed stationery, ‘with compliments’ slips, patient-information sheets and practice leaflets. Small quantities can be produced at any time and amendments can be introduced immediately. It is often cheaper to outsource large quantities of printing as most standard printers are expensive to run.
Practice accounts
There are a number of software packages available to enable a practice to computerise their accounts, including invoicing and maintaining an income and expenditure ledger. To minimise accountancy fees, it is sensible to contact the practice accountant to get advice before any purchase is made. It may be that the chosen software is compatible with the accountant’s own system and that data can be transferred via discs, with the supporting documentation retained at the practice for inspection. For in-house financial performance monitoring, a simple spreadsheet software package may be sufficient. This will allow the manager to tailor-make reports to meet the specific partnership needs; indeed, all the examples given in Chapter 3 are taken from a spreadsheet package. This type of task is ideally suited to computerisation, because it allows information to be produced quarterly in a simple format that enables the partners to take remedial action in-year, rather than waiting for the annual audited accounts. To safeguard security, the information can be protected by passwords or downloaded onto discs, but, as with all important information, there should be a back-up copy of all the data.
Electronic banking
All major high street banks offer electronic banking to their customers, and managers are advised to contact their branch to see what services are available. The advantages are instant access to bank accounts to establish balances, make payments and transfer funds from one account to another.
Payroll
One of the priorities for any manager, in terms of saving time, is the computerisation of the payroll. To do the monthly salaries on a manual ledger system is both time-consuming and repetitive. There are a number of excellent software packages on the market and again, the advice of the practice accountant should be sought, because some software packages are more acceptable to the Inland Revenue than others. There are a few questions that will help to narrow down the choice, for example:
— Can the system produce all the end-of-year statements?
— Can the system accommodate the staff superannuation scheme?
— Is the system updated annually when the new tax allowances are announced?
— Can the system deal with Statutory Sick Pay (SSP) and Statutory Maternity Pay (SMP)?
— Is the system able to cope with more than one hourly rate for each member of staff?
To streamline the preparation for the payment of salaries, some practices devise their own monthly data collection sheet for staff to complete and sign. This will confirm any records of absence and holidays that the manager may keep. Ideally, the data collection form headings will reflect the sequence in which information needs to be entered into the payroll software, and the forms should be retained to verify payments or to address any queries about payment or holiday entitlement.
Consequences of computerisation
Traditionally, a large part of office space is occupied by storage units, either in the form of filing cabinets or large units to house records. When space is tight, it is not unusual for practices to store archives in the practice loft. If the manager’s business files, headed stationery, practice brochures, patient leaflets, address books and diaries are stored electronically, the need for storage space is dramatically reduced. This is also true of medical records if they are all computerised. This has an impact on office planning, especially for those designing new premises or seeking to increase administration space. Instead of filing paper manually, the relevant information can be retrieved from the computer hard disc or a floppy disc and copies printed to order.
Sadly, much of the documentation that a manager files is never used or needed again and only serves to provide them with a sense of security in knowing that they have it! However, as the level of computerisation increases, the number of computer workstations is likely to increase, so any storage space gained may be needed for additional computer equipment.
Retrieval of data
An efficient manager or administrator will be able to retrieve information quickly if they use a manual paper-based filing system, and the same is true of a computerised one. All electronic documentation should be logged in a master file. Too often it is difficult to recall a specific file name several months after it was created. A routine must thus be established of recording the names of new files along with their full explanation and a record of every document entered in that file.
Staffing implications
Technology has had, and will continue to have, an impact on the skills that a practice seeks to recruit. There has been a gradual shift away from specialist administration skills to more generic keyboard abilities. Many practices have already decided that they no longer need the secretary to have shorthand, and dictaphones and word-processing have already made this an optional ability. If a practice invests in good computer training for all staff, they will be able to achieve a greater degree of flexibility and redeploy staff time saved to more proactive duties. Every business plan that a practice writes should reflect this trend and evaluate the manpower and financial implications.
Information technology support
PCOs are responsible for providing and maintaining core IT systems for general practice. However, many practices use software and hardware outside of the scope of the PCO and it is important to have support systems in place to ensure reliability and good technical support. The IT departments at PCOs are often very good at advising practices about making suitable arrangements. In some areas these are still through Clinical Commissioning Groups (CCGs), whilst in others the support is through the IT offer with Commissioning Support Units (CSUs). If GP-led provider federations or groups are successful they are likely to be another source of IT support.
Notification of disease
There are several circumstances when doctors are obliged to notify statutory agencies about disease or side-effects of drugs.
Occupational illness
If a patient develops an occupational disease, a doctor is obliged to notify the employer in writing with the patient’s consent. The doctor does not need to make a judgement about whether the disease is, in that particular case, caused by the occupation. A list of notifiable industrial diseases is provided in Box 12.3. Employers must then inform the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR) incident contact centre (0845 300 99 23, www.hse.gov.uk/riddor). Self-employed patients must contact RIDDOR themselves.
Notifiable industrial diseases (Note: This is not a complete list).
Poisoning by industrial agents, e.g. lead, arsenic, mercury
Repetitive strain injury
Vibration white finger
Bursitis, e.g. housemaid’s knee
Occupational asthma
Folliculitis and acne (associated with work with tar, pitch or oils)
Occupational infection, e.g. hepatitis B in healthcare workers, anthrax in farmers
Chrome ulceration
Irritant dermatitis, such as hairdressers’ dermatitis tenosynovitis, e.g. as a result of repeated movements of the hand/wrist.
Pneumoconiosis
Extrinsic allergic alveolitis
Occupational deafness
Occupational cancers, e.g. nasopharyngeal cancer in woodworkers, bladder cancer in plastic workers, cancers as a result of ionising radiation, mesothelioma due to asbestos exposure.
Patients who do not give consent for the doctor to notify their employer may allow the doctor to inform the employer’s occupational health department or RIDDOR directly instead. The CQC inspections typically pick up on these areas too as an area looking at what each practice does under these circumstances.
Industrial injury
Injured employees should always report details of any accident occurring at work to their employer and record them in the accident book as soon as possible – however trivial the injury. Employers must inform RIDDOR of:
— dangerous incidents, even if no-one was hurt
— incidents where death or serious injury occurs
— incidents resulting in injury requiring more than 3 days’ absence from work
— incidents involving gas.
Infectious diseases
Notification of certain diseases is required under the Public Health (Control of Disease) Act 1984 and Health Protection (Notification) Regulations 2010. Notification is made to the local authority’s Medical Officer for Environmental Health, who also provides forms for notification purposes. It is important to note that the patient’s ethnicity must be included on the notification form. Diseases included are listed in Box 12.4. In addition, notification should be made if:
contamination from the environment, for example with chemicals or radiation, could have played a part in a patient’s illness
the patient has any other infectious disease that presents, or could present, significant harm to human health
the patient dies with, but not necessarily because of, any notifiable disease or other infectious disease or contamination that presents, or could present, significant harm to human health.
Notifiable infectious diseases.
It is not necessary to wait for laboratory confirmation before notification of infectious disease if there is reasonable clinical suspicion. If you have good reason to believe that another doctor has already notified the public health services about your patient’s disease, then there is no reason for you to notify too, but prior notification by the laboratory does not remove the doctor’s responsibility to notify. For urgent notification of matters of serious public health significance, contact the local health protection unit office or out-of-hours telephone of the local hospital and ask for the on-call public health consultant.
Further information:
Public Health (Control of Disease) Act 1984, Health Protection (Notification) Regulations 2010. www.opsi.gov.uk/si/si2010/uksi_20100659_en_1
Health Protection Legislation (England) Guidance 2010.
https://www.gov.uk/guidance/notifiable-diseases-and-causative-organisms-how-to-report
Adverse drug reactions
The possibility of rare or delayed reactions means that the safety of new medicines cannot be established until they have been used for some time in a large population. A 24-hour freefone service is available for information and advice about suspected adverse reactions (0800 731 6789).
Suspected adverse reactions
Suspected adverse reaction to any therapeutic agent (whether over-the-counter, herbal or alternative medication, or prescribed by a doctor) should be reported to the Medicines and Healthcare products Regulatory Agency (MHRA, 10–2 Market Towers, 1 Nine Elms Lane, London SW8 5NQ; www.mhra.gov.uk). Forms (‘Yellow cards’) are available from that address or in the back of the BNF.
The yellow card scheme is also accessible electronically (https://yellowcard.mhra.gov.uk/the-yellow-card-scheme/).
— For new drugs (marked ˆ in BNF): Doctors are asked to report all reactions whether or not causality is clear.
— For established drugs: Doctors are asked to report all reactions in children; all serious suspected reactions even if the effect is well documented (e.g. anaphylaxis, blood disorders, renal or liver impairment, drug interactions); but not well-known, relatively minor side-effects (e.g. constipation with opioids, insomnia with SSRIs).
Defective medicines
A medicine which does not conform to its specification is deemed defective. Report suspected defective medicine with as much detail as possible on both the product and the nature of defect to: The Defective Medicines Report Centre, Medicines and Healthcare Products Regulatory Agency, Room 1801, Market Towers, 1 Nine Elms Lane, London SW8 5NQ; 020 3080 6574 (08:45–16:45 Monday to Friday) 020 7210 3000 (urgent calls outside working hours, at weekends or on public holidays).
Consumer Protection Act (1987)
If a patient is damaged by a defective product, liability falls on the producer, unless outside the European Community in which case it falls on the importer. If the importer cannot be identified, liability falls on the supplier. This is important for GPs. Those who dispense are at greatest risk, but all GPs occasionally supply drugs in an emergency or for procedures within the surgery (vaccinations, minor surgery, contraception). Always record manufacturer, batch number and expiry date when using such drugs, and keep records of storage of drugs and maintenance of equipment.