At HTN Now: Digital Primary Care, we welcomed Dr Osman Bhatti, GP and Chief Clinical Information Officer at North-East London ICB.
Osman joined us to discuss the debate around patient access to online GP records, with focus on what is happening, how practices should prepare, and how his own ICB have handled the change.
Contractual obligation
Osman began by highlighting some sections from The National Health Service (General Medical Services Contracts) Regulations 2015, available to read in full on the government’s legislation website.
The document lays out provision of online access to coded information in medical records and prospective medical records, highlighting how contractors should promote and offer the facility along with specific clauses around excepted information, reasonable delays in providing the facility and more.
On how North-East London ICB have approached access to online records, in view of the guidance, Osman said, “The main thing that we looked at was the issue around prospective medical records. The guidance says that the contractor may ‘delay providing this facility if we consider that providing it would have an adverse impact on its provisional of essential services’.
“We certainly felt in our area that there actually was a lot of pressure, as is the case across most of the GP estate. There is so much going on that we are dealing with, without having to deal with prospective access as well. We felt that this would have an impact on the provision of our essential services.”
Osman added that the document also provides this clause with regards to ‘delaying giving the patient access to any information added to the prospective medical record after they have gained access.’
“The more content that we start including and the more patients get exposed to seeing, the more chance there is of generating additional workload,” he said. “It may not have a great impact in terms of numbers but things can add up and have an adverse impact on everything that we are currently working on in primary care.”
The ICB explored other options to decrease workload pressure on colleagues, Osman explained. “It’s about informing the patient of what we are doing, when that information is going to become available. In a nutshell, we’ve looked at this guidance and decided that we’re not going to stop patients having access, but we are very much doing it as an opt-in process rather than a generic opt-out where everybody gets their record on mass.”
Prospective access
“With prospective access, if patients have got automatic access then they will have information that we may not be happy with or may not be aware that patients have access,” Osman said. “Most patients will be fine, but there may be some vulnerable patients who we need to think about a lot more closely.”
Across North East London, practices have been informed to let system suppliers know that the ICB does not want them to initiate automatic access. “As of 1 February, if practices have not informed their system suppliers about this, then automatic access will be switched on.”
Osman shared that 20 percent of England went live yesterday with prospective access, indicating that the other 80 percent have come to an alternative decision like the one made in his own ICB.
“This tells me that there is certainly an impact with prospective access that NHS England has got to review,” he said.
“The other question that we really looked at in terms of our decision making is around clinical safety review,” he said. “One of the biggest questions is around who has done the clinical safety review. The requirement through NHS England’s new standard is the fact that every new tool that has an impact on clinical information should have a clinical safety review.”
He emphasised the importance of setting out roles and expectations around this. “Is that the responsibility of the practice, the PCN, the Federation, the ICB? It needs to be done by someone.”
NHS England has completed its own clinical safety report, published in September 2022, which highlights several hazards to watch out for if prospective access is to be rolled out.
“The next question is: who has done the mitigation to those hazards?” Osman asked. The publication in September 2022 may have come in late for practices, he noted, raising uncertainties around whether practices are aware of them and the need to address them.
NHS England’s clinical safety report
Next, Osman examined the report in more detail. It is available on the Future NHS website. To view the sections Osman chose to share, click to 08:19 on the video below.
“Basically, there’s lots of mitigation that general practice needs to do,” he said. He highlighted some of the hazards identified in the report, such as the fact that allowing prospective access to happen could lead to patients coming “to psychological trauma and/or physical harm if their data is viewed by a person other than themselves.”
It’s “good that we are aware of this,” Osman said, “but we need to be appreciative of what we are doing to actually mitigate that concern and whether steps have been taken.”
The report includes a section on businesses processes, focusing on how practices need a process to review their records on a continual basis. Again, the report emphasises a risk to patients ‘if their GP practice fails to safely implement change.’
With this in mind, Osman asked: “Are all GP practices aware of the changes that they need to make to their processes, such as making sure that they are redacting information properly or making sure that there is not third-party information in records?
In terms of recommendations put forward by NHS England, the guidance highlights how ‘analysis and review on additional controls have been documented within the hazard log which general practice should implement to ensure they can reduce the likelihood of the hazards’.
It goes on to share additional controls for general practices to be completed by the national programme, including a need to raise awareness of the change to third-party organisations; to provide citizens with a safe route to contact their practice if they have seen potentially harmful information; to provide general practice with a safe route to report incidents using existing processes; to provide redaction guidance at least four weeks in advance; and more.
“This document tells us that there were concerns raised centrally, and if we are to do this properly, each area has to look at this report and mitigate against all of those hazards,” Osman said.
Issues with access
Osman stressed the question of who has access as a main issue with automatic prospective access. Patients with mental health issues or capacity, those at risk of domestic violence or coercion, or patients with potentially sensitive information or diagnoses could all potentially pose an issue.
A mitigating factor put forward by a pilot site suggested that proactive searches can be completed in order to exclude patients who have been coded with severe mental illness or other specific codes from prospective access.
However, Osman noted: “That’s all well and good for the patients that you know about and have coded, but it doesn’t work for anyone else.”
The lack of redaction software poses another issue, and Osman added: “In addition to that, there’s no redaction transfer from the previous practice. If I’ve got a patient in my practice and I’ve redacted information on them, and they come and join your practice, all of my redaction gets lost. It isn’t transferred with the medical record. The new practice has to do it again and doesn’t know any of the concerns I have previously raised. It’s not as relevant to prospective, more retrospective, but it’s still an issue that we were concerned about.”
North-East London ICB’s plan
With those concerns in mind, Osman described how his ICB “wanted to avoid placing undue clinical and information risk onto our local GP practices. As data controllers, GP practices should be able to review the records prior to individual release to ensure that the data is without coercion and the information is accurate.”
Osman said that the ICB’s plan involves practices continuing to offer prospective and retrospective access to patients using a step-by-step process.
“The main focus is on good patient care. We’re behind the NHS App as the app of choice – we’re building a lot of things around it such as online consultation and care planning. We’ve said that patients can access their records through the NHS App and the vast majority of those interactions revolve around repeat prescription requests.
“We’re encouraging patients to look at their record as well, mainly those with long-term conditions. For example, if I’ve seen a patient for a blood test and I know the results are normal, I’ll encourage them to look for their results on the app.”
Osman moved on to share the ICB’s step-by-step process:
- Patients request online access. Osman encourages practices to ensure that they have a good process in place for this and support patients to contact them in whichever manner best suits the patient, in order to request this.
- Practices issue an application form to the patient following the request. “We’re thinking about ways to make this a bit easier – perhaps we can do it as an online form rather than paper,” Osman said. He showed an example of the ICB’s form at 16:36 on the video below, highlighting how they have included ‘things to consider’ for patients on topics such as forgotten history, abnormal results and bad news.
- Patient returns form and practice verifies identify of patient.
- Practices add a specific code to indicate that patient registration data has been verified to the medical record. “This is just so that we’ve got that governance in place, so it’s been recorded,” Osman said.
- Patients are either given full access as per their request on the application form, either at the point of verification or after the record review in the next step. “Some practices decide to give access straight away and then look at the notes, because they are confident in their processes; others want to review the record and then provide access. It’s very much up to the practice.”
- The practice reviews the record within a set time frame. “We’ve given them a rough aim of about two weeks,” Osman explained. “We recommend that at this point, you also look at tidying up the record. You want to make sure that the problem list is accurate so that the patient gets an accurate picture of their medical record and their problems. Again, this is something that can be overlooked if everyone is granted prospective access automatically.” He also recommended checking the medication list.
“In addition to these six steps, it is very much about making sure that as a practice you’ve got an ongoing process in place,” Osman said. “It’s about improving training within the practice – one of the other areas we’ve focused on is what training practices need, particularly around the admin team. When we get documents coming into the practice, are we in a good place where we are reviewing them and making sure that there is no third-party information? If there is, is it getting redacted where it needs to be? There needs to be a good focus all of this at the point of entry to the practice, a good review so that everything gets coded properly.
“A lot of practices do this already, but I think that when you’ve got a lot happening, the pandemic on top of your long-term management, one of the things that can often get overlooked is the actual record and how we maintain it. We’ve been trying to get our practice staff access to good coding training to make sure that everyone is aware of good data quality.”
Finally, Osman shared his blog on which he shares more information: click here to access it.
Many thanks to Osman for joining us – the session can be watched in full on the video below.
