Preparing for online patient access to records

PATIENTS in England with the NHS App or other online accounts are to be provided digital access to all new entries in their GP health records from 1 November 2022, under current NHS Digital plans.

The access arrangements will apply to practices using TPP and EMIS systems and will include test results, free-text letters, consultation notes and other documents entered or filed onto their record in the clinical system after the planned November “go live”. Arrangements with practices using Vision as their clinical system are under discussion.

MDDUS medicolegal adviser Dr Emily Shepherd and medical practice adviser Mimi Salgado delivered a webinar on 13 July 2022 which addressed some of the concerns practices may have leading up to the go-live date. This is now available to watch on demand here.

Below we include answers to some of the most frequently asked questions by members.

What should we be doing now to prepare for online access to records?

As well as accessing our on-demand webinar addressing common questions, you can also check out resources available from NHS England, NHS digital and the RCGP. NHS England are running a number of webinars which should help practices create a comprehensive policy addressing online access and advise on best practice for systems and training for staff.

What is appropriate to write in patient records?

Patient records should be a contemporaneous clinical record and should only contain factual clinical data and clinical decisions, and the notes should accurately represent what was discussed with patients in terms of their healthcare management plan. Comments a patient may make during their consultation which are not clinically relevant should not be recorded. Patient complaints and other medicolegal correspondence should be held in a separate file from the patient medical record.

From what date will patients be able to view their records and what systems/apps will be affected?

The planned go-live date is currently 1 November 2022, and from this date onward anything recorded in patient notes that is not ‘hidden’ will be accessible by the patient. The change will apply to the NHS App and all other approved patient-facing service apps that provide record access, for example Evergreen, Airmid, SystmOnline and Patient Access. NHS Digital also aims to enable patients to request their historic coded records in 2023 via the NHS App. We understand this will be a gradual process and clear guidance will be released in due course.

Can I use medical terminology and abbreviations?

It is reasonable to continue using medical terminology in health records but it may be helpful to advise patients at the outset that entries will contain such terminology and they are welcome to ask questions to help clarify anything they are unsure of. Some practices have offered a list of common abbreviations to help reduce the number of likely queries coming into the practice.

I’m concerned that we’ll have a lot of patient enquiries. What are our obligations regarding explaining why we have written what we have? What about when we have concerns about cancer or other serious diagnoses?

Clinicians should give consideration as to how they document concerns or differential diagnoses. In most cases, these should be discussed with the patient as part of the consultation. If a patient does raise concerns about what you have written, you should explain that this was part of your thought process at the time of consulting and that recording differential diagnoses is important in terms of both continuity of care and patient safety.

How do we alert staff to abusive patients if we can’t record incidents in their records?

Incidents should be recorded via other systems rather than the patient record. If the practice has ongoing concerns about a patient, an alert can be placed within the record. It is our understanding that alerts will not be visible to patients via their online accounts, however, you may wish to check this with your system provider.

Is there a risk that consultations ‘hidden’ from online view will be seen by patients?

It is our understanding that if a clinician chooses to hide a consultation, it will not be accessible to patients online. Patients will not have access to administrative tasks or communications between practice staff.

From what age can patients request access, and what about parents accessing their children’s records?

Patients aged 16 or over (or aged to 13-16 and deemed ‘competent’ by their GP) can register for an online account to view their medical record. Parents or carers of younger children may be allowed proxy access. We would recommend each practice has a policy on this and develops a system to ensure that once a child is deemed competent or reaches the age of maturity, a decision is taken to switch off proxy access, unless the child consents to this remaining.

If a patient moves to a new GP practice will the previous redactions remain?

When a patient moves to another GP practice it is our understanding that their online access to records will no longer be available. Once they are fully registered with the new practice though the patient will be able to view any new information entered from that date onwards. Patients are still entitled to request manual copies of their past records, which the new practice can provide if appropriate.

What do we do about historical entries in the notes which may not be deemed appropriate for a patient to read?

Access is prospective from 1st November 2022, so past consultations will not be visible at this time. If a patient makes a subject access request for historical records, this should be reviewed and consideration given to whether any information needs to be redacted, such as third-party data or anything that is felt likely to cause serious harm to the patient or others.

Will patients be able to see attachments, such as secondary care communications and letters?

It is our understanding that all attached documents will be visible unless redacted. These would need to be redacted as a whole document, as there does not appear to be the option of redacting only some information from attached documents. However, we would suggest you check this with your system provider.

When can/should we refuse access?

If you have concerns that access may cause harm to a patient by either their own reading of the records or if you believe they may be at risk of coercion by a relative or carer, you can refuse access. You can either do this by redacting certain sensitive information, or if you feel there are multiple entries throughout the record that could cause harm if accessed, you can switch off access for this patient. It will be important to have a practice policy in place to help decide when this may be appropriate for certain patients.

Should we start actively screening patients and decide whether to grant access or not based on the risk of causing potential harm?

It is our advice to start identifying patient groups now whom you do not wish to have access to their records: for example, patients that have a history of domestic violence where there is a risk that they are being coerced into accessing their records with the potential of them being accessed by an abusive partner. It is important to alert practice staff to any vulnerable patients, and a system should be in place to support decisions about access for these patients.

Should carers or those with powers of attorney have access?

It is important to be aware that consent is still needed for any proxy to access the records of a patient with capacity. Where a patient lacks capacity, decisions as to whether anyone with power of attorney (or who are otherwise caring for the patient) are given access should be considered on a case-by-case basis and must be justifiable. You may decide to allow limited access (if possible) in the first instance and then review the need for further access later as appropriate. Having a policy in place addressing proxy access is advisable, as well as regularly communicating any changes to this policy or issues that arise. Having an alert on the patient record to show that there is proxy access is also advisable so that anyone making entries is aware someone else may access the notes.

How else can our practice prepare?

Practices should ensure that relevant staff training has been undertaken in advance of the online access. Polices and systems should also be developed to ensure access requests are dealt with appropriately and consistently where possible, and that clinicians are involved where necessary.