The Royal College of General Practitioners has published a report on the implementation and use of shared electronic patient records systems (SEPRs) in primary care.
‘Informing Shared Clinical Care’, which was commissioned by NHS Connecting for Health, details 16 key principles that it says should be “the first step” towards creating guidelines for SEPRs.
It calls for patients to act as “full partners” in sharing clinical data and says this will help to inform professional practice and maintain patient confidence.
However, it adds that “health professionals must respect the wishes of patients who object to particular information being shared with others providing care.”
It also says that health organisations should be able to explain to patients who will have access to their SEPR and that they must make information available to patients about such disclosures.
Furthermore, it adds that governance arrangements should be in place to deal with errors and differences of opinion in SEPR systems.
“Organisations should have the facility to update and correct erroneous information added to their SEPRs from other sources,” it says. The report argues the originator should be able to make corrections, but if they are unable to do others should be able to make amendments.
The RCGP says the report provides the most comprehensive literature review yet on shared record systems. However, it also says that the evidence base on the development and deployment of SEPR systems is at present “weak.”
It adds that “systems deployments should be accompanied by a rigorous evaluation” and “the success of the programmes should be measured alongside the operational characteristics of these programmes allowing evaluation of such systems in a wider context.”
The report also highlights the need for joint guidance on record sharing to be produced and maintained collaboratively by professional regulatory bodies and representative organisations, to ensure a multi-professional approach to record quality, consistency and clarity.
Other recommendations include a call for the government to clarify issues of data and record preservation and deletion in shared patient record systems.
In a statement, CfH said that document will provide key points of reference as the health service moves into a “new world” of patient centered records.
“We recognise that no single report can be expected to provide all the answers to such wide ranging and challenging questions,” the statement said. “However by informing the ongoing debate with a literature review, structured questionnaires and a scenario analysis, it can make a significant contribution.”
CFH Clinical Safety said it will assess the report for potential implications.
Link: Shared Record Professional Guidance
Opinion and analysis: Mary Hawking asks whether the content of records is fit for sharing.