Important information about your patient record – Updated October 2014

Important Information About Your Patient Records Held At This Practice

Patient Choices Regarding Sharing of Health Records

Electronic records are kept in all the places where you receive healthcare. Often, NHS care services can usually only share information from those records by letter email, fax or phone. At times, this can slow down your treatment and mean information is hard to access. Westgate Surgery uses a secure computer system that allows the sharing of full electronic records across different NHS care services.

There are several data sharing schemes that affect your medical records.

You have control over what is shared and who with. Here is a summary of the schemes with links to where you can obtain more information. You can also contact the practice for more information, or to opt out of any data sharing schemes. You should research the schemes carefully should you wish to opt out as it is possible this may affect the quality of medical care you receive.

1. Summary Care Record

The Summary Care Record is an electronic record which contains information about the patient’s current medication and any allergies or adverse reactions the patient may have. Having this information stored in one place makes it easier for healthcare staff to treat the patient in an emergency.

Question Answer
Data shared with who and why? The National Care Record Service (NCRS) for sharing important summary clinical data nationwide for emergency direct care purposes. For example, if you were admitted to hospital in a different part of the country this record would enable the doctors to see vital information about your care
What is shared? Medication, Allergies, Drug reactions, optionally specific Read coded entries (called rich SCR)
How is the data shared? Access is restricted to NHS Smartcard holders in Hospitals, Out of Hours Services and GPs
How is consent given? Implied consent with patient opt out via Read Code and requirement to explicitly opt in for Rich SCR
How do I get more information? You can also visit the NHS Care Records website or download the NHS Care Record Guarantee

2. SystmOne Enhanced Data Sharing Model (eDSM)

Sharing enables a clinician to get a full picture of all elements that affect your treatment. If some parts of your record are not available, this could adversely affect your treatment. Your information will only be shared with the health care staff involved with your care.

We use a computer system called ‘SystmOne’ to record your consultations. This system is also used by most GPs and community health services in Leeds and surrounding areas, and has the facility for sharing information. This has the advantage of quicker access and less transfer by printed paper methods.

Sharing Out:   Our policy is to make information entered here potentially shareable. This means that if you are registered with NHS services such as District Nurses etc. that uses SystmOne; then you will have the option to let them view your consultation records. Please let us know if you want us to continue doing this. You can change your mind at any time.

Sharing In:   Our policy is to be able to view information you may have shared out from other NHS services that use SystmOne, such as District Nurses and Community Matrons etc. Please let us know if you want us to continue being able to do this. You can change your mind at any time.

   Question Answer
Data shared with who and why? A scheme developed by our Clinical computer supplier SystmOne (S1). A S1 to S1 national patient centred sharing model for direct primary and secondary care for patients registered on S1
What is shared? All data unless specific items are marked as private
How is the data shared? Access is restricted to NHS Smartcard holders in Hospitals, Out of Hours Services, Community Health and GPs
How is consent given? There is a Leeds Wide policy for implied consent. You may choose to dissent at any time. Please tell us and we will record this on your medical records.

3. Care.data (Currently suspended)

Your date of birth, full postcode, NHS Number and gender rather than your name will be used to link your records in a secure system, managed by the Health & Social Care Information Centre (HSCIC). Once this information has been linked, a new record will be created. This new record will not contain information that identifies you. The type of information shared, and how it is shared, is controlled by law and strict confidentiality rules.

Question Answer
Data shared with who and why? NHS England national secondary uses data. Collected by HSCIC from primary and secondary care for service planning and quality
What is shared? Summary data including Specific ranges of Read codes – Mainly QoF and others, including pregnancy outcomes, referral codes, medication, NHS no, Date of Birth, Post Code, gender
How is the data shared? A sharing agreement. The data is extracted to create a second anonymised record and processed using a “traffic light” rating of how patient identifiable the data is
How is consent given? Read code opt out for both collection from practices and divulging by HSCIC
How do I get more information? For further detailed information please read Better Information Means Better Care

4. Leeds Care Record (LCR)

This is a newly developed scheme that has now gone live in Leeds, including Westgate Surgery.

Question Answer
Data shared with who and why? Leeds Teaching Hospital Trust/Primary Care such as your GP/Leeds Mental Health/Leeds Social Care. It is designed to be a local one stop shop shared record for direct care to enable health professionals to provide better care by seeing all your information together in one place
What is shared? Problems, medication, Allergies, Appointments, Test Results, Communications, Discharges, Demographics
How is the data shared? Held on a secure computer system and records remain confidential. All existing data protection laws apply. Only accessed by people directly involved in your care. This is role based access by Leeds Teaching Hospital Trust/Primary Care/Leeds Mental Health/Leeds Social Care
How is consent given? GP Practices Opt in – Westgate Surgery has opted in. Patients can opt out via Leeds Teaching Hospital Trust (by phone on 0113 206 4102, by email “leeds.carerecord@nhs.net”, or by letter to “Access to Health Records, Leeds Teaching Hospitals NHS Trust, St James University Hospital, Lincoln Wing/Chancellor Wing Link Corridor, Beckett Street, Leeds, LS9 7TF
How do I get more information? Go to Leeds Care Record Website

5. SystmOnline Patient Access

Patients will soon be able to access their own GP medical records online.

Question Answer
Data shared with who and why? SystmOne online access by patients to their own GP record
What is shared? Most Data
How is the data shared? Via the internet and mobile phone and tablet apps using username and password provided by the practice
How is consent given? The patient applies for access. Clinician has option to accept or deny patients request to access records
How do I get more information? We will make more information available soon.

6. Risk Profiling

This practice is taking part in a new NHS service that helps your family doctor (GP) to spot whether you need more help to manage your health. The service is called “risk profiling”.

 

Question Answer
Data shared with who and why? Using information from your health records, a secure NHS computer system will look at any recent treatments you have had in hospital or at this surgery, and any existing health conditions that you have, and alert your doctor to the likelihood of a possible future hospital admission.
What is shared? Most Data
How is the data shared? The information will be seen only by qualified health workers involved in your care. NHS security systems will protect your health information and patient confidentiality at all times. The clinical team at the surgery will use the information to help you get early care and treatment where it is needed.
How is consent given? If you don’t want your information being used in this way, or have any other concerns, please contact the Practice
How do I get more information? NHS England Website

The Leeds Clinical Commissioning Groups have produced an information leaflet that you may find helpful.

LNCCG_J000444_Leaflet_SharingHealthcareRecords_Nov15_A5_WEB

Please let us know your choices. You can change your mind at any time by informing us.

In the event of an emergency: In certain circumstances, such as if you are unconscious or there is a court order, healthcare staff may look at your record without asking you. If they have to do this, a note will be made on your record. If we share information without your permission, we will make sure that we keep to the Data Protection Act 1998, the NHS confidentiality code of practice and other national guidelines on best practice.

 


 

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