Patient Access to Records & Transactional Services
P.A.R.T.S.
Phase 1 Report
March 2013
NHS South of England Health Informatics Team
Becky Gayler and Isabella Davis-Fernandez
Contents
1 Executive Summary 5
1.1 Background 5
1.2 Where are we now? 5
1.3 Where do we want to be? 7
1.4 What needs to happen to get there? 7
1.4.1 Clinically driven objectives 8
1.4.2 Systems Designed for the Purpose 9
1.4.3 Support Change and Evidence Benefits 9
1.4.4 Generate Awareness and Demand 9
1.4.5 Records Access is embedded in Health and Well-being Strategies 10
2 Project Approach 12
2.1 Background 12
2.2 Scope 12
2.3 Objectives 13
2.4 Approach 13
2.4.1 Awareness raising 13
2.4.2 Patient Reference Group 13
2.4.3 Demonstrator Sites 14
2.4.4 Surveys 14
2.4.5 Supplier workshops 14
2.4.6 Developing exemplar materials 15
2.4.7 Sharing resources 15
2.5 Advisory Board 15
2.6 Evaluating Costs and Benefits 15
2.7 Assumptions and Inhibiting Factors 16
3 Drivers for Change 18
3.1 Evidence of Benefits 18
3.1.1 Quality Innovation Productivity and Prevention (QIPP) 18
3.1.2 Health Policy Drivers 18
3.1.3 Informatics Policy 19
3.1.4 Cultural and social change 20
4 Current status 21
4.1 Attitudes towards Access 21
4.1.1 Public and Patients Views 21
4.1.2 Professional and Practice Views 23
4.2 Systems currently available and in use 25
4.2.1 GP system suppliers offerings 25
4.2.2 Deployment of GP Online Services 26
4.2.3 GP Systems – Fit for Purpose 29
4.2.4 Non-integrated access solutions 31
4.2.5 Use of SMS to “push information” to patients 32
4.3 How practices are managing online services 32
4.3.1 Promotion to Patients 32
4.3.2 Registration and Authentication of patients 33
4.4 Guidance 34
4.4.1 Guidance for health professionals 34
4.4.2 Guidance for Practices 34
4.4.3 Guidance for Patients 35
5 Lessons from Demonstrator Sites 36
5.1 Practice Approach 37
5.2 Benefits 38
5.2.1 Records Access 38
5.2.2 Transactional Services 39
5.3 Barriers 40
5.3.1 Lack of Clear Professional and Legal Guidance 40
5.3.2 Practice Capacity 40
5.3.3 System Issues and Usability 41
5.3.4 Costs 41
6 Critical Success Factors for Patient Online Access 43
6.1 What do all stakeholders need? 43
6.2 What do the Public and Patients need? 43
6.2.1 Awareness of what services are available and how they can be used 44
6.2.2 Services which are easy to use 44
6.2.3 Health information which is easy to use and is relevant 44
6.2.4 Assurance that services are safe 45
6.3 What Health Professionals and GP Practices need? 46
6.3.1 Systems that can be locally configured and introduced in a step-wise fashion 46
6.3.2 Support to introduce new ways of working 46
6.3.3 Better technical support with online systems 47
6.3.4 Guidance about professional and legal responsibilities 47
6.4 What do NHS and Health & Wellbeing Partners need? 48
6.4.1 An understanding of the strategic fit 48
6.4.2 Understanding of the fit with wider informatics agenda 49
6.4.3 Clarification of responsibilities and resources to take forward online services 50
6.4.4 Local clinical support and clinical champions 50
6.5 What do the System Suppliers need? 51
6.5.1 A clear mandate for development and investment 51
7 The Next Stage 53
8 Appendices 54
8.1 Demonstrator GP sites case studies 54
8.2 Glossary 64
8.3 References 65
8.4 Index of PARTS resources 66
8.5 Safeguarding Issues and Recommendations 67
8.6 Survey analysis 68
8.7 GP Systems Workshops 69
8.7.1 Hints and Tips 69
8.7.2 Issues and Enhancements 69
8.8 Advisory Board 70
8.8.1 Membership and Terms of Reference 70
8.8.2 Advisory Board Benefits workshop 71
8.9 Acknowledgements 72
1 Executive Summary
This Summary should be read in conjunction with the Critical Success Factors and recommendations outlined in Section 6.
1.1 Background
Key policy drivers for patient online access are:
1. Empowering people to better manage their health and care
2. Delivering transparency to improve quality of care and patient experience
3. Integrating and personalising care packages
4. Improving the effectiveness and productivity of services
The NHS Commissioning Board has mandated[1] that by 2015 all general practices in England will offer patients online access to:
· transactional services such as booking appointment, requesting repeat prescriptions
· the medical record, including test results, letters, medication, summary information
· secure communication with clinicians.
This project has looked at what needs to happen to deliver this ambition and ensure benefits are realised for patients, clinicians and the NHS.
The project name, Patient Access to Records and Transactional Services (PARTS), was chosen to illustrate that Transactional Services are a key stepping stone for Records Access. PARTS also refers to the ambition that online services will help combine information to provide a patient centred view of health and care and enable patients to become a more active partners in the process.
This report brings together information gathered from GP practice demonstrator sites, a number of surveys, and consultation with a range of stakeholders, to address:
· Where are we now?
· Where do we want to be?
· What needs to happen to get there?
1.2 Where are we now?
In principle, there is strong support for the concept of online services among the majority of patients. Patients see that online services have the potential to save them time and could make accessing health services easier.
Although Transactional Services have been introduced to improve practice efficiency and in response to public demand for greater convenience, GP practices often say there has been little demand from patients for online access to records. However a PARTS survey showed that over 75% of patients felt Records Access was a “good idea” and that it could help support decisions about health and care.
In particular patients felt that Records Access would:
Protect patients and improve data quality
“I have had access to medical records in past at huge cost and found that there were unjustified and incorrect recordings. [Records Access] would protect the patient and ensure the best treatment is always given.”
Facilitate joined up care and patient choice
“Having immediate access to medical history and information would make planning my treatment and care easier for me. I have to pay privately for physiotherapy and pilates and I would like those therapists to have access to my medical history.”
Help vulnerable patients and their carers
“My mother is often confused by hospital and GP appointments. I cannot attend all of these with her so it would enable me to help her and avoid chasing the GP for updates.”
Around a third of GP Practice clinicians and staff surveyed by PARTS acknowledged the potential of Records Access to improve:
• patient trust and communication
• clinical record keeping.
• effectiveness of consultations
• patient compliance
Among many health professionals and service providers there is a general acceptance of the need for change in line with public expectations, the transparency drive and also with QIPP agendas.
“I think this is inevitable and being more aware about patients likelihood of reading their notes will focus staff on recording things well and reduce future problems.”
GP Practice Manager November 2013
However, there are reservations about the pace and resourcing of this change, which is commonly perceived as politically, rather than, clinically driven. Whilst the benefits of transactional services are acknowledged by GP practice teams, less than 40% of practice staff / clinicians surveyed felt the potential benefits of Records Access outweighed their current concerns. Concerns that exist focus on security and workload issues and the potential for online services to be used as a replacement for personal contact.
Transactional services are becoming widely used and valued by patients, with 40% of practices now offering them. There is growing evidence to support the potential efficiency savings of these systems where they work well, however some practices still feel that the tipping point between costs and benefits of introducing them has taken too long to reach. Others feel that the solutions and their associated support services are not yet sufficiently robust to actively promote to patients, and hence they are also unwilling to consider expanding online services to allow records access.
The term Records Access in this report refers to patients being able to view part (e.g. test results, letters, medication, summary history) or all of their GP electronic record. Currently two of the three main GP suppliers offer Record Access to the full GP record, with options for the practice to limit access to consultation entries. However practices using these systems cannot currently choose to enable individual elements (e.g. test results) separately. The third main system supplier is developing Record Access functionality in a modular way, prioritising the delivery of test result viewing in 2013.
Records Access was not offered by any GP practice in the region prior to December 2012, however as a result of the project, it is now being piloted with invited patients in 5 GP practices (see Section 5 for details).
1.3 Where do we want to be?
Both practices and patients want Transactional Services which are easy to use and access to improve efficiency and convenience. This simply mirrors use of similar technology in other areas of everyday life.
There is more debate about whether the NHS should make Records Access “a right” for all patients, or whether it should be available at the discretion of practices / clinicians for those with a clinical requirement who need it, or stand to benefit most.
Our consultation shows that if patients and professionals are to embrace the culture change required to reach government objectives, Records Access needs be clearly linked to clinical objectives. Specially designed patient interfaces for particular conditions and care packages could include decision support tools, with information shown in context, in an easily accessible way e.g. as dashboard / traffic light displays, with diary dates, care and treatment plans. This could include prompts for the patient to take action and support them to make a decision about their lifestyle. Unless the patient interface supports access for non-expert patients, online access could exacerbate rather than resolve health inequalities.
However this does not mean restricting access only to those considered “active service users”. If combined with proactive messaging services, access could be a useful tool to engage hard to reach members of the public with health campaign messages and lifestyle advice.
1.4 What needs to happen to get there?
The RCGP have recently published Patient Online: The Road Map[2] which provides:
· explanations of the different online options available
· potential strategies to support GP practices with the implementation
· guidance about information governance and safeguarding risks
· recommendation for support, training and education tools needed
· advice about communications work required
· advice about market development of solutions
Key messages from the report are that:
· online elements should be capable of being implemented incrementally,
· systems need to develop within a framework of common standards and
· IG and safeguarding risks need further consideration to ensure they are properly managed.
These recommendations will inform the development of national strategy. Similarly the PARTS project has found that although local consultation suggests that there are significant potential benefits on online access, there are a range of risks and inhibiting factors for patients, clinicians and practices which need to be addressed.
Individual decisions about whether to use / offer online services must be informed by a balance of risks v. benefits. Online access to health services / records is still in its infancy in the UK. More work needs to be done to:
• Inform patients, professionals, and practices about the relative benefits v. risks of using / offering online services.
• Develop information systems, guidance and support processes which can mitigate the risks, and optimise benefits to an acceptable threshold for stakeholders.
The following diagram summaries the development process required:
1.4.1 Clinically driven objectives
Transactional services can be justified wholly on the grounds of improving convenience, access and efficiency. If the systems work well and are fit for purpose, there is an overwhelming economic case.
The case for Records Access is a clinical one. It enables patients to take better, safer decisions about their health and care. It allows them to share information to support decisions by those who care for them. It also allows patients to see understand what decisions have been made about them and why. A lesson from the Francis Inquiry[3] is that transparency is not simply an end in itself, but an important enabler of good clinical care.
Records Access needs be viewed not as an informatics initiative but as an enabler of improved patient experience and outcomes, and as such should be incorporated in clinical protocols and pathways of care.
1.4.2 Systems Designed for the Purpose
Once it is clear how Records Access will be used to support clinical objectives, systems can be designed specifically for these purposes. Current systems have evolved in response to “customer” demand in an ad hoc way, without national standards or accreditation. Online access currently provides a view of the patient record written and structured to support clinical and not patient decision-making. Online access systems need to provide a patient-centric view which helps patients find the most relevant or important information about them. Until now the GP record has been the only place where information about the patient is brought together. Furthermore primary care informatics and data quality is much more advanced than in other sectors. However the development of integration tools, telehealth systems, and health apps allow the development of patient-centric rather than service centric access systems, which can support the active exchange of information from clinical and patient sources. Future strategy should not be constrained by what GP systems alone can offer there needs to be commercial frameworks in place which encourage and support partnerships between solution suppliers.
1.4.3 Support Change and Evidence Benefits
Once systems have been designed for the purpose of supporting patient decision-making, they will need to be introduced into day to day clinical practice. This will require a huge culture change and a high level of both change management and practical support for both clinicians and patients.