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Access to patient records and safeguarding

The GP practice can give patients access to their GP health records through the NHS Wales App. The level of access GPs can provide is the same as was possible for My Health Online. 

Practices should already have summary care records (SCRs) enabled for all patients as standard. This level of access provides details of allergies that are recorded on their GP health record and medicines that are, or have been, prescribed by the practice. This can be enabled or disabled by the practice and is shown in the practice global settings, or EMAS Manager. 

Implementing detailed coded record access 

GP practices are encouraged to provide patient access to elements of the detailed coded record (DCR), where this is possible and appropriate. Configurable options include: 

  • laboratory test results 
  • problems 
  • diagnosis 
  • medicines 
  • risks and warnings 
  • procedures 
  • investigations 
  • examinations 
  • events and recalls 
  • documents 
  • immunisations 
  • problems 
  • consultations 

The practice should have a process in place for handling DCR requests that takes account of any risks that may need to be addressed, including whether there are any safeguarding issues or whether the patient has been coerced into providing access.  

The process should consider: 

  • who should make the decision to give, or not give, access to any part of the DCR 
  • whether there are any risks in giving access to any part of the DCR when a patient requests access 
  • how to communicate decisions about providing access to patients in a non-discriminatory way in a format the patient can understand 
  • how patients can appeal a decision, including information which answers any concerns 
  • the level of access appropriate to any risks that have been identified 

Laboratory Test Results – Risks 

When switching on Investigations at a Patient level, be mindful of the way results are displayed to patients within their account. 

Practices with EMIS

Laboratory results will become visible as soon as these are processed and filed in the GP system. If DCR access is provided, it may be necessary consider the workflow within a practice to ensure that test results are only filed after these have been explained to the patient. 

Practices with Vision

A delay of 3 working days is in place before results are made available for display by the Vision system. This may not be enough time to explain to the patient what the result means, and this could impact the practice’s decision to enable or disable access to test results in the app. 

Practice staff should be aware: 

  • of how to ensure sensitive information is hidden from patient view when entered onto the clinical system 
  • that there will be rare circumstances where it could be inappropriate to give a patient access to their record, explained below 

If your practice uses EMIS, your staff should also be aware that: 

  • patient access will include letters and documents (if not redacted) 
  • patients will see new entries in their GP record 
  • this change will not give new access to historic or past health record information, unless this is individually authorised by their practice 

While functionality enabling documents and free text to be displayed is made available by your GP system supplier, Digital Health and Care Wales (DHCW) recommends that this option should not be activated at a practice or patient level at this time. Such information would need reviewing to ensure that there is no information relating to third parties or other information that may cause harm to the patient. Options that can be configured can be activated at a practice and patient level. 

Safeguarding and managing inappropriate use 

While enabling patients to view their health records through the NHS Wales App will help most patients, there may be challenges for some, particularly where access to information could cause serious mental or physical harm to the patient or a third party. 

Safeguarding patients or any third party who may be affected by making information available from any harm is extremely important. You may need to redact specific information entered into the GP health record or prevent the patient from having access. 

Vulnerable and at-risk patients 

In some cases, a vulnerable patient's record may contain information that could cause them physical or mental harm, so it’s in their interest that they do not see it. 

In some circumstances there may be safeguarding plans in place and known to the practice. You should consider switching off access to parts of the record where you consider a patient vulnerable to coercion, where giving access to the record to them is likely to cause harm to their physical or mental health or that of others. This functionality already exists in GP systems. 

There may be other circumstances where, in the opinion of the GP practice, access to information from detailed coded records would not be in the patient's best interest. 

For example: 

  • it may cause serious harm to the physical or mental health of the patient or someone else 
  • the record has information about someone who has not consented to its disclosure 
  • there is information in a text field that you cannot separate or redact from the rest of the detailed coded record 
  • the patient cancels appointments they need, such as if they have dementia (appointments can be cancelled through the App even if they were booked offline) 
  • the patient is at risk of coercion through online access 

Guidance on coercion and other considerations can be found in RGCP guidance on GP online services

The Royal College of General Practitioners have also produced a Child Safeguarding Toolkit and an  Adult Safeguarding Toolkit  that can be consulted when considering general safeguarding issues. 

Sensitive information 

Some sensitive situations might need a stricter approach to access, for example: 

  • pregnancy status 
  • fertility treatment 
  • information about abortion 
  • alcohol and drug misuse or abuse 
  • criminal activity 
  • gender and sexuality 
  • mental health 

Patient login and online access 

As the NHS Wales App uses NHS login, most patients can get access to the GP online services available through the App without the practice having any involvement. 

If patients do not already have a GP online services account, when they create one online, they will get the practice's default level of access to these services. 

Generally, that means they can book appointments and request repeat prescriptions as well as view their Summary Care Record. 

Stop patients accessing services 

To stop a patient having access to the default services, you will need to adjust the settings within their patient record online services details in your clinical system. 

If you need to revoke patient access to appointment booking or record access, it’s important to do it this in the individual patient's online account settings. If you simply delete their whole online access account, the default access settings will not have been altered, and a new account will automatically be generated the next time they use the NHS Wales App. 

Discussing limited or no access with the patient 

You may be concerned about conflict with a patient when you make the decision to restrict or deny their access. 

Where a patient is refused access or given significantly restricted access, consider whether a face-to-face discussion between the clinician and the patient is necessary. Early involvement and transparency with the patient can help to avoid conflict and complaints. 

Further guidance 

In response to safeguarding concerns, the Royal College of General Practitioners is updating its GP Online Services toolkit, in collaboration with safeguarding experts. This will cover situations where concerns may arise, and the steps clinicians could take to mitigate these risks. 

Protecting and processing patient data 

The GP Practice will be the Controller of Personal Data processed in relation to the delivery of GP services provided by the NHS Wales App within the meaning of the UK General Data Protection Regulation and the Data Protection Act 2018. The practice will therefore have overall responsibility for ensuring that all data processing is undertaken in accordance with the Act. 

Policies and procedures used by the GP practice for offering patients access to their Detailed Coded Record should be approved by the Data Controller before the service is implemented by the practice. 

Practices should: 

  • review all new policies and practices to ensure they align with regulatory revisions or changes in local practice 
  • agree a consistent approach to how patient records will be checked and who will be able to grant access for patients to their detailed coded information 
  • tell staff about how the service will be made available so that they understand their role in the process 

You can check standards against the Welsh Information Governance Toolkit self-assessment tool

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