The Good Practice Guidelines for GP electronic patient records

1 The Good Practice Guidelines for GP electronic patient records Version 4 (2011) 1 The Good Practice Guidelines for GP electronic patient records v4 (2011) DH INFORMATION READER BOXP olicyEstatesHR / WorkforceCommissioningManagementIM & TPlanning / FinanceClinicalSocial Care / Partnership WorkingDocument PurposeGateway ReferenceTitleAuthorPublication DateTarget AudienceCirculation ListDescriptionCross RefSuperseded DocsAction RequiredTimingContact Details015787 Best Practice GuidanceFor Recipient's UseThe Good Practice Guidelines for GP electronic patient records v4 (2011)LS2 7UE0113 397 4468 Lesley CookeDH Informatics1N24 Quarry HouseLeedsThe Good Practice Guidelines for GP electronic patient records v4 will act as a reference source of information for all those involved in developing, deploying and using general Practice IT of Health (DH)/Royal College of General Practitioners (RCGP)/British Medical Association (BMA)21 Mar 2011 GPs#VALUE!

2 0 GPG [Gateway 5098] GPG [supplement to GPG ]N/A 2 The Good Practice Guidelines for GP electronic patient records v4 (2011) Contents Executive Chapter 1 - Strategic context for the Good Practice Guidelines for GP electronic patient records v4 (2011)..10 GPGv4 scope and GPGv4 Chapter 2 - The Purposes of Health Clinical Non-clinical Additional Emerging purposes ..14 Chapter 3 Clinical Safety Clinical safety Clinical safety assurance and Current NHS safety standards for IT systems (DSCN 14/2009 & 18/2009)..18 Future Safety Standards including changes to the Medical Device Key clinical safety summary Chapter 4 - records Information governance Legal Other relevant publications.

3 32 Governance issues particular to shared electronic patient records and record keeping guidance from health professional Information governance and data Retention of GP electronic patient records and associated audit trails when a patient is no longer registered with a Practice ..47 The Information Governance Toolkit, & Information Governance Statement of Compliance (IGSoC)..51 Chapter 5 Shared electronic patient Shared electronic patient records Sharing records with patients (Record Access)..59 Chapter 6 - High Quality patient Information quality and modern general Practice ..65 Capturing information in the Capturing information from outside the Recognising high quality patient System specific Data quality and shared records .

4 79 Chapter 7 - Clinical Coding Coding schemes in current Future standardisation of coding schemes across health care Features of Read 3 The Good Practice Guidelines for GP electronic patient records v4 (2011) General issues relating to terminology use ..92 Sharing coded Preparing to move to SNOMED-CT, what to The International Classification for Primary Care (ICPC)..101 Chapter 8 - Data Transfer and Clinical safety Chapter Chapter 8a - The Personal Demographics Service (PDS)..103 Access & PDS The NHS Number (England & Wales) ..105 Data Chapter 8b - GP2GP electronic Record The rationale for electronic GP2GP record The nature of electronic GP2GP record The limitations of electronic GP2GP record General clinical electronic and paper GP2GP record GP electronic record GP2GP record transfer - good Practice Chapter 8c - Data Formalising the process of data Data migration Chapter 8d Clinical Processes involved in handling clinical messaging data Pathology Radiology Out Of Hours (OOH)

5 A/E encounter, outpatients encounter, inpatients Chapter 8e- The Summary Care Record and the Emergency Care Data Future Chapter 8f - High Quality Medication records and The electronic Prescription High Quality Medication Why is the EPS service being introduced?..143 Different Releases in EPS Release Getting Ready for EPS Consultation Benefits for patients and Benefits for Release 2 Readiness (& figure )..150 Security & Access EPS Unsupported Chapter 9 A pathway to good paperless 4 The Good Practice Guidelines for GP electronic patient records v4 (2011) About this chapter ..152 From paper to Benefits and Data quality recording Moving Practice business to System user Accreditation of paperless Chapter 10 - electronic Document Attached electronic Format of Storage of attachments.

6 191 Attachment identification and Transferring e-referral Other Chapter 11 - Working in an e-business Working in an e-business NHS Practice websites and on-line Consumer oriented Internet health Using the Internet for Supporting general Privacy and security in the online world ..213 Data Chapter 12 - Education and Why education and training are Learning Meeting these learning Some learning GPGv4 - Appendix 1 - GPGv4 Appendix 2 GPGv4 List of organisations 5 6 Foreward The UK has an international reputation for widespread implementation and innovation in the area of GP computing. To a large extent this has arisen through the enthusiasm and efforts of doctors who have seen the benefit these clinical systems can bring to their practices.

7 Current Practice computer systems contain vital records on which patient care depends. As information technology develops and becomes more integrated and interoperable, it is important that Practice and Primary Care Organisation staff should be fully aware of the procedures and management arrangements that should be in place to ensure that the dependence on these electronic records is safe and justified. These Good Practice Guidelines , have been written by national experts who are also users of clinical systems in their own practices. They are intended to support and encourage practices as they continue the move to be becoming paperless and beyond. I welcome the publication of these Guidelines and am grateful for the work of the doctors who have developed them.

8 Dr Laurence Buckman Chairman, BMA General Practitioners Committee The Good Practice Guidelines for GP electronic patient records v4 (2011) NHS Connecting for Health is pleased to have been able to support the updating of these Guidelines at a crucial time for the NHS in our drive to accelerate the Information revolution . As clinical information exchange with patients , carers and healthcare professionals becomes a reality, I am very pleased that the new Guidelines reflect best Practice and innovation in the use of health information. This guidance is developed for General Practice , but has impact, lessons and influence across the wider health and care community and is an important update to widely referenced and respected guidance and I would like to thank all clinicians who have contributed to this excellent work.

9 Charles Gutteridge Clinical Director Clinical Division, DH Informatics Directorate GPs and their Practice teams are operating in an increasingly complex world and guidance which helps us to do our job more efficiently and deliver safer care to our patients is very welcome. This resource has been produced by clinicians who know from their own experience what is practical and beneficial to practices and patients . The guidance provides GPs and patients with reassurance and confidence that the systems we are using are safe, secure and confidential. The RCGP would like to acknowledge the efforts of everyone involved. Dr Clare Gerada Chair of Council Royal College of General Practitioners 7 The Good Practice Guidelines for GP electronic patient records v4 (2011) Executive summary A recent joint review by representatives of the Department of Health Informatics Directorate and the BMA & RCGP Joint GP IT Committee (JGPITC) concluded that there was a continuing need for professionally owned, authoritative guidance to update the Good Practice Guidelines for GP electronic patient records ( 2005).

10 The new Good Practice Guidelines for GP electronic patient records v4 (GPGv4 2011) would act as a reference source of information for all those involved in developing, deploying and using general Practice IT systems. GPGv4 would also need to maintain and update the link between earlier versions of the GPG and the GMS & PMS regulations. The joint review of the scope and content of demonstrated the need for a complete re-write of the Guidelines to include all the existing sections, and extend the scope to include new services ( Summary Care Record, electronic Prescription Service and GP2GP messaging) into the mainstream guidance. The review also concluded that there is a need to develop new guidance in areas such as high quality clinical records and data quality to facilitate records sharing, inter-operability and communication.