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Single Shared Electronic Patient Record; whose in control?

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Shared EMRA great deal has been written about the electronic health record/electronic patient record (EHR/EPR) without any clear agreement about what it is or even what functions it is supposed to serve. This can make rational discussion difficult. Who is allowed to enter and alter data for items entered personally and by their own organisations and data entered in other organisations?

Is it desirable and safe to have a Single Shared Electronic Patient Record (SSEPR), asks Mary Hawking, a GP and level 3 UKCHIP registrant, in the March 2008 issue of BCS' Health Informatics Now. Here, she outlines her concerns.

Even in systems where the EHR is supposed to be shared between different parts of an organisation - such as the Veteran's Administration in the US - the rules for the internal management are not clear.

In England, the declared intent of the National Program for IT (NPfIT) is to have a detailed local shared record - a single electronic patient record for each individual shared by all the local healthcare providers involved in their care. Definitions may change. I will refer to this concept as the Single Shared Electronic Patient Record (SSEPR).

A number of important problems such as security, confidentiality, access etc. have been discussed extensively. I have not seen discussion of the internal management of the SSEPR itself or the roles and responsibilities for the maintenance of the record.

Who is allowed to enter and alter data for items entered personally and by their own organisations and data entered in other organisations? There might be errors - such as wrong or evolving diagnoses - or items expected to be changed, for example prescriptions and management plans.

In short, who is the data controller in Data Protection Act terms, and who is responsible both for maintaining the record and ensuring that action is taken when required - especially if the information comes from one organisation, but the action needs to be taken by another?

Most GP practices in the UK are 'paperlite'; patient records are only held electronically. These records are essential for patient care and for the financial survival of the practice, especially since the introduction of the Quality and Outcomes Framework (QOF) in 2004 with the new GMS contract. Information is extracted from communications from other organisations and entered into the patient's record.

General practice in the UK would appear to be unique in its dependence on read code - a coding system which has terms for almost everything relevant to general practice (including diagnoses, procedures, values, claims) - which makes the information machine searchable, attributable and available for audit.

The needs of community - district nurses, health visitors etc. - and other organisations in primary care are different. Few of them have any electronic records or an understanding of read code. The consequences of inaccurate coding are not part of their training. EPRs - in the GP sense of the term - are not mission critical to others.

When looking at secondary care, it is hard to see how the SSEPR would be implemented.

At present, there would appear, in many instances, to be a lack of information sharing between departments, let alone between different hospitals and primary care. While good quality information and sharing is essential for patient care and safety, is a SSEPR feasible? If so, how would control of, and responsibility for, the record be managed? For instance, would a doctor in orthopaedics be able to change the medication prescribed or diagnoses entered by oncology or the GP?

I am aware of one system where the organisation entering the data is responsible as data controller for those items, and only the people in that organisation can alter them. This would not appear to address the problems of errors or prescriptions, especially when the patient has been discharged by the organisation.

For instance, if someone in Community entered an erroneous diagnosis of diabetes mellitus, and then discharged the patient, would they be permitted to go back and change the erroneous diagnosis?

If not, how would it ever get corrected? Would prescriptions remain as repeat prescriptions forever once started as repeat prescriptions by community or on hospital discharge?

There is yet another problem with the SSEPR when patients move house. If the patient moves from an area served by one local service provider (LSP) to one served by a different LSP or lives close to a national or LSP boundary, can the SSEPR be moved or include services in more than one jurisdiction?

As a GP accustomed to working in a paperless environment, I find the prospect of a SSEPR disturbing - and particularly so when these fairly fundamental problems appear not to have been adequately addressed.

GEt the full issue here, 


Last Updated ( Monday, 14 April 2008 00:49 )  

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