Summary Care Record

Enhanced Data Sharing Model

For a number of years, work has been ongoing to improve the way that medical records are made available to treating clinicians. Our main computer system is called SystmOne, which has the advantage of enabling information to be shared between certain health professionals.

Enhanced Data Sharing Model (EDSM) enables us, with your consent, to share your medical records with those in the NHS who are involved in your care. NHS staff can only access shared information if they are involved in your care and being an electronic service an audit log is maintained showing when and who has accessed medical records.

EDSM only allows those treating you to access medical records. It does not enable your records to be used for research or other purposes.

We already share records of children for child protection reasons and patients who are under the care of the District Nursing Team. This helps clinicians to make decisions based upon a wider knowledge of you and also helps to reduce the number of times that you or your family members are asked the same question. In short it assists clinicians to provide more ‘joined up care’.

If I agreed, who could see my records?

EDSM will allow clinicians treating you, who have access to SystmOne to view and in some cases update your medical records. Locally this includes the Walk-In-Centre, many departments at local hospitals (including A&E) and community services, such as the District Nursing Team. It is anticipated that over time more health services will be able to benefit from EDSM.

Clinicians outside of the surgery who wish to access your medical records will ask for your permission to do so and will need to have been issued with a NHS Smartcard. The is a chip and pin card – similar to a bank card.

Can I ‘opt out’ pick and choose who sees my record?

Yes, you can. Under EDSM there are two levels of consent. The first is to agree to sharing your medical records OUT of the practice. This is your agreement that records maintained by your GP can be seen, subject to your authority at the time, by clinicians working outside of the surgery. The second is agreeing to share your records in. This means that your GP can see records made by other health professionals who have access to EDSM.

However, as the treating clinician needs to ask your permission to see the records at the beginning of each period of care you are in control of who can see your medical information.

I can see the benefits of the other people treating me seeing my notes, but what if there is a matter that I want to stay between me and my doctor? You can ask for any consultation to be marked as private, this means that viewing is restricted to the surgery, but allows the rest of the record to be viewed by whoever else is treating you. It is your responsibility to ask for a consultation to be marked as private.

Haven’t I agreed/disagreed to do this before?

EDSM may seem very similar to patients as the Summary Care Record which went live some years ago. The Summary Care Record contains a very small part of your record that is available to be seen by clinicians who might be treating you in A&E departments, Walk-In-Centres or if you register temporarily somewhere else within the UK.

The Summary Care Record allows other NHS Services to see your current medications and the drugs that you are allergic or sensitive to. Your Summary Care Record can be enriched by your GP to include information that is important to pass on in the case of an emergency.

Can I change my mind?

Yes, you can always change your mind and amend who you consent to see your records. For instance you can decline to share your records out from the surgery, but if you build up a relationship with the Physiotherapist who was treating you and they asked you if they could look at an x-ray report, you could give your consent at that point form them to view your records. You will be referred back to us to change your preference, so the physio treating won't be able to see your records instantly, but should be able to by, the next time of your next appointment.

If I decline – what happens in an emergency?

In the event of a medical emergency, for instance if you were taken unconscious to A&E, and the clinician treating you feels it is important to be able to see your medical records he is able to override any consents set. However, the doctor has to give a written reason for doing so. Where this happens an audit is undertaken by the local Caldicott Guardian (the person with overall responsibility for Data Protection compliance).

Can anyone else see my medical records?

On a daily basis, we get requests from Insurance Companies to either have copies of medical records or excerpts from patients medical records. This requires your signed consent as it has not been requested to treat/care for you. Occasionally we are asked for information from the medical records for legal reasons, again this has to be done with your written consent, or in very exceptional circumstances, by court order.

Any questions?

If you have any questions, please speak to reception. If necessary the receptionist will arrange for someone to give you a call.

Enhanced Summary Care Record

The summary care record will initially consist of basic information from the patient record such as your date of birth and address, details of allergies, current prescriptions and bad reactions to medicines. Then, each time a patient uses an NHS service, more information may be added to it.

In Norfolk, many patients have had summary care records created. These can be accessed, with patient consent, by hospitals, A&E departments, the out of hours services, 111 and the ambulance service.

Red more about enhanced summary care records on the North Norfolk CCG website.