Your electronic health record
As a practice we aim to provide you with the best quality care that is safe and effective. To facilitate that we now work with a wider team to provide a comprehensive range of health related services to you and your family. The practice uses the clinical computer system called SystmOne, which enables your full electronic record to be shared to anyone involved in providing direct care to you, across different healthcare services.
Why is sharing my health information important?
Your electronic health record contains lots of information about you, including your medical history, the types of medication you take, any allergies you have and demographic information like your home address, and your next of kin.
In many cases, particularly for patients with complex conditions, the shared record plays a vital role in delivering the best care. Health and social care professionals can ensure coordinated response, taking into account all aspects of a person’s physical and mental health. Whilst some patients have extensive knowledge of their conditions and care requirements, this is not true for everyone. Many patients are understandably not able to provide a full account of their care. The shared record means patients do not have to repeat their medical histories at every care setting, or make guesses about their previous care.
A shared record ensures health or social care professionals always have the most accurate, up to date information. They can rely on their colleagues, sharing accurate and relevant data in a timely way, to provide you with safe and efficient care.
Which services could I go to that could access my medical record with your consent:
- GP practices
- Community services such as district nurses, therapists and diabetes services
- Child health services that undertake scheduling of treatments such as vaccinations
- Urgent care organisations such as Minor Injury Units and Out of Hours services
- Community hospitals
- Palliative care hospices and community services
- NHS Hospitals (including A/E Departments) and Mental Health Trusts
- Care homes
- Social care – registered and regulated professionals within social care organisations coordinating care (not social care providers
Can I choose what is made available?
To give you the most personalised care, it is recommended that you share your whole health record with every service that cares for you. However, you have control over your record and have the choice to specify specific elements of the record you don’t want to be shared. For example, if you have had a consultation about a particularly sensitive matter, you can ask for this section of the record to be marked as private. That way, even if you consent for another service to see your record, that consultation will not be shown. If a consent override is used, then consultations marked as private will be accessible.
As a practice we would strongly advise patients to register for online services with your mobile number and email address. This will allow you to order prescriptions and book appointments over the web as well as being kept up to date with all practice information. By registering online you can also request access to view your medical record.
Why we collect information about you and what records do we keep
To provide you with the best quality care possible, we must keep health records about you. These contain information about the treatment and support you receive which is recorded by the professionals who have been involved in your care. This may include:
- basic details about you such as address, date of birth, next of kin;
- any contact we have had with you such as clinical visits;
- notes and reports about your health;
- details and records about your treatment and care;
- hospital letters;
- results of x-rays, laboratory tests etc.;
- any other relevant information from people who care for you and know you well such as health professionals and relatives.
How we keep your records confidential
Everyone working for the NHS has a legal duty to keep information about you confidential and secure. To help us protect your confidentiality, it is important to inform us about any relevant changes that we should know about, such as change of address, telephone, change of personal circumstance.
All staff working in the practice sign a confidentiality agreement that explicitly makes clear their duties in relation to personal health information and the consequences of breaching that duty. Access to patient records by staff other than clinical staff is regulated to ensure they are only accessed when there is a genuine need to do so, such as when identifying and printing repeat prescriptions for patients, or when typing referral letters to hospital consultants. We will share information in your health record to allow health professionals to work together more effectively to ensure you receive the best quality care.
Summary Care Record
One of the ways of sharing your health information for your care is through the Summary Care Record (SCR). The SCR is available nationally to health professionals who may care for you. It contains important information about any medicines you are taking, any allergies you suffer from, and any bad reactions to medicines that you have had. Access to this information can prevent mistakes from being made when caring for you in an emergency, or when your GP practice is closed. If you are registered with a GP practice in England your SCR is created automatically, unless you have opted out. You can also ask for your SCR to include additional information about you, such as your current health conditions. This is known as an Enhanced SCR.
SystmOne – GP Clinical System
Our Practice and our Primary Care Network (PCN) share your information for your care through the confidential electronic record system that we use, called SystmOne. This is a fully auditable system that is used widely across the NHS and care organisations to keep accurate medical records about you. These records store important information about your illnesses and the care you have received in the past. Your record will contain information from different health and social care organisations such as a hospital, a minor injuries unit, or from a community care service such as district nursing. Your record is only accessed by individuals who have a legitimate reason to do so and who are providing you with care.
How does this work?
Local trusted organisations who work with our PCN on a regular basis will be able to access your record immediately when delivering direct care. Other local health care organisations close to your home, but outside of our PCN, will only access your medical record if you give them permission.
For organisations that are further afield and that we do not work with on a regular basis, we can send you a verification (security code) which allows you to choose whether to let that organisation view your medical record or not. For example, you may be working or on holiday in another part of the country and need care from a hospital or a clinic. Having access to your whole medical record will improve the care they can provide you. We will use your preferred mobile phone number or email address recorded on your medical record, so remember to let us know if this changes.
If you already use the SystmOnline patient portal, then you can select organisations to allow or prevent them from accessing your records. If you do not have a phone or email address and don’t use SystmOnline, then we will be happy to record your choices about which organisations you are happy to share your whole record with.
If you are a carer and have the appropriate and evidenced authority, then you can agree access to the record on behalf of the patient who lacks capacity. If you do not have authority to make decisions about access to a patient record, then you can raise any concerns with the patient’s doctor, who will make a decision in the best interests of the patient.
If you have parental responsibility and your child is not able to make an informed decision for themselves, then you can make a decision about information sharing on behalf of your child. If your child is competent then they can make this decision for themselves.
Can I access my records?
The Data Protection Act 2018 (DPA) and the General Data Protection Regulation give every living person, or authorised representative, the right to apply for access to their health records. An audit log is maintained showing who has accessed your record, and when. You are also entitled to request a copy of this log.
You can view your own health record, change how your record is accessed, and view an audit trail of who has accessed your record by using the SystmOnline patient portal or NHS app. Ask your practice for details on how to set up a SystmOnline account or download the NHS app. Alternatively, you can make a request in writing and we will respond within a month. You will be required to provide ID before any information is released to you.
If you would like any further details about your information rights under the General Data Protection Regulation or think that anything in your record is factually inaccurate, please contact us.
Other people who may view my record
Occasionally we may receive requests from insurance companies. Once the insurance company has provided a copy of your consent, we will issue a medical report rather than releasing your medical records.
We may also need to provide limited information to local authorities about some infectious diseases or if you have had food poisoning. Very rarely, doctors may also be required to disclose information in order to detect a serious crime. Likewise, a Court Order can require doctors to disclose certain information during a court case.
Data sharing outside of our GP practice for secondary uses
You can register a type 1 opt with us if you wish to prevent your personal information being used outside this GP practice for purposes other than your individual care. A Type 1 secondary use objection does not in any way affect how healthcare professionals provide patients with direct medical care or prevent them from accessing a patient’s medical record if, and when, appropriate. Secondary uses are not about information sharing between healthcare professionals, your information can still be used to provide secondary care, for example, if you are referred to a specialist.
Data sharing by NHS Digital and other health and care organisations for secondary uses such as research and planning
NHS England links together information from all the different places where you receive care, such as hospital, community service and your GP Surgery. This allows them to compare the care you receive in one area against the care you receive in another. This information is held in a secure environment by NHS Digital. The role of NHS Digital is to ensure that high quality data is used appropriately to improve patient care. NHS Digital has legal powers to collect and analyse data from all providers of NHS care. They are committed, and legally bound, to the very highest standards of security and confidentiality to ensure that your confidential information is always protected. This data can also be used, with permission from NHS England, for research purposes.
You can choose whether or not you want your confidential patient information to be shared by NHS Digital and other health and care organisations for purposes other than your individual care such as research and planning. You can set your own opt-out choice by the NHS Website or by phoning 0300 303 5678. You will need to provide:
- your NHS number, or your postcode (as registered with your GP practice)
- your mobile phone number or email address provided previously at your GP practice or other NHS service.
If you would like to view this information in an alternative format, for example large print or easy read, or, if you need help communicating with us, for example because you use British Sign Language, please let us know on 01258 474500 / 01747 856700