Data Protection
It's often important for information to be shared within a healthcare team in order to provide you with the best care. All employees working in the NHS are bound by a legal duty of confidence to protect personal information they access in the course of their work.
Sharing medical information
Work is always ongoing to improve the way that medical records are made available to treating clinicians. At Norfolk & Waveney Community Health, our main computer system is called SystmOne.
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. Your express consent will be asked for and obtained where possible. 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 does not enable patient records to be used for research or other purposes.
We already share records of children for child protection reasons. This helps clinicians to make decisions based upon a wider knowledge of the patient and also helps to reduce the number of times that patients or 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 our GP surgeries, some departments at local hospitals and community services, such as the District Nursing Team.
Clinicians outside of East Coast Community Healthcare who wish to access your medical records will ask for your consent to do so and will need to have been issued with an NHS Smartcard. This is a ’chip and pin’ card, similar to a bank card.
Can I ‘opt out’ or 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. This is your agreement that records maintained by your clinician can be seen, subject to your authority at the time, by other health professionals providing you with care. The second is agreeing to share your records IN. This means that your clinician can see the 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.
As EDSM has been designed to enhance patient care, we will automatically 'opt you in' to both parts of the scheme. If you prefer not to be, please mention it to your clinician. You are free to change your mind at any time.
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 just between me and my clinician?
You can ask for any consultation to be marked as private. This means that viewing is restricted to the organisation, 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 came into use some years ago. The Summary Care Record contains only 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 it 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. Just contact your clinician to advise that you have changed your mind and they will update your record.
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?
We can get requests from insurance companies to either have copies of medical records or excerpts from patients’ medical records. This requires your signed consent.
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 a clinician. If necessary the clinician will arrange for someone to give you a call.