LATHOM HOUSE SURGERY. Records Online Access. Online Electronic Medical Record Viewing Patient Information Leaflet

Transcription

1 LATHOM HOUSE SURGERY Records Online Access Online Electronic Medical Record Viewing Patient Information Leaflet 1

2 Introduction : This practice is piloting a project that allows you to view your medical record online via a personal computer (PC) or mobile device that has internet access. This information leaflet explains what the project is and how you can use it. Before registering to use this facility you will need to have read this leaflet and signed that you understand the risks and benefits to using online access to your medical record. You will also be required to complete a questionnaire and sign a consent form which will then be considered by your GP, who will, dependant on your answers to the questionnaire, authorise your access. When access has been authorised you will then be required to choose a password and register on the patient access site, this process will be explained in more detail below. What is online access to medical records? As part of the government s commitment to bringing care closer to the patient, online access to medical records will give patients the information they need to make appropriate choices about the care they receive, giving them increased control over their own care and care records. Access to medical records is through a website that allows you to view your medical record over the internet from a PC or other mobile device. It allows patients to easily and quickly view the electronic medical information held about them by their GP Practice. The information is presented in a format that is easy to navigate and offers links to other resources such as, patient information leaflets about diseases, test results and investigations, support groups and medications etc. Access will also link patients to other websites such as NHS Direct Online and Patient.co.uk, where you can find additional information to help you understand and educate yourself about what you read in your medical record. Registering and consenting to use online access to medical records To be able to use online access to your medical records, patients will need to have: Access to a computer or mobile devices that have web browser such as Internet Explorer (version 6 or later) and have a connection to the internet. You must have read this information leaflet and understand the benefits and risks of using online access. Completed the questionnaire at the end of this leaflet and handed it into your practice with the signed consent form. Before signing the consent form, patients should be happy that they understand what the system does, what their responsibilities are and how their data is stored. The completed questionnaire and signed consent form should then be handed into the GP receptionist, who will pass it onto the patients GP who will consider the application. You will then be contacted by a member of the administration staff at the practice informing you of the decision of your application. Please Note: Any data held by the practice concerning you is subject to the regulations laid down in the Data Protection Act (1998). The consent is between you and your GP Practice. How do I use the online access to medical records viewing system? Once the practice has your signed consent and both parties (you and your practice) have decided to enable the online access to medical records, you will be required to use a password. You may already be registered to order your repeat prescriptions or book and cancel appointments online, if you are you will already have a password, however for online access to medical records a second password is needed, this gives added security. Once the patient has chosen a password they will need to register via the following: From a link at your practices own website From a link at 2

3 Then follow the instructions to sign up and begin using emis access to medical records. Once you have signed in you must select the View Medical Record section which will further prompt you to enter the password specifically assigned to allow you to view your online medical record. Use the menu and links to view each area of your medical record. There is an online help section to help you use the system. What will I see when viewing my medical record? The system allows you to view the following areas of your medical record: A summary that gives you the most important and recent entries in your medical record. Consultations including: date, practitioner seen, reason for visit, history, examination, outcome, investigations, etc. Medical Record showing diagnoses, investigations, procedures and allergies. Patient Information Leaflets linked from the diagnoses in the medical record section. Results showing all investigations such as blood results, liver tests, blood pressure etc. Vaccinations. Medications. Why would I want to look at my medical record? There are many benefits to you having access to your record; it can offer a range of benefits by improving your health and management of diseases by offering the following: Enables patients to have a better understanding of their conditions and in doing so help them manage the conditions more appropriately Enable patients to have the information they need to make informed choices Patients feel they are equal partners with health care professionals in making decisions about their treatment and care It encourages a more open and honest relationship with health care professionals and patients which leads to better treatment and care outcomes. By patients having access to their health care records it can also ensure that the information that is held on them is accurate, giving better clarity. Patients are also able to share their medical records with others such as other family members which may help in their understanding of patient s conditions and treatment, as well as sharing records with other health professionals involved in their care which could again lead to better diagnoses, treatment and care leading to improved health outcomes for the patient. The following are some quotes from patients who already have access to their records: I am able to record my blood sugar, blood pressure, weight, to help myself and the clinician improve myself care I have 5 consultants in 3 hospitals - there is no sharing of information even in the same hospital, I print off relevant details of my records, graphs of results and effects of my lifestyle changes on them and bring this to all my consultations, this saves time and money for me - and the NHS I am a passionate advocate of online access for those who wish to participate. I have a chronic disease and feel a real partner in the management of my health. Whether I am at home or abroad I can monitor information and share it with any other health professional involved in my care. I would be lost without it now 3

4 Who has access to my medical record and where is my confidential information held while I am viewing my medical record online? Using the online medical record system does not allow any other person to view your medical information other than the people who would normally have access to it in the GP practice or unless you have given permission for other people to view your information. The information you view on the online medical record system comes from the clinical system in your GP practice. Portions of this information are encrypted (this means it is very difficult for someone else to intercept and read the information) and securely sent from the GP system to your PC web browser. None of the medical information that is shown on the online medical record system is held permanently on any computer except the computer which holds the original data in the GP practice. When you log off from the online system or if a problem occurs with your computer, for instance a power failure, all your confidential medical information is cleared from the system. REMEMBER TO LOGOUT FROM THE SYSTEM WHEN YOU ARE FINISHED. How will other people be prohibited from seeing my medical record? To view your online medical record you will have to identify yourself with passwords and PINs that only you know. Unless you reveal this information to someone else you will be the only person able to access your medical record via the online system. What if I find an error in my medical record or if I see someone else s medical information? If you find any errors or missing information in your medical record you can tell the receptionist or discuss it with your GP. It is important if you see someone else s medical information you should immediately exit from the system and inform the practice staff immediately. What if I don t want to register to use the online medical record system? If you do not want to register to use the online medical record system this won t make any difference to the service you receive from the practice, you can still use all the practices services exactly as before. Your decision not to register will not affect your treatment or your relationship with your GP practice in any way. Can I have online access to my children s records? Parents or anyone with parental responsibility for children are entitled to access to their child s medical record if it is in the child s best interest. If your child is considered by a health professional to be able to make their own decisions ( Gillick competent ) then you can only look at their medical records with their permission. Online access to your child s medical record is at the discretion of each individual practice so please ask your practice for details: As this is a pilot trial Hall Green Surgery will not be offering access to Children s Records at this point: This will be reviewed after a period of time. When won t I be allowed to access my medical records online? Online access to your medical records at your practice is only currently being piloted and unless you are part of the pilot cohort you will not be allowed to have access. However, there are also other circumstances were you practice would not allow online access as follows: 4

5 Were it is likely to cause serious harm to the physical or mental health of you or any other person Were your records contains information about another person who has not given permission for you to see the information Other frequently asked questions Password considerations Passwords are case sensitive, when choosing your password if you have used a capital letter you will always need to input this letter in capital when logging on Difference between O or 0, make sure you use O for the letter and 0 for the number If you leave passwords lying around then no it s not secure, keep passwords secure Identity Theft? No addresses, NHS numbers or National Insurance numbers are given on the screen they are only obtainable by reading letters What if I mess it up? No matter what you click you can t alter anything in your medical record. What if I am seeing a doctor and there is no computer in the room? It can easily happen. If you know you are going to see a doctor then take a print out with you. This could include any of their letters to your GP and any recent test results What are the advantages and Disadvantaged for having online access to medical records from a patient perspective Before registering to use online access to your medical records it is vitally important you read the advantages and disadvantages and understand what they mean to you. Having online access to medical records has proved to be very popular with many patients who report by using it, they no longer have to queue to get test results, they can ensure that all information held in their medical record is accurate and it helps them to become more involved in their care and treatment. The following lists highlight further the advantages and disadvantages from a patients perspective: Advantages GP/Healthcare The patient has an active role in their own healthcare and develops a good relationship with their GP and Practice. ALSO If you are going to see a healthcare professional outside your area you or you are away on holiday you can allow them to see your records online (if facilities exist) or print out the relevant information and take it with you to your appointments. Repeat Prescriptions These can be ordered via the internet at or a link on the practices website You can register to order repeat prescriptions online whether you take advantage of the online access to medical 5

6 records or not. If you are not already registered to use this facility and would like to do so please ask at reception for details Results With online access to your medical records you can check any results 24hrs a day 7 days a week. Holidays You may be in another country or another part of the UK and be taken ill, you can choose to share your medical record online with the doctor or clinician looking after, which may help them with diagnoses and effective treatment ALSO It might be that you forgot to order your repeat prescription before you went away and you need them ready on your return, if you are registered you can do this by using the internet from anywhere, which has been tried very successfully from abroad. Appointments You can book and cancel appointments with your GP online 24hrs a day 7 days a week. Community It might be that you are receiving care at home and it is necessary for latest test results are known before treatment is given. You can check the results yourself at home and share them with your carers or health professional or give permission for another person to have access. Nursing Homes If a relative is in a nursing home, and you have been given access to their records, by monitoring the consultation section you can monitor their care, records of visits by doctors along with comments by the doctor will be recorded. This could be done from anywhere in the world. Relatives Only if you wish you can share all your records with relatives or just part by printing the part you wish to share. Time For most people there is never enough time doctors included. Much time can be saved by ordering repeats prescriptions, checking blood results and x-rays online. If they are normal it saves you time by not having to travel to the surgery (can be lengthy & expensive if you don t have your own transport). It also leaves a free appointment allowing the doctor to see someone who is in need of an appointment. Information You have access to an array of information which will help you manage your own treatment and care more effectively by checking information about any medication prescribed by clicking on the blue i' button listed next to your medication in the list. This also includes information on how to take the medication such as on an empty stomach or with food etc which is not always available when you receive tablets in bottles. You can also check what results mean or check a condition and have access to help guidelines. There are links to support groups e.g. Diabetes UK. Security Online access to medical records is as safe as internet banking which millions of people use across the world daily. To ensure security however it is vitally important that you keep your passwords secure. You wouldn t leave your bankers card and pin numbers lying around so it 6

7 is equally important that you don t leave your passwords for online access to you medical records lying around for others to see them. This would also include at home if you don t want family members to view your records. When choosing a password, don t choose obvious ones such as names, birthdays or anniversaries etc. REMEMBER TO LOGOUT FROM THE SYSTEM WHEN YOU ARE FINISHED. Disadvantages/risks Forgotten History Bad News Abnormal Results X-rays Diagnosis Comments There may be something in your history you don t want any family members to see. It might be information you had put to the back of your mind and are now confronted with it. You may read some bad news before the doctor has seen it or has had time to speak to you about it and could be at a time when the surgery is closed. Results may be abnormal and cause you to worry. A chest x-ray may show a shadow or something abnormal. Sometimes you may see different or more than one possible diagnosis in your medical record, your doctor may put different or more than one diagnosis in your record in order to help to plan diagnostic tests and treatments to rule out conditions. You might see diagnosis that you don t agree with or comments that upset you or confuse you. What should I do if any of the above apply to me? Contact you surgery and ask: For clarity on information you don t understand Give them clarify on information which is wrong Ask for more information if required Gain reassurance from your GP/Healthcare clinician If your practice isn t open consider the following: Don t look at the results if you are prone to worry Wait until the surgery opens before checking Speak with NHS direct on Contact out of Hours Service on 111 Remember had you not had access to your medical record you would not have known the results until either the doctor/practice/contacted you or you rang for the results. 3rd Party Info You might want to tell the doctor something about your spouse/partner/child etc. in confidence, this is known as third party information. If the doctor records the information and the patient then sees this it could cause problems. If the doctor doesn t, vital information may get lost or forgotten. The information may be malicious and again cause problems. Before registering you need to consider what you would do if you see 3 rd party information written in your record that you weren t aware of. Also when allowing others access your medical records you need to be aware that you may have spoken to your GP/Healthcare professional about that person in the past and this information may have been recorded. 7

8 What to Do Next Carefully weigh up the advantages against the disadvantages. Consider are there other issue that have not been answered for you? If any of the disadvantages are a problem for you then online access to your medical records may not be for you. The treatment you receive or the relationship with your doctor will not be affected in any way if you decide not to have online access to your medical records, you could still use the online prescription ordering or booking and cancelling appointment facilities. Being able to choose to have online access to medical records is for the benefit of the patient and it is necessary to apply for such. You may wish to discuss this further with the doctor before registering for online access. If you have decided to continue and register for online access to your medical records you will now need to complete you questionnaire and sign the consent form below and hand it into reception. Your application will then processed and if you re GP authorises you to have online access you will be informed by the practice. Once the practice has activated you at the practice you will then need to choose a password and register through patient access via the following: From a link at From a link at your practices own Remember to access this site you will need internet explorer version 6 or above When creating your own passwords Create a good (strong) password: Include both uppercase and lowercase letters (case-sensitive) if you have a good memory or just 1 case if not. Include both letters and numbers (alpha-numeric but not birthdays). Do not include your login name, a.k.a. username, in any form (as-is, reversed, capitalized, doubled) or any other name. Avoid words that can be found in a dictionary (including foreign and technical dictionaries) these include names. Do not use a password that has been given as an example of a good password. 8

9 Questionnaire on Your Medical Records Access This questionnaire is about Online Medical Records Access and goes through the main issues you need to understand before you can access your medical records over the internet. This is not a test with a pass or fail its purpose is to go through issues with you so that you feel happy to be able to decide whether you wish to access your medical records over the internet or allow access to others that you have specifically allowed to-do so. Please feel free to turn the page over to answer any questions further if need be. All questions are mandatory (Please use a black pen as the document needs to be scanned) Patient Name: DoB: 1. Have you read the Patient Information entitled Online Electronic Medical Record Viewing? 2. Have you watched the videos on You Tube about Records Access? 3. Have you registered for booking online appointments? (This is a prerequisite before you are able to view your online Medical Record) If NO to question 3 then why? * * Please speak to a receptionist I do not currently book appointments online Did not know I could do this t interested in this 4. The system allows you to see a summary of your medical record: diagnoses, allergies, medications, consultations, and certain letters and test results. Do you agree that you should be able to see this information? If NO to question 4 then why do you think you should not be able to see this information? Other (please state) Too detailed Too personal I won t understand it I don t know I am not interested Other (please state) 5. You need 2 passwords one for booking online appointments, the second to see your medical record. Keep them safe and secure. You should not share your passwords. Do you agree this is safe and secure enough? If NO to question 5 why do you not feel this is a secure enough way to access your medical records? The internet is not secure whatever you say I don t understand 9

10 I won t remember my passwords 6. Sometimes information may be recorded that is incorrect or there may be information that you think is missing would you like to be able to inform the practice so that your records can be corrected? 7. Only people who are in the practice can change records and there is a record to show who has changed it and when it was changed. This protects you and the staff. Do you agree this will safeguard your medical record? 8. You can fall ill at any moment and this solution allows you to share your medical record with others. Do you agree that this may be a good thing and could even one day save your life? 9. Blood tests may be done as part of routine tests for common conditions. If you view your results and they are normal then you can continue as before. If the results are abnormal you need to see a clinician could this save you time? 10. What happens if you see your blood result and find it is abnormal? Would this make you very anxious? If so what would you do? 11. What happens if you have a test done that shows something bad that you were not expecting e.g. an X- Ray done which shows that you have a shadow on your lungs and suggests this may be a cancer? What do you do? 12. You see a new letter has arrived in your medical record. You have not been to the hospital or seen anybody for a long time. You open up the letter to find it is about another patient in the practice. What do you do? 13. Your record may contain details about you given by someone you know well and done in your best interest. It says who said this and what they said. This could cause you some distress. Would this make you very angry? Other (please state) t view them but go and see the Doctor/nurse for result Panic and get worked up Look at some of the recommended web-sites Wait and contact the practice the next day Contact NHS Direct to get further information Contact the Out-of-Hours service Go to A&E for further help Other (please state) t view them but go and see the doctor/ nurse for result Panic and get worked up Look at some of the recommended websites Wait and contact the practice the next day Contact NHS Direct to get further information Contact the Out-of-Hours service Go to A&E for further help Other (please state) Read it then tell others what the person suffers with Shut the computer down and inform the practice Stay quiet and not tell anybody about it 10

11 If YES to question 13 then why? 14. We do not differentiate between those who wish to access their records and those that don t. However those who access their records are more likely to understand their own health better. Do you agree that this is true? 15. Do you feel you now have a better understanding of online access to medical records and what the issues are about it? If NO to question 17 then why do you not have a better understanding? I don t want this information kept on my record You shouldn t believe what others say This could destroy our relationship Don t know Too complicated t interested Too much information I want someone to explain it to me 16. Finally, we would like to evaluate this questionnaire. Did you think this is a useful way for us to check that you have understood the issues relating to Records Access? 17. Was it easy for you to understand the questions? If NO then why was this? Too difficult to read t enough time Questions too difficult Other (please state) Thank you for your time. We hope this questionnaire and Information leaflet has given you the information you need to decide whether you wish to access your medical records online. Please sign the questionnaire and the following consent form and take it to the Receptionist if you wish to have access to your medical records online. If you have any further questions about online access to medical records, please leave a message with the Receptionists along with your contact details so that we may be able to contact you later and go through any issues you may still have. We hope you found this to be a pleasant experience and that you will enjoy being able to access your own medical records online at a time of your choosing. PRINT NAME DOB SIGNATURE DATE 11

12 Online Medical Record Viewing System Consent Form I have read and understood the information Patient Information Leaflet booklet about the Online Access to Medical Records and subject to the information in the leaflet; I consent to my GP practice enabling me access to my online medical record via the internet. I further agree to use the system in a responsible manner in accordance with all instructions given to me by the GP practice and to immediately report any errors I encounter whilst using the system. If I see any patient data which does not relate to me I will immediately log out and report the matter to the GP practice. Signed: Print Name: Date: Date of Birth: Tel no: Mobile no: Address: Please choose a PASSPHRASE to enter your medical record. This must be 8 characters long contain at least 1 numerical character and 1 alphabetical character. It can be no more or no less than 8 characters. Passphrase: Remember it is not a test, so it doesn t matter how you answered the questionnaire, but each Person wanting online access to their medical record must sign their own consent form. Please hand in your completed & signed questionnaire and consent form to the receptionist at your practice. You will be notified of access once a GP has reviewed your records and authorised you request. 12

13 Additional Information to help you understand Patient Online Access to Medical Records Glossary of Terms - The following table gives a list of abbreviations commonly used in medical record. If you come across any abbreviations that you do not understand please contact the surgery or go to following web site 13

14 What help is available to understand your health better? Your practice. It might sound like the obvious but your practice is there to help you understand your health better. They have the added advantage of knowing your personal circumstances better and helping to understand what these mean for you. If your practice is closed Out-of-Hours service - You will be given the telephone number for this service from your practice. There is always a doctor or nurse available. But remember the out of hours service do NOT have access to your medical records. You may have to read out or show them what you can see on your computer screen! NHS Direct or This is a web-portal which gives you access to other web-sites on almost any health related problem. This is usually a good place to start if you want to know more about a condition that you suffer from. - This is a web-site that has been designed for members of the public to know the best treatments for common conditions. - This is an excellent web-site which describes different blood tests that you may have and what they mean. and - This is the international body that is taking a lead on Records Access and describing what is happening throughout the world. If you click on Record Access, it will direct you to a number of resources. A large number of people throughout the world are now looking at this as a way of keeping up to date on what is happening. There is also the world s first Blog where patients, clinicians, people in the system and system suppliers can all post ideas to inform others about what they think. We want as many different people to post ideas here and what their thoughts and experiences are. Please pass this on to friends and family members all over the world so that they can also see what is happening too. There may be other sources as well that we have not included. This is by no means an exhaustive list but it may help you to understand your health conditions better. Of course if there is something you do not understand then it is important that you contact the practice to help you further. 14