Electronic health records Flashcards
What are patient medication records (PMRs)?
Pharmacists’ records of medicines supplied to patients:
dispensed
non-prescription (not often used)
Why use PMRs
To monitor prescriptions for errors & omissions
To enable the pharmacist to monitor and manage patients’ medicines
Changes in therapy
Interactions
Contraindications
New medicine service
Minor ailments consultations
Supplies of private PGDs
Responding to symptoms
To check compliance
To facilitate emergency supplies
Potential problems with drug interaction software
All systems should identify drug interactions and highlight those which are potentially hazardous
Historically, systems were not consistent
Market consolidation of fewer data-providers led to standardisation
Errors could be caused by:-
Use of out-of-date reference sources / Inadequate literature review
Using pharmacological groups rather than specific drugs
Inadequate consideration of route of administration
THINK through what your drug interaction software is telling you!
Data Protection Act 2018
Updated the previous legislation (Data Protection Act 1998) and brought the General Data Protection Regulation (GDPR) into force
Regulation (EU) 2016/679 of the European Parliament and of the Council of 27 April 2016 on the protection of natural persons with regard to the processing of personal data and on the free movement of such data
The General Data Protection Regulation (GDPR)
Adopted by the EU in April 2016, and came into force in May 2018.
New legislation designed to supplement the existing data protection provisions in theData Protection Act 1998.
Pharmacy owners are data “controllers” under this legislation
The controller must be able to show that consent for processing patient data was given explicitly, either verbally or in writing
any information given by the controller to the patient to inform their decision was given in language that was clear, concise and easily accessible.
All controllers to appoint a data protection officer (DPO), whose contact details must be published. This person’s responsibilities will include:
Monitoring the pharmacy’s compliance with GDPR and with procedures
Being a contact point for all patients with data protection issues, including reporting breaches to theInformation Commissioner(http://ico.org.uk)
Informing and advising pharmacy staff of their data protection obligations
Monitoring assignment of responsibilities and awareness training.
Data Processors
Processors are those who do exactly what you ask them to do with the personal data you send to them. They are not other data Controllers to which you pass information.
The main Processors for community pharmacies will be:
The PMR supplier and the aggregator (usually by the PMR supplier) which together transfer prescription data from the community pharmacy to the NHS;
any organisation that provides data capture and reporting systems (e.g. PharmOutcomes)
Having identified Processors, the question is whether the necessary GDPR safeguards are included in the relevant contract (or sometimes legal provision), which include:
Details of the processing that will be carried out on your behalf;
The Processor will ensure the security of the personal data;
The Processor will only act on the written instructions of the Controller; and
The Processor will assist you as the Controller to fulfil your obligations, for example, in relation to the security of the data and data breaches.
Caldicott Guardians
Caldicott Guardians are senior staff in the NHS and social services appointed to protect patient information
All NHS organisations and local authorities which provide social services must have a Caldicott Guardian
The ETP Programme
The ETP Programme will deliver the Electronic Prescription Service and integrate it with the NHS Care Records Service
Integration with NHS CRS
There will be a separate programme to explain NHS CRS to healthcare professions and to the public
Prescribing and dispensing information will be used to update patients’ care records – but full details of how the Electronic Prescription Service will be integrated with NHS CRS are still under development
In particular, the extent of any pharmacist access to care records is still subject to consultation
Key first stage benefits
Pharmacists will be assisted by downloading the information on the prescription leading to:
prescriptions being processed faster at pharmacies due to the reduced need to key in data
fewer errors from data re-keying which then need to be clarified or corrected
a reduction in the number of queries due to incomplete prescriptions
Key second stage benefits
Patients will not need to visit their GP surgery just to collect a paper prescription, saving time for both patients and surgery staff
GPs and surgery staff will find administering repeat prescriptions easier and repeat dispensing will be possible from a single electronic prescription
It will be easier for GPs to amend or cancel a prescription
Pharmacists will be able to manage their workflow and stock control more effectively and be able to prepare prescriptions before the patient arrives to collect them
The need for pharmacies to physically collect prescriptions from GP surgeries will become virtually obsolete
More options will develop for patients, including those provided by e-pharmacies
NHS Care Record
Concept of “cradle-to-grave” record
Detailed Care Record
Every health care professional treating a patient makes detailed notes. Together these will form the patient’s Detailed Care Record.
Who can see all, or parts, of the Detailed Care Record will depend on clinical need and patient wishes.
Summary Care Record
Over time, a Summary Care Record will be built up from selected information in the Detailed Care Record. It will contain essential information such as allergies and medications.
Who can see all or parts of the Summary Care Record will depend on clinical need and patient wishes.
SNOMED Clinical Terms
Systemised Nomenclature of Medicine”
NHS-wide standard terminology
Merger of UK Clinical Terms Version 3 (“Read Codes”) and US SNOMED system
Implemented by NHS Connecting for Health & College of American Pathologists
NHS Dictionary of Medicine and Devices (dm+d)
Uniquely code medications and appliances
Relationship between generics, alternative products, packs etc.
Used across primary and secondary care
Identify all the medicines and devices that have been used in the diagnosis and treatment of individual patients
