Executive Summary by DonnaCollins670

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									Patient Access to Records &
Transactional Services
P.A.R.T.S.

Phase 1 Report
March 2013

NHS South of England Health Informatics Team
Becky Gayler and Isabella Davis-Fernandez




                                    1          15/07/13
Contents

1     Executive Summary ..........................................................................................................5
    1.1     Background................................................................................................................5
    1.2     Where are we now? ...................................................................................................5
    1.3     Where do we want to be? ..........................................................................................7
    1.4     What needs to happen to get there?..........................................................................7
      1.4.1        Clinically driven objectives..................................................................................8
      1.4.2        Systems Designed for the Purpose ....................................................................9
      1.4.3        Support Change and Evidence Benefits.............................................................9
      1.4.4        Generate Awareness and Demand ....................................................................9
      1.4.5        Records Access is embedded in Health and Well-being Strategies.................10
2     Project Approach.............................................................................................................12
    2.1     Background..............................................................................................................12
    2.2     Scope.......................................................................................................................12
    2.3     Objectives ................................................................................................................13
    2.4     Approach..................................................................................................................13
      2.4.1        Awareness raising ............................................................................................13
      2.4.2        Patient Reference Group..................................................................................13
      2.4.3        Demonstrator Sites...........................................................................................14
      2.4.4        Surveys.............................................................................................................14
      2.4.5        Supplier workshops ..........................................................................................14
      2.4.6        Developing exemplar materials ........................................................................15
      2.4.7        Sharing resources.............................................................................................15
    2.5     Advisory Board.........................................................................................................15
    2.6     Evaluating Costs and Benefits .................................................................................15
    2.7     Assumptions and Inhibiting Factors .........................................................................16
3     Drivers for Change ..........................................................................................................18
    3.1     Evidence of Benefits...............................................................................................18
      3.1.1        Quality Innovation Productivity and Prevention (QIPP) ................................18
      3.1.2        Health Policy Drivers.......................................................................................18
      3.1.3        Informatics Policy ............................................................................................19
      3.1.4        Cultural and social change .............................................................................20
4     Current status..................................................................................................................21
    4.1     Attitudes towards Access.........................................................................................21
      4.1.1        Public and Patients Views ................................................................................21



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      4.1.2      Professional and Practice Views ......................................................................23
    4.2    Systems currently available and in use....................................................................25
      4.2.1      GP system suppliers offerings ..........................................................................25
      4.2.2      Deployment of GP Online Services ..................................................................26
      4.2.3      GP Systems – Fit for Purpose ..........................................................................29
      4.2.4      Non-integrated access solutions.......................................................................31
      4.2.5      Use of SMS to “push information” to patients ...................................................32
    4.3    How practices are managing online services...........................................................32
      4.3.1      Promotion to Patients .......................................................................................32
      4.3.2      Registration and Authentication of patients ......................................................33
    4.4    Guidance..................................................................................................................34
      4.4.1      Guidance for health professionals ....................................................................34
      4.4.2      Guidance for Practices .....................................................................................34
      4.4.3      Guidance for Patients .......................................................................................35
5     Lessons from Demonstrator Sites...................................................................................36
    5.1    Practice Approach....................................................................................................37
    5.2    Benefits ....................................................................................................................38
      5.2.1      Records Access................................................................................................38
      5.2.2      Transactional Services .....................................................................................39
    5.3    Barriers ....................................................................................................................40
      5.3.1      Lack of Clear Professional and Legal Guidance...............................................40
      5.3.2      Practice Capacity..............................................................................................40
      5.3.3      System Issues and Usability.............................................................................41
      5.3.4      Costs.................................................................................................................41
6     Critical Success Factors for Patient Online Access ........................................................43
    6.1    What do all stakeholders need?...............................................................................43
    6.2    What do the Public and Patients need?...................................................................43
      6.2.1      Awareness of what services are available and how they can be used.............44
      6.2.2      Services which are easy to use ........................................................................44
      6.2.3      Health information which is easy to use and is relevant ...................................44
      6.2.4      Assurance that services are safe......................................................................45
    6.3    What Health Professionals and GP Practices need?...............................................46
      6.3.1      Systems that can be locally configured and introduced in a step-wise fashion 46
      6.3.2      Support to introduce new ways of working .......................................................46
      6.3.3      Better technical support with online systems....................................................47
      6.3.4      Guidance about professional and legal responsibilities....................................47



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    6.4     What do NHS and Health & Wellbeing Partners need?...........................................48
      6.4.1        An understanding of the strategic fit .................................................................48
      6.4.2        Understanding of the fit with wider informatics agenda ....................................49
      6.4.3        Clarification of responsibilities and resources to take forward online services .50
      6.4.4        Local clinical support and clinical champions ...................................................50
    6.5     What do the System Suppliers need?......................................................................51
      6.5.1        A clear mandate for development and investment ...........................................51
7     The Next Stage ...............................................................................................................53
8     Appendices .....................................................................................................................54
    8.1     Demonstrator GP sites case studies........................................................................54
    8.2     Glossary...................................................................................................................64
    8.3     References...............................................................................................................65
    8.4     Index of PARTS resources ......................................................................................66
    8.5     Safeguarding Issues and Recommendations ..........................................................67
    8.6     Survey analysis........................................................................................................68
    8.7     GP Systems Workshops ..........................................................................................69
      8.7.1        Hints and Tips...................................................................................................69
      8.7.2        Issues and Enhancements ...............................................................................69
    8.8     Advisory Board.........................................................................................................70
      8.8.1        Membership and Terms of Reference ..............................................................70
      8.8.2        Advisory Board Benefits workshop ...................................................................71
    8.9     Acknowledgements..................................................................................................72




                                                                  4                                                            15/07/13
1 Executive Summary
 This Summary should be read in conjunction with the Critical Success Factors and
recommendations outlined in Section 6.

1.1 Background
Key policy drivers for patient online access are:
1.        Empowering people to better manage their health and care
2.        Delivering transparency to improve quality of care and patient experience
3.        Integrating and personalising care packages
4.        Improving the effectiveness and productivity of services
The NHS Commissioning Board has mandated1 that by 2015 all general practices in England
will offer patients online access to:
      transactional services such as booking appointment, requesting repeat prescriptions
      the medical record, including test results, letters, medication, summary information
      secure communication with clinicians.

This project has looked at what needs to happen to deliver this ambition and ensure benefits
are realised for patients, clinicians and the NHS.
The project name, Patient Access to Records and Transactional Services (PARTS), was
chosen to illustrate that Transactional Services are a key stepping stone for Records
Access. PARTS also refers to the ambition that online services will help combine
information to provide a patient centred view of health and care and enable patients to
become a more active partners in the process.
This report brings together information gathered from GP practice demonstrator sites, a
number of surveys, and consultation with a range of stakeholders, to address:
     Where are we now?
     Where do we want to be?
     What needs to happen to get there?

1.2 Where are we now?
In principle, there is strong support for the concept of online services among the majority of
patients. Patients see that online services have the potential to save them time and could
make accessing health services easier.

Although Transactional Services have been introduced to improve practice efficiency and in
response to public demand for greater convenience, GP practices often say there has been
little demand from patients for online access to records. However a PARTS survey showed
that over 75% of patients felt Records Access was a “good idea” and that it could help
support decisions about health and care.

In particular patients felt that Records Access would:

Protect patients and improve data quality
“I have had access to medical records in past at huge cost and found that there were


1   http://www.dh.gov.uk/health/2012/11/nhs-mandate/


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unjustified and incorrect recordings. [Records Access] would protect the patient and ensure
the best treatment is always given.”
Facilitate joined up care and patient choice
“Having immediate access to medical history and information would make planning my
treatment and care easier for me. I have to pay privately for physiotherapy and pilates and I
would like those therapists to have access to my medical history.”
Help vulnerable patients and their carers
“My mother is often confused by hospital and GP appointments. I cannot attend all of these
with her so it would enable me to help her and avoid chasing the GP for updates.”

Around a third of GP Practice clinicians and staff surveyed by PARTS acknowledged the
potential of Records Access to improve:

•      patient trust and communication
•      clinical record keeping.
•      effectiveness of consultations
•      patient compliance

Among many health professionals and service providers there is a general acceptance of the
need for change in line with public expectations, the transparency drive and also with QIPP
agendas.
“I think this is inevitable and being more aware about patients likelihood of reading their
notes will focus staff on recording things well and reduce future problems.”
GP Practice Manager November 2013

However, there are reservations about the pace and resourcing of this change, which is
commonly perceived as politically, rather than, clinically driven. Whilst the benefits of
transactional services are acknowledged by GP practice teams, less than 40% of practice
staff / clinicians surveyed felt the potential benefits of Records Access outweighed their
current concerns. Concerns that exist focus on security and workload issues and the
potential for online services to be used as a replacement for personal contact.

Transactional services are becoming widely used and valued by patients, with 40% of
practices now offering them. There is growing evidence to support the potential efficiency
savings of these systems where they work well, however some practices still feel that the
tipping point between costs and benefits of introducing them has taken too long to reach.
Others feel that the solutions and their associated support services are not yet sufficiently
robust to actively promote to patients, and hence they are also unwilling to consider
expanding online services to allow records access.

The term Records Access in this report refers to patients being able to view part (e.g. test
results, letters, medication, summary history) or all of their GP electronic record. Currently
two of the three main GP suppliers offer Record Access to the full GP record, with options for
the practice to limit access to consultation entries. However practices using these systems
cannot currently choose to enable individual elements (e.g. test results) separately. The third
main system supplier is developing Record Access functionality in a modular way, prioritising
the delivery of test result viewing in 2013.




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Records Access was not offered by any GP practice in the region prior to December 2012,
however as a result of the project, it is now being piloted with invited patients in 5 GP
practices (see Section 5 for details).

1.3       Where do we want to be?
Both practices and patients want Transactional Services which are easy to use and access
to improve efficiency and convenience. This simply mirrors use of similar technology in other
areas of everyday life.

There is more debate about whether the NHS should make Records Access “a right” for all
patients, or whether it should be available at the discretion of practices / clinicians for those
with a clinical requirement who need it, or stand to benefit most.

Our consultation shows that if patients and professionals are to embrace the culture change
required to reach government objectives, Records Access needs be clearly linked to clinical
objectives. Specially designed patient interfaces for particular conditions and care packages
could include decision support tools, with information shown in context, in an easily
accessible way e.g. as dashboard / traffic light displays, with diary dates, care and treatment
plans. This could include prompts for the patient to take action and support them to make a
decision about their lifestyle. Unless the patient interface supports access for non-expert
patients, online access could exacerbate rather than resolve health inequalities.

However this does not mean restricting access only to those considered “active service
users”. If combined with proactive messaging services, access could be a useful tool to
engage hard to reach members of the public with health campaign messages and lifestyle
advice.

1.4 What needs to happen to get there?
The RCGP have recently published Patient Online: The Road Map2 which provides:

         explanations of the different online options available
         potential strategies to support GP practices with the implementation
         guidance about information governance and safeguarding risks
         recommendation for support, training and education tools needed
         advice about communications work required
         advice about market development of solutions

Key messages from the report are that:

          online elements should be capable of being implemented incrementally,
          systems need to develop within a framework of common standards and
          IG and safeguarding risks need further consideration to ensure they are properly
           managed.

These recommendations will inform the development of national strategy. Similarly the
PARTS project has found that although local consultation suggests that there are significant
potential benefits on online access, there are a range of risks and inhibiting factors for
patients, clinicians and practices which need to be addressed.
2http://www.rcgp.org.uk/clinical-and-research/practice-management-resources/health-informatics-
group/~/media/Files/CIRC/POA/RCGP-Road-Map.ashx



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Individual decisions about whether to use / offer online services must be informed by a
balance of risks v. benefits. Online access to health services / records is still in its infancy in
the UK. More work needs to be done to:

•        Inform patients, professionals, and practices about the relative benefits v. risks of using
         / offering online services.

•        Develop information systems, guidance and support processes which can mitigate the
         risks, and optimise benefits to an acceptable threshold for stakeholders.

The following diagram summaries the development process required:



                                                 Clinically
                                                  driven
                                                objectives



                             Access
                          embeded in                                    Systems
                           health and                                 designed for
                           well-being                                   purpose
                           strategies




                                                               Support
                                    Generate
                                                              Change and
                                   Awareness
                                                               Evidence
                                  and Demand
                                                               Benefits


1.4.1 Clinically driven objectives
Transactional services can be justified wholly on the grounds of improving convenience,
access and efficiency. If the systems work well and are fit for purpose, there is an
overwhelming economic case.

The case for Records Access is a clinical one. It enables patients to take better, safer
decisions about their health and care. It allows them to share information to support
decisions by those who care for them. It also allows patients to see understand what
decisions have been made about them and why. A lesson from the Francis Inquiry3 is that
transparency is not simply an end in itself, but an important enabler of good clinical care.

Records Access needs be viewed not as an informatics initiative but as an enabler of
improved patient experience and outcomes, and as such should be incorporated in clinical
protocols and pathways of care.




3   http://www.kingsfund.org.uk/projects/anticipating-francis-inquiry-report


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1.4.2 Systems Designed for the Purpose
Once it is clear how Records Access will be used to support clinical objectives, systems can
be designed specifically for these purposes. Current systems have evolved in response to
“customer” demand in an ad hoc way, without national standards or accreditation. Online
access currently provides a view of the patient record written and structured to support
clinical and not patient decision-making. Online access systems need to provide a patient-
centric view which helps patients find the most relevant or important information about them.
Until now the GP record has been the only place where information about the patient is
brought together. Furthermore primary care informatics and data quality is much more
advanced than in other sectors. However the development of integration tools, telehealth
systems, and health apps allow the development of patient-centric rather than service centric
access systems, which can support the active exchange of information from clinical and
patient sources. Future strategy should not be constrained by what GP systems alone can
offer there needs to be commercial frameworks in place which encourage and support
partnerships between solution suppliers.

1.4.3 Support Change and Evidence Benefits
Once systems have been designed for the purpose of supporting patient decision-making,
they will need to be introduced into day to day clinical practice. This will require a huge
culture change and a high level of both change management and practical support for both
clinicians and patients.

Clinical leadership and patient trust will be critical success factors. These need to be grown
through a managed programme of early adopter sites, which would thoroughly test both
technical solutions and support packages. These pilots would provide:

       Robust comparable information on benefits essential to promote access to practices
        and patients and feed the development of future solutions and strategies.
       A framework of standards for solutions, support and implementation processes
        which can be replicated across the country to ensure safe and effective online
        services are consistently available.

1.4.4 Generate Awareness and Demand
Patient and Public demand will be key to shaping and sustaining the development of the
online services

It will be important to show that Records Access is a core clinical NHS initiative. Patient and
carer representative and educational bodies such as Diabetes UK, Asthma UK, the British
Heart Foundation and the Carers Trust will be important not only in terms of specifying
trialing solutions but also in promoting awareness and demand.

HealthWatch organisations national and locally and PPGs representing GP practices
populations will be fundamental to championing access will need to be supported in this
tasks with evidence and communication tools.

Wider health literacy and health promotion campaigns and well as those targeted on
promoting self-care will also need to embed messages of how access can help support
improved experience and outcomes.




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Robust evidence of clinical efficacy and experience from well supported pilot sites will help
grow more clinical champions both with the GP community and other clinicians treating
patient with Records Access (e.g. hospital specialists, urgent care clinicians). Peer to peer
endorsement of online services will be essential to change the prevailing GP view that
records access is more of a risk, rather than an opportunity. Demand must be promoted
from within the local GP and wider clinical community.

1.4.5 Records Access is embedded in Health and Well-being Strategies
Records Access is currently an informatics lead initiative. Although it needs to clinically
driven, there are key questions which need to be answered about the NHS approach before
it can be embedded as an enabler in Health and Well-being Strategies:

    a. “Access for All” or “Clinically Targeted”?
       Systems which are designed only to display the clinical record will meet the
       requirement of transparency and access as a “right for all” but will fail to optimize the
       potential for health gain. Online systems need be aligned to best practice clinical
       protocols and add value by combining data from different sources and intelligently
       analyzing the information, so the patient is signposted to further actions and
       information. The clinically targeted approach will further successfully engage
       clinicians and patient groups
    b. GP Records or Patient Portal?
       This project has focused on what online access can be provided by current GP
       system suppliers. This route was chosen because up until now the GP record has
       been the only place where information about the patient is brought together.
       Furthermore, primary care informatics and data quality has been far more advanced
       than in other sectors of health . However the development of integration tools and
       also patient facing apps potentially allow the development of patient-centric rather
       than service centric systems, in which data is combined from different clinical sources
       with patient information to enhance its value. Specialist care providers are already
       leading the way with initiatives such as Renal Patient View4, and My Diabetes My
       Way5, and myhealthlocker™ (for mental health service users)6. Whilst the GP record
       is a good place to start, and is likely to remain the most significant feeder system to a
       Patient Online system, it should not restrict the ultimate vision of delivering patient-
       centric, problem orientated systems.
    c. How can we get what we need from System Suppliers?
       Clarifying A and B above will allow the development of a set of national requirements,
       against which delivery can be managed. A commercial framework needs to be
       developed which allows suppliers to combine best of breed elements to bridge the
       gap between systems designed to maintain clinical records and systems designed to
       support patients. This approach will allow systems to develop in a flexible way so that
       the patient interface can be integrated with one or many different sources of
       information depending on patient requirements and local service configuration.
       Accreditation against national standards will ensure systems are safe, clinically
       relevant, consistent and usable.



4 https://www.renalpatientview.org/
5 http://www.mydiabetesmyway.scot.nhs.uk/
6 https://www.myhealthlockerlondon.nhs.uk/Default.aspx




                                                10                                        15/07/13
Attempts to deliver a new right of “online access for all” unsupported by systems and
processes which have been developed for the purpose, are likely to prove counter-
productive and expensive. A clinically focused series of achievable implementation goals is
more likely to be sustainable and generate demand for access among patients and the
healthcare professionals who need to embrace this culture change.

Online Access represents significant cultural, organisational and technical challenges.
These will only be tackled if there is a clear and shared vision of what “good access” looks
like and how it could be used to change behaviours and deliver better outcomes.
Commissioners, Patient Groups and Health and Well-being Boards need to consider how
patient access benefits can support the delivery of strategic objectives, and from this
analysis, develop detailed user case scenarios which will in turn inform future information
strategy and solution requirements.




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2 Project Approach
2.1 Background
The Project was set up in response to the Department of Health’s information strategy “The
Power of Information”7, which set out the following aspirations:
           o   From April 2013, patients will be able to see which general practices make
               available online access to records and other transactional services on the NHS
               Choices website (or via the national online portal.)
           o   By 2015, all general practices will be expected to make available electronic
               booking and cancelling of appointments, ordering of repeat prescriptions,
               communication with the practice and access to records to anyone registered with
               the practice who wants it.

2.2 Scope
The term “Patient Access to Records and Transactional Services” (PARTS) covers the
provision of online patient access to, and interaction with, patients’ electronic General
Practice record, including the ability for patients to:
        make / cancel appointments
       order repeat prescriptions
       access test results
       pre-register / request registration with the practice
       review past consultations, including diagnoses, advice and treatment
       view letters between their GP and other health professionals
       check their own medical record
       find out more about their condition through links to trusted resources, including
        information sheets, websites and support groups
       securely message clinicians.


The focus of the project was to consider what could be done to implement GP online access
with currently available systems. Although other online solutions (e.g. Patients Knows Best)
are available which would allow the patient to build a portal view of clinical information from
various healthcare providers to produce a Personal Health Record, the project did not
consider these solutions in any detail. It would not have been possible to pilot these
solutions within the scope of this project, requiring as they would much greater local health
economy planning and co-ordination8.

The project was initiated in August 2012. Given the transition to new NHS structures, phase
1 of the project was time limited to end in March 2013. However further phases of the project
will be informed by:

       The findings of phase 1
       The RCGP Patient Online Access9 to Records programme (which has been running
        in parallel to this project and whose report was also published in March 2013)
       The response of the Department of Health to the RCGP report and findings of NHS
        regional projects.
7
8http://www.patientsknowbest.com/
9http://www.rcgp.org.uk/clinical-and-research/practice-management-resources/health-informatics-
group/patient-online.aspx



                                                12                                          15/07/13
      Clarification of organisational responsibilities for strategy, implementation and
       delivery of Patient Online Access in the NHS.
      Evolution of technical solutions and the development of integrated electronic patient
       records.

2.3 Objectives
The project set out to:

      Raise awareness of solutions, opportunities and benefits
      Identify barriers to adoption and use
      Develop and share good practice resources
      Recommend actions to address these
      Inform and shape future roll-out strategies nationally and locally

2.4 Approach
This project has had a very practical focus, with a high proportion of time being spent
working out in practices and consulting with key stakeholders. This section looks at the
methods used by the project to raise awareness, support and extend use of online services,
and gather learning.

2.4.1 Awareness raising
A launch event was held on 18th October 2012, with contributors from the RCGP, early
adopter projects, GP systems suppliers, the Department of Health and patient groups. The
key-note speakers at the event were Dr Amir Hannan (GP) and Mrs Yvonne Bennett (Patient
Access user) from the Haughton-Thornley Medical Centre. The event was attended by over
60 delegates representing a range of stakeholders; patient representatives, GPs, CCGs,
LMCs and local NHS leads.

A presentation about the project was given to the October meeting of the full Kent LMC. This
generated a lot of debate and volunteers for demonstrator sites. A similar offer was made to
Surrey and Sussex LMC.

The project team visited PPGs, System User Groups and Practice meetings to host
discussions and gather feedback about online services.

An article was printed in the December edition of the SHA online publication “The Month”,
aimed at Chief Executives across the South. A briefing was sent to all LINks in the SEC
area for inclusion in their newsletters/websites signposting them to the project Patient Survey
and to their own GP practice for further information about availability of online services. In
March 2013, a briefing was prepared to inform engagement with Health and Well Being
Boards and Local Authorities.

A webinar was hosted by the Department of Health Informatics Directorate in March and
delivered by the PARTS project lead to provide a summary of the projects achievements, its
products and network of contacts. Summary briefings of the project’s work and
recommendations were produced for Commissioner and Public / Patient audiences.

2.4.2 Patient Reference Group
Via SHA and PCT PALS colleagues, contact was made with patients who were willing to be
involved with the project as a virtual patient reference group. The group were consulted
about the development of exemplar patient materials (e.g. consent forms and leaflets) and a
patient questionnaire. The reference group was subsequently asked to complete and




                                              13                                        15/07/13
distribute the questionnaire to groups they were in contact with. They were also asked for
input about what the user interface for Records Access should look like.

This group has played an essential part in the project, and the individuals concerned are
acknowledged at Appendix 8.9.

2.4.3 Demonstrator Sites
The project set out to promote and facilitate the roll-out of Patient Access to Records and
Transactional Services by establishing a range of GP demonstrator sites. A range of sites
using different solutions and approaches were involved in the project, in order to ensure that
the project was relevant for as wide a range of GP practices and patients as possible.

The demonstrator GP practices were recruited either through PCT leads or approached
directly, as information about where online services were offered was not initially available
from GP system suppliers due to confidentiality constraints.

Each site was visited and a practice profile was produced covering:

      Practice demographics, organizational characteristics and system details
      Current use of online services: benefits and issues to date
      Practice objectives for using / expanding use of online services
      Future development requirements
      Attitudes regarding access to records
      Project work to be undertaken

The project work, varied depending on the capacity of the practice and the degree to which
they wanted to become actively involved in the project. Activities ranged from undertaking
audits of current online services to implementing and reporting back on new functionality.

Although all practices were offered reimbursement for the time they worked on project
activities, many simply did not have the capacity to undertake substantial project work, in
addition to the other practice priorities.

Brief outline case studies have been produced to flag the lessons learned from these sites
(see Appendix 8.1)

2.4.4 Surveys
The project team used online surveys to reach a wider audience than would be possible
through face to face meetings. Three surveys were developed and distributed to different
audiences:

       Patients and the Public
       GP practice clinicians, managers and staff
       GP practices actively using online services

The results of these surveys can be found at Appendix 8.6.

2.4.5 Supplier workshops
In order to ensure greater engagement with a wider range of practices beyond the
demonstrator sites, a series of practice workshops were arranged with InPS and EMIS. The
objectives for the workshops were to:



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         Raise awareness of currently available online service functionality
         Provide an opportunity for practices to recap on basic training
         Explore what can be done to ensure services are used most effectively
         Identify known issues and feedback on enhancements required to suppliers
         Inform future development of the Transactional Services and Records Access
          products.

As a result of these workshops documents were produced summarising “Hints and Tips” for
practice users, as well as requested system enhancements and issues flagged for supplier
development. (See Appendix 8.7)

2.4.6 Developing exemplar materials
By collating materials from early adopter projects and practices around the country the
project has compiled a resources toolkit to share good practice and support the demonstrator
sites. These resources have been developed in conjunction with GP demonstrator sites and
the Patient Reference Group.

The pack includes planning tools; an outline implementation plan, a checklist to help
practices agree their approach to online services, an audit toolkit, patient information leaflets,
consent forms, and practice protocols. (See Appendix 8.4)

2.4.7 Sharing resources
The project found there was no national resource pool for patient online services / records
access and therefore established a PARTS network site10 on NHS Networks, where PARTS
resources and those from other regional access projects have been shared.

2.5 Advisory Board
An Advisory Board, representing key stakeholders, including patients, GPs, practices and
SHA subject matter experts, was established to promote, advise and support the project.
The Board did not have any performance management role, as the project remained directly
accountable to the SHA Board. The Advisory Board Terms of Reference are set out in
Appendix 8.8 below.

2.6 Evaluating Costs and Benefits
In order to capture baseline and monitoring data from practices the project developed and
Audit Toolkit (please see Appendix 8.4 below). The toolkit is an Excel workbook comprising
separate resources and benefits sheets. These were intended to be used by practices to log
cost (actual / time) of implementation and operation of online services, and quantify benefits
based on measurable changes in practice activity (e.g. reduction in DNAs etc.). Only two
practices completed this sheet, due to the fact that the audit and monitoring information is
not readily available from systems and practices have little capacity to undertake this work.
Furthermore in many practices online services are still used by less than 5% of the
population, making it difficult to measure the impact on practice activities as these were often
small or negligible.

A practice review survey was developed to obtain more anecdotal feedback from practices.
It was thought that this would easily facilitate cost/benefit assessments. The results of this
survey are included in the practice case studies, presented in Appendix 8.1.

10   http://www.networks.nhs.uk/nhs-networks/patient-access-to-records-and-transactional


                                                   15                                      15/07/13
In future, it is hoped that practice based metrics will be available directly from the system
suppliers. System suppliers were asked to provide these reports, but although EMIS have
provided the information to colleagues in NHS North West, despite requests for similar
information none has been provided through supplier contacts to this project.

2.7 Assumptions and Inhibiting Factors
A number of assumptions were made during the planning of the project, which did not hold
true and impacted on progress and approach:

     1. Record Access solutions were or would within the life time of the project be
        available to most GP practices to pilot. Only EMIS and, from 14th February 2013,
        TPP SystmOne, offered Records Access solutions to practices. Pilots of Record
        Access were restricted to EMIS sites, as TPP were unwillingly to expand their pilot to
        include practices in the South East.
     2. GP system supplier training and support for operational products was in place.
        In some cases training materials and packages were still under development. There
        is a general lack of awareness about online services among support and training
        staff.
     3. PCT colleagues would be able to assist the project team at a local level. Due to
        the transition to new organizational structures, colleagues at PCT level did not have
        the capacity or were not given direction to support this initiative with in Surrey and
        Sussex. In Kent, colleagues were able to offer some limited but very valuable
        training and facilitation support.
     4. Information about system usage would be readily available. Information about
        what online services were offered by practices was not initially available from
        suppliers for confidentiality reasons. This meant it was difficult to engage with users
        and seek their feedback. Information on practice offerings became available in mid-
        January prior to its publication by the Health and Social Care Information Centre as
        part of the GP Indicator Set.
     5. Links would be established with the RCGP Patient Online programme11 to
        facilitate the exchange of information and ideas. This project has run in parallel
        with the programme of work being undertaken by the RCGP. However, although
        links were made during early phases of work with the Programme and some key
        workstream leads, opportunities to either input to or exchange thinking with the
        programme were extremely limited.
        Although the RCGP Patient Online programme provided reassurance that complex
        issues were being considered, its existence also served to inhibit pilot practices
        signing up. They felt there was little point in getting involved in something which may
        never happen or change significantly. They also felt that there may be little prospect
        of influencing the outcome of the national work.
     6. Offering to reimburse practice time would ensure sufficient levels of
        engagement. A reimbursement policy was developed to ensure practice would be
        compensated for the time spent on this project. However many practices have not
        been able to complete audits or pilot work agreed due to system issues and staffing
        problems which could not be addressed by ad hoc payments.



11http://www.rcgp.org.uk/clinical-and-research/practice-management-resources/health-informatics-
group/patient-access-to-records.aspx


                                                16                                          15/07/13
17   15/07/13
3 Drivers for Change
This section references the key drivers for online services.

3.1 Evidence of Benefits
There is a growing body of evidence that suggests significant benefits in terms of
quality, effectiveness and productivity are being derived from Patient Online Access.
This evidence is being rigorously reviewed as part of the RCGP Patient Online Access
Programme, and will not therefore be reviewed in this report. However, the key themes
emerging from experience both in the UK12 and also the US13, where online access is
already used by millions, is that:

        Patients achieve a greater understanding of health and illness, leading to
         informed choices and judgements, better compliance, and equipping them to
         better manage their health and conditions.
        Clinical and administrative resources are used more effectively.
        Patient / clinician relationships and communication are improved.

A very useful summary of potential benefits can be found in: “A Guide to Records
Access”, produced by the Patients Information Forum.14

This project did not set out to evaluate or replicate the extensive research which has already
taken place into either perceived or actual benefits of online access to patient records.

Evaluation of benefits, possibly using this toolkit, would be a key objective of a future phase
of the project.

3.1.1 Quality Innovation Productivity and Prevention (QIPP)

The NHS is being urgently required to do more for less by the Quality, Innovation,
Productivity and Prevention (QIPP) programme which aims to improve the quality and
delivery of NHS care while reducing costs in order to make £20bn efficiency savings by
2014/15. QIPP is a response to the recent economic crisis and also the so called “scissors
of doom,” i.e. the upturn of an aging population with increasing demands and the downturn
in a working population able to fund the care for the elderly.

Online access is one way in which the NHS can respond to the pressing requirement to do
more for less. Dr Amir Hannan sees patient online access as a key enabler in this respect:
“Patients, carers and the information to support them are the most under-utilised resources
the NHS has available.”15

3.1.2 Health Policy Drivers

There are a range of health policy initiatives which require patients to be better informed
about their own health and treatment, to take an active role in staying healthy, managing
their conditions and making informed choices to ensure they get the most appropriate

12 Fisher B, Bhavnani V, Winfield M. How patients use access to their full health records: a qualitative
study of patients in general practice Journal of the Royal Society of Medicine 2009; 102(12): 539–44.
13 http://annals.org/article.aspx?articleid=1363511
14 http://www.pifonline.org.uk/new-pif-guide-to-health-records-access/
15 http://www.guardian.co.uk/healthcare-network/2011/nov/30/patients-access-electronic-health-

records


                                                   18                                            15/07/13
care and best outcomes.

Very briefly these may be summarised as:
 Putting the patient at the centre of their care16, including integrated care pathways,
   and greater personalisation of care packages.
 Greater transparency and accountability17
 Empowering patients to take control of their health, and support shared decision-
   making
 Bringing care closer to home, avoiding unnecessary and unplanned activity.

3.1.3 Informatics Policy
“An Information Revolution” (the 2010 DH consultation paper ) set out the
Government’s plans to transform the way information is accessed, collected and
analysed. It also set out plans to give patients greater control of their own care records.
Further consultation by NHS Future Forum showed there was public and patient
demand for patient online access.

Operating Framework technical guidance for 2012/13 published in December 2011
introduced a new performance indicator: Percentage of patients with electronic access
to their medical records. This defined medical records as “medication, test results,
letters and a summary” or “the full medical record”.

The first timetable for delivery of online services and Records Access was set out in
“The Power of Information” (May 2012), and subsequently enshrined in the NHS
Mandate published in November 2012.

HealthSpace was a potential alternative to Patient Online Access via GP systems, as it
would have provided patients’ access to their Summary Care Record via the Spine.
However this service was closed down at the end of 2012 due to poor uptake and
difficulties with patient registration.

NHS Constitution (2009) gives patients the right to access their own health records.
Accessing the record using the legal process of Subject Access Requests under the
Data Protection Act can be both a bureaucratic and lengthy process which patients must
pay for.18

Although NHS policy requires patient letters to be shared with patients, this policy is not
always strictly adhered to. Providing access online would ensure letters were available
and could be safely stored and referenced for future information.

Data Quality and GP Electronic Records Keeping. Over the last ten years there have
been various initiatives aimed at improving and maintaining good quality GP clinical
records; PRIMIS19, IM&T Directed Enhanced Service, Quality and Outcome Records
Indicators and Paperlight Accreditation processes. From 2013 GP practices will also be
required by Care Quality Commission (Records Outcome 21) to have processes in place
to maintain accurate clinical records. Online access can only be considered now
because of the great progress made in improving data quality. In future the transparency
offered by online access will be a driver for health professionals to maintain good quality
records and provide an opportunity for patients to validate these.

16

http://webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/en/MediaCentre/Pressreleases/DH_1275
77
17 The Francis Report: http://www.midstaffsinquiry.com/pressrelease.html
18 http://www.ico.gov.uk/for_the_public/personal_information.aspx
19 http://www.primis.nottingham.ac.uk/




                                              19                                        15/07/13
The Second Caldicott Review. Dame Fiona Caldicott is currently leading a review into
the balance between protecting confidentiality and the sharing of health and social care
information. It is anticipated that this review will feed into professional guidance
concerning what can be shared via Patient Online Access.

Greater electronic sharing of information across NHS and other providers, for
example, with electronic pathology and radiology results, discharge notifications and
referrals, the GP electronic record is more comprehensive than ever before. The GP
record is the place where care is coordinated and has become the closest thing we have
to a patient (as opposed to service or condition) centric record.

Telehealth and telemedicine advancements present the possibility of online access
being developed into a truly interactive and integrated clinical tool. This would mean
Records Access would not just be a decision support tool for patients, but also facilitate
capture and analysis of remote monitoring information.

3.1.4 Cultural and social change
The public has become very used to accessing services online, even where there are
requirements for high levels of security and confidentiality to be maintained (e.g. online
banking). Busy lifestyles, combined with the increasing availability of internet access on
devices such as smartphones TVs, mean there is demand for access to information and
services in ways that support greater choice and convenience.

Figures from the Office for National Statistics20 show that internet use is continuing to
increase among all age groups:

        In 2012, 21 million households in Great Britain (80 per cent) had Internet access,
         compared with 19 million (77 per cent) in 2011.
        Most adults use the internet every day: 16 to 24 = 82%, 55-64 = 63%, 65 and
         over = 29%.

In response to the growing opportunities for patients to access their own records,
information and reports have been produced to support patients to consider the issues
of online access to records, for example, “Keeping your Health and Social Care Records
Safe and Secure”21 produced by BCS Health and “It's Your Record: A guide to
accessing health records online”22 produced by London Connect.




20 http://www.ons.gov.uk/ons/rel/rdit2/internet-access---households-and-individuals/2012/stb-internet-
access--households-and-individuals--2012.html#
21 http://www.bcs.org/upload/pdf/social-care-records.pdf
22 http://www.myhealth.london.nhs.uk/sites/default/files/u3246/ItsYourRecord.pdf




                                                  20                                            15/07/13
4 Current status
The section summarises the starting point for the expansion roll-out of online access, in
terms of:

         Prevailing attitudes towards access; patients and GP practices
         Systems currently available and in use
         How practices are managing services
         What guidance is available

This information has been sourced from questionnaires, practice visits, workshops,
discussions with health professionals and patient representatives, information from systems
suppliers, other regional access projects and the Department of Health.

4.1 Attitudes towards Access

4.1.1 Public and Patients Views
Patients and members of the public consulted by the project have been contacted via
existing patient networks such as PPG, LINKs and PALS. We acknowledge that this group
is not necessarily representative of the wider population, however, the group is well informed
and do take a wider, rather than purely personal perspective, on the issues raised.

The interest among patients and the public has been demonstrated by the high turn-out at
the launch event (17 delegates), offers of assistance with the Patient Reference Group and
the high level of response to the online survey (105 respondents).

Do the public want online access?

Yes. Our survey showed that 75% of respondents felt that online access to records is a good
idea in principle. All transactional and records access services were considered “important”
by at least 60% of respondents. Viewing test results was considered important by 75%.

This general finding corresponds with London Connect survey findings over a similar time
periodi23 from over 300 respondents, 86% of whom said that they would look at their health
and care records if they were available online.

How many people currently use online services?

We cannot currently answer this question. Statistics released by the DH and soon to be
published on NHS Choices show that Appointment Booking and Repeat Requesting is
potentially available to 37% of the population (via their GP clinical system supplier.)
However, there is no audit data on actual levels of online registration by patients.

The PARTS project survey showed that ordering of repeat prescriptions was the most used
online service with 90% of respondents saying they had used it. 54% indicated that they had
booked an appointment online whilst18% had sent a message to their GP or nurse online
(normally via email).

The discrepancies between these figures and the DH statistics can be explained by the
unrepresentative patient group surveyed (those already involved in patient / practice work),
23   http://www.lhib.org.uk/attachments/article/123/LondonConnect-survey-summary.pdf



                                                  21                                    15/07/13
and that many patients are using web-site based services which are not integrated with their
GP clinical system and not counted in the statistics to be published on NHS Choices (see
section 4.2.2 for further information).

The survey also showed that around 20% of respondents didn’t know what online services
their GP practice offered. Given the respondents were mainly taken from PPGs and other
similar groups; the level of awareness among the general population is likely to be
significantly lower.

How do patients feel online access could benefit them?

Patients think that online access will support them to make better decisions. The table below
summaries responses from the PARTS patient survey

 It would help me make decisions about my health and treatment                       83%
 It would improve my understanding of my condition                                   83%
 I would feel more involved in my care                                               79%
 I could check information on the record is correct                                  79%
 I could share the information with others treating me e.g. when abroad              73%
 It would help me get more from appointments with the GP or nurse                    65%


The London Connect survey showed similar benefits would be anticipated but the positive
response rate was weaker. This survey is likely to reflect a more broader and more
representative cohort:
57% felt they would be more involved in their healthcare
56% felt they would be able to make better decisions about their care
54% felt they would be more aware of individual health issues
52% felt they would be more in control
50% felt they would trust health professionals more.

Will online access contribute to better, safe, more effective care?

In addition to supporting patients to be more proactive in their care, patients believe that
access to records will facilitate better information sharing and better quality records across
the NHS. This would enable clinicians to make better, safer clinical decisions and services
be provided more cost-effectively:

Patient comments from January 2013:
 “I think that on line access to medical records by patients is an important step forward in
ensuring that the quality of medical records improves and hopefully will contribute to the
reduction in the large amount of compensation the NHS pays out as a result of poor medical
record keeping. Last year the Royal College of Physicians produced a report that showed
that during 2009, the NHS spent £798 million on settling complaints and litigation cases.
Such cases are often settled out of court because they cannot be defended, owing to
substandard medical notes.”

“I can never remember when I have seen a GP about a condition and I often forget what they
have told me. [Online access] would save my time and theirs.”

What concern do patients have about online services?


                                               22                                         15/07/13
The PARTS survey showed that 10% of patients surveyed thought online access was a “bad
idea”. The key concern for many patients is how safe their data is:

Someone else may be able to see my confidential information            61.7%
Patients may not understand medical language                           56.7%
The website may be unreliable                                          43.3%
Patients may get upset or confused by what they see                    40.0%
It is not fair for people who cannot use the internet                  38.3%
It will create too many queries for the GP practice                    30.0%
The website may be difficult to use                                    28.3%


A London Connect survey24 showed that although 65% were concerned about online security
for GP records access, 87% said that it would be acceptable if security was similar to online
banking.

Patients also expressed a fear that online access would become a replacement for face to
face contact, and that as a result, time with clinicians could be reduced, losing the “personal
touch”.

Inequality was another concern for patients who felt those without internet access would be
put at a disadvantage. This comment was often balanced in discussion at PPGs with the
suggestion that patients would benefit from improved telephone access and there would be
fewer DNAs.

How aware are patients of online services?

The PARTS patient survey showed that 80% of respondents felt they were aware of the
services offered by their practice. However responses showed the potential for
misunderstandings. Two respondents indicated they could access their medical record it via
email.

At PPG meeting, patients commonly raised the issue of Summary Care Records and
indicated that they believe they had already signed up for online access, not understanding
that SCR is essentially to provide access to health professionals and not patients. (These
patients were is areas were HealthSpace had not been offered.)

Moreover, there was no awareness of the 2015 Power of Information pledge by the
Government, even among well informed PPG members in proactive practices.

4.1.2 Professional and Practice Views

The PARTS Primary Healthcare Team survey gathered responses from 212 people working
in GP practices (among them 19% clinicians and 71% Practice Managers).

Are GP practices aware of initiatives to facilitate Records Access?

The survey showed that although 46% of non-clinical staff felt that they have a good
awareness of patient access, 29% of clinicians said they had only limited awareness of. This
result may indicate that Records Access is regarded as an informatics / administrative issue
and is not seen as being clinically driven.
24   http://www.lhib.org.uk/information-transparency


                                                       23                                15/07/13
Do GP practices think Records Access is a good idea?

The survey showed that this issue splits opinion: 42% of clinicians and 36% of non-clinical
staff feel that there are more benefits than concerns to offering online patient access.
However there are still a significant number of respondents that feel there are more concerns
to offering online patient access; 42% of clinicians and 31% of non-clinical staff.

This findings correlate closely with a survey published in February 2012 by doctors.net.uk,
which found that half of the 1,000 GPs who responded, felt that records access would be
useful.

“I've asked my practice about it. One older, but on a clinical level really good GP, was
horrified at the thought ..... A younger GP, at the same practice was very keen and
interested; he just didn't know who could support the practice to give it a go and what he
should do next.”
Patient comment January 2013

How will records access bring benefits?

45-47% of non-clinical staff felt the most likely benefits would be in relation to improving trust,
communications and record-keeping. This was closely followed by improved patient
compliance and improved shared decision-making. These results, though not statistically
significant suggest GPs acknowledged the potential for records access to improve patient
participation in their care.

What concerns do GP practices have about online services?

As with patients, security and confidentiality is the main concern for GP practices with 89%
indicating this was of either medium or high concern. The potential for patients to see
information about a third party was also a major concern, with 63% classing this as a high
concern.

Concerns about patients’ health literacy and their ability to understand and use the
information they access scored highly for both clinicians and non-clinicians with over 55%
rating this as “high”.

Clinicians consulted at practice visits raised the concern that unless there were facilities to
hide or delay access to specific items of information, professionals may be inhibited from
making full and accurate records. They argued that this could lead to clinicians keeping
separate records in another system / place, which would have significant patient safety and
medico-legal implications. One practice explained that clinicians were required to maintain
records about any patient behavior which was violent or abusive. If the records were open to
the patient this could lead to further repercussions including a worsening of the patient /
clinician relationship.

4.2 Systems currently available and in use

4.2.1 GP system suppliers offerings
This project focused on the online services available via GP system suppliers. This type of
service is integrated with the practice clinical system so that the patient gets a real-time view
of the appointments, medication or clinical data as it is recorded on their practice system.


                                                24                                         15/07/13
EMIS were the first system supplier to offer online services with transactional services
available since 2004.

This project has focused on the 3 major GP Clinical Systems in use across Kent, Surrey and
Sussex which offer online services and account for 95 % of all practices.

The following table summarises the functionality currently available from these suppliers:

                           EMISWeb and LV              InPS Vision             TPP SystmOne
                            Patient Access            Vision Online             SystmOnline
Functionality                                        Services (VOS)
Appointments
                                                                                   
Repeat Requests
                                                                                   
Change contact
details                                                                            
Pre-registration
                                                                                   
Patient
questionnaires                                          Planned
                                                          2014                       
Records Access:
Full Record**                                                                      
                                                                                 since Feb 13
Records Access:
Test Results*                                           Planned
                                                          2013                       
Links to Patient
Information                                                                      Planned
                                                                                    2013
Sources
Secure Messaging
                                                        Planned
                                                          2013                       
*Available to switch on independently of full records access
**TPP’s SystmOnline Patient Record Access offers individual consultations to be marked as not
visible to the patient.



In addition to the 3 main providers, it should be noted the following GP systems are also
used by some practices, however due to their market position these systems have not been
included in the project:




Supplier and       Comments
System
iSOFT Synergy      CSC announced in September that it was withdrawing Synergy and
and Premiere       Premiere from the primary care market but would support these systems
(less than 5%      for at least another year.
of sites)



                                                25                                           15/07/13
Microtest                Microtest offer The Waiting-Room.Net which is an on line patient access
Evolution (3             system that gives enabled users the ability to book appointments and
sites)                   request repeat medications on line. It integrates fully with the clinical
                         system Evolution and is hosted by Microtest. Surgeries have control over
                         which patients they enable to use the service, and over which clinic slots
                         are made available to book on line. A module allowing on line registration
                         of new patients is in development.
HealthySoft              No online services currently available.
Crosscare (2
sites)

4.2.2 Deployment of GP Online Services
In January 2012 data showing which GP practices offer online services was published for the
first time on the Information Centre GP Indicators Portal25. December 2012 figures show that
since TPP has enabled its Records Access functionality:

75% of practices could offer patients Records Access
98% of practices could offer patients Transactional Services

The following table summarises which services GP practices are actually offering by SHA
cluster in terms of % of practices and % of patients covered.


      % General Practices                 Appointment                          Repeat prescription                Access to own
         which offer:                    booking online                          ordering online                  records online
                                      By % of     By % of                     By % of      By % of              By % of    By % of
                                     practices   patients                    practices     patients            practices patients
     London SHA Cluster                 26           35                         26            33                  1.2         1.8
       North SHA Cluster                37           45                         42            50                  0.8         1.3
     Midlands & East SHA                44           52                         49            56                  0.5         0.7
                  Cluster
       South SHA Cluster                   37             43                     37               41              0.6        0.5
                 England                   37             45                     40               47             0.75        1.0


Data showing the position of GP practices as of December 2013 is due to be published on
NHS Choices by April 2013. PCT colleagues in South East Coast have been asked to alert
practices so that they are able to validate this data with HSCIC.

There is no national information about the actual level of take-up and usage by patients in
each practice. However we are grateful for audit information obtained by colleagues in NHS
North West which gives an idea of the scale of activity in one region. The figures below are
for EMIS practices using Patient Access during December 2012.



  View Record Views                 Appt Bookings                          Appt Canc'ns                           Repeat
                                                                                                                 Requests
Practices




                               Practices




                                                               Practices




                                                                                                   Practices
                    practice




                                                    practice




                                                                                       practice




                                                                                                                            practice
                    Ave per




                                                    Ave per




                                                                                       Ave per




                                                                                                                            Ave per
            Usage




                                            Usage




                                                                               Usage




                                                                                                                 Usage




25    https://gpoutcomes.ic.nhs.uk/DomainInfo/ClinicalIndicators


                                                                     26                                                      15/07/13
                                                                                                                                                                                                                                                                                                                                                         12




                                                                  0%
                                                                                 10%
                                                                                          20%
                                                                                                30%
                                                                                                      40%
                                                                                                            50%
                                                                                                                  60%
                                                                                                                        70%
                                                                                                                              80%
                                                                                                                                    90%
                                                                                                                                          100%
                                    NHS ASHFORD CCG
                                                                                                                                                                                                                                                                                                                                                         1,154




                          NHS BRIGHTON AND HOVE CCG
                     NHS CANTERBURY AND COASTAL CCG
                                                                                                                                                                                                                                                           have been offered.


                         NHS COASTAL WEST SUSSEX CCG
                                                                                                                                                                                                                                                                                                                                                         96




                                    NHS CRAWLEY CCG
                                                                                                                                                                                                                                                                                                                                                         225




           NHS DARTFORD, GRAVESHAM AND SWANLEY CCG
                                 NHS EAST SURREY CCG
           NHS EASTBOURNE, HAILSHAM AND SEAFORD CCG
                                                                                                                                                                                                                                                                                                                                                         11,900




                     NHS GUILDFORD AND WAVERLEY CCG
                        NHS HASTINGS AND ROTHER CCG
                                                                                                                                                                                                                                                                                                                                                         53




                    NHS HIGH WEALD LEWES HAVENS CCG
                     NHS HORSHAM AND MID SUSSEX CCG




27
                                                                                                                                                                                                                                                                                                                                                         230




                                    NHS MEDWAY CCG
           NHS NORTH EAST HAMPSHIRE AND FARNHAM CCG
                                                                                                                                                                                                                                                                                                                                                         3,440




                          NHS NORTH WEST SURREY CCG
                                                                                                                                                 Online Appointments




                           NHS SOUTH KENT COAST CCG
                                                                                                                                                                                                                                                                                                                                                         15




                              NHS SURREY DOWNS CCG
                               NHS SURREY HEATH CCG
                                      NHS SWALE CCG
                                                                                                                                                                                                                                                                                                                                                         268




                                                                                                                                                                       technically enabled (but not used) by CCGs in Kent, Surrey and Sussex:




                                     NHS THANET CCG
                                  NHS WEST KENT CCG
                                          Grand Total
                                                                                                                                                                                                                                                                                                                                                         41,109




                                                                                                                                                                       The following graphs show % of practices where online services are actual used or
                                                                                                                                                                                                                                                           how proactively the services are promoted by the practice, and the length of time services
                                                                                                                                                                                                                                                           Activity will vary greatly dependent on a number of factors including patient demographics,




                                            Appt NK




15/07/13
                                                                                                                                                                                                                                                                                                                                                         153




                                                                                  Appt Used


                                                      Appt None
                                                                  Appt Enabled
                                                                                                                                                                             10%
                                                                                                                                                                             20%
                                                                                                                                                                             30%
                                                                                                                                                                             40%
                                                                                                                                                                             50%
                                                                                                                                                                             60%
                                                                                                                                                                             70%
                                                                                                                                                                             80%
                                                                                                                                                                             90%
                                                                                                                                                                            100%




                                                                                                                                                                              0%




                                                                            0%
                                                                           10%
                                                                           20%
                                                                           30%
                                                                           40%
                                                                           50%
                                                                           60%
                                                                           70%
                                                                           80%
                                                                           90%
                                                                          100%
                                    NHS ASHFORD CCG                                                                        NHS ASHFORD CCG

                          NHS BRIGHTON AND HOVE CCG                                                              NHS BRIGHTON AND HOVE CCG

                     NHS CANTERBURY AND COASTAL CCG                                                         NHS CANTERBURY AND COASTAL CCG
                                                                                                                NHS COASTAL WEST SUSSEX CCG
                         NHS COASTAL WEST SUSSEX CCG
                                                                                                                           NHS CRAWLEY CCG
                                    NHS CRAWLEY CCG
                                                                                                  NHS DARTFORD, GRAVESHAM AND SWANLEY CCG
           NHS DARTFORD, GRAVESHAM AND SWANLEY CCG
                                                                                                                        NHS EAST SURREY CCG
                                 NHS EAST SURREY CCG
                                                                                                  NHS EASTBOURNE, HAILSHAM AND SEAFORD CCG
           NHS EASTBOURNE, HAILSHAM AND SEAFORD CCG                                                         NHS GUILDFORD AND WAVERLEY CCG
                     NHS GUILDFORD AND WAVERLEY CCG                                                            NHS HASTINGS AND ROTHER CCG
                        NHS HASTINGS AND ROTHER CCG                                                        NHS HIGH WEALD LEWES HAVENS CCG
                    NHS HIGH WEALD LEWES HAVENS CCG                                                         NHS HORSHAM AND MID SUSSEX CCG




28
                     NHS HORSHAM AND MID SUSSEX CCG                                                                        NHS MEDWAY CCG

                                    NHS MEDWAY CCG                                                NHS NORTH EAST HAMPSHIRE AND FARNHAM CCG




                                                                                 Records Access
                                                                                                                 NHS NORTH WEST SURREY CCG
           NHS NORTH EAST HAMPSHIRE AND FARNHAM CCG
                                                                                                                                                                                           Repeat Prescriptions




                                                                                                                  NHS SOUTH KENT COAST CCG
                          NHS NORTH WEST SURREY CCG
                                                                                                                     NHS SURREY DOWNS CCG
                           NHS SOUTH KENT COAST CCG
                                                                                                                      NHS SURREY HEATH CCG
                              NHS SURREY DOWNS CCG
                                                                                                                             NHS SWALE CCG
                               NHS SURREY HEATH CCG
                                                                                                                            NHS THANET CCG
                                      NHS SWALE CCG                                                                      NHS WEST KENT CCG
                                     NHS THANET CCG

                                  NHS WEST KENT CCG
                                                                                                                              Repeats NK
                                                                                                                                                                            Repeats Used


                                                                                                                                           Repeats None




15/07/13
                                                   RA Used
                                         RA None
                                                                                                                                                          Repeats Enabled




                                                             RA Enabled
Most common reasons given for GP Practices not using online functionality provided
by system supplier included:
   1. Cost. EMIS and TPP offer online services as part of core functionality. However
      InPS currently charge for online services: set-up costs £930 plus VAT (including
      training) and annual support is £325
   2. Alternative repeat ordering system in place. This is most commonly a web-based
      form which is not integrated with the clinical system (see below.)
   3. Practice is using “Doctors First” triage system for appointments.
   4. Practices are concerned about workload from processing patient registrations and
      dealing with queries.

4.2.3 GP Systems – Fit for Purpose
Although all GP system suppliers have developed online service functionality, there remain
concerns, at least among a significant proportion InPS and EMIS users that systems need
further development before they could be considered fit for purpose.

We are grateful to EMIS and InPS contacts for their co-operation with this project which has
enabled us to gain a better understanding of the problems practices have encountered and
start working with suppliers to address these.

We have not been able to establish a similar relationship with TPP, and therefore apart from
direct reports from our two demonstrator sites which are generally favorable, the project has
little further information to offer about system usability.

Problems with systems are summarised in the table on the following page.




                                              29                                       15/07/13
Robustness        There is a general perception that systems are not fully developed. There
and reliability    are numerous snags still to be ironed out and functionality is basic.
                 Patients complain that system are down when they try to log on and other
                   patient facing functionality like password resets do not work properly.
                   Practices feel frustrated that they have promoted systems in good faith but
                   are taking criticism from patients and dealing with queries when these
                   systems fail.
                 Both EMIS and InPS online services have multiple known issues which
                   have not been reported to practices. In some cases issues have been
                   outstanding for several months. If issues had been shared practices could
                   have worked round them.
Training,        Many practices felt they did not have enough information to configure
Support and        systems in the most effective way. This may have been because the
Materials          practice decided not to purchase the optional on-site training which
                   suppliers offer. Training costs range from £405-435 plus VAT.
                 Practices felt that supplier helplines were generally not very well informed
                   about online services – though there were notable exceptions.
                 Hints and tips about system idiosyncrasies had not been shared.
                 Some training documentation was still under development or not
                   comprehensive enough.
                 Practices felt that a dedicated patient helpline was needed to answer
                   patient queries about system use /availability which practices were often
                   powerless to resolve.
                 Materials for patients were difficult to obtain - meaning practices often
                   photocopied copies / created their own which sometimes looked
                   unprofessional. Registration forms provided do not support the process.
                   VOS did not include a place for ID checks or patient signature. EMIS did
                   not emphasis that patients would need to supply an email address and
                   mobile phone number to reset the password.
                 TPP had produce materials for patients which practices could use, but
                   practices were unaware of these or how to obtain them.
Patient          Both EMIS and InPS practices fed back that patient registration and login
friendliness       processes are unnecessarily complex and do not provide enough help
                   when incorrect information is entered e.g. length / composition of
                   username.
                 A practice manager using test patient login: “If I was a patient, I’d get really
                   annoyed and wouldn’t be bothered to try again.”
                 The patient interface could be significantly improved, particularly
                   instructions to patients.
Practice        Practices wanted to be able to edit / configure systems to allow them to better
configurability support the way individual practices worked, for example;
                     practice specific messages to be displayed to the patient. (Not
                        currently possible with EMIS).
                     ability to offer a menu of choices re type of appointment
                     ability to display full range of medications (including unauthorised)
Changes to       Information about when fixes and enhancements are planned is not always
system             shared and changes are made to user-front ends without practices being
                   aware.
                 EMIS practices in particular were frustrated that changes were made to
                   Patient Access screens where practices were not notified. This prevented
                   practices from effectively helping patients use the services.
                 Although change documentation was sometimes issued by suppliers
                   practices did not get time to read it.



                                              30                                       15/07/13
Online access has not been a development priority for suppliers. There has been a
piecemeal response to the development of transactional services, and although there is an
acknowledgement of the Government’s commitment to online services, there little indication
that suppliers will be proactive unless GP practices demand it directly.

Appendix 8.7 includes outputs from the workshops held with EMIS and InPS:

          Hints and Tips for Users
          Issues and Enhancements for Supplier Action.

At the timing of writing, these issues and enhancements had been submitted to suppliers.
InPS have logged requests for development and formal response is awaited from EMIS.

4.2.4 Non-integrated access solutions
The Department of Health data on online GP access only includes information on the
integrated online solutions offered via GP system suppliers. However this project discovered
there was a high level of implementation of other online access solutions:

          GP web-site solutions, provided via GP web-site providers such as those provided by
           “mysurgery”26
          Bespoke solutions either developed by practices themselves or commissioned by GP
           practices from specialist software and web developers. This could be a simple web
           form with no security or validation rules.

It is impossible to estimate the precise level of usage of these solutions, however
approximately a third of the practices consulted by the project were using a service of this
kind.

The point was made by practice managers that the more “go-head” practices would have
implemented online solutions before these were available from the GP system suppliers.
These solutions are often very popular with patients as they allow greater flexibility (e.g. to
list and request any medication) and are less cumbersome to log on to, because the security
controls need to be less stringent as patients are not accessing any information on the
clinical system.

The disadvantages of these web-site systems are that:

          They are not integrated with the GP clinical system, therefore repeat requests have
           to be printed and manually entered by practice staff.
          Appointments must be reserved for web use only and cannot simultaneously be
           available for telephone booking.
          Security controls are much less rigorous. Patients can set up their own accounts on
           line without needing to validate their identity with the practice. This could mean for
           example, that an unauthorised third party could request medication in the name of
           patient.

Practices who have recently introduced the GP clinical system online solutions are finding it
difficult to switch patients from the non-integrated solution. Some are considering whether or



26   http://www.mysurgerywebsite.co.uk/live/default.aspx


                                                   31                                       15/07/13
not simply to force the move and close the web-site system, whereas others fear the loss of
convenience for patients would be too greater price to pay.

4.2.5 Use of SMS to “push information” to patients
In parallel with online services which allow patients to contact practices or view their own
transactional / records information, there is also widespread and increasing up take of SMS
solutions which “push” information and messages to patients:

      Appointment confirmation / reminders
      Screening / vaccination / review invitations
      Survey questions e.g. re smoking status
      Health campaign messages.

There are a variety of “partner products” including MJOG, Reminder Time, Patientxt, and
Appointment Process flows, which integrate with the GP system but which work
independently of the online services, and require separate patient consent.

Some GP system supplier solutions, such as InPS Vision Online Services, do incorporate
SMS functionality to send reminders to patients, although this is currently not working.
Practices have expressed the opinion that it if SMS functionality was completely integrated
with online services, it would be easier to manage and more cost effective for practices, and
also less confusing for patients.

4.3 How practices are managing online services
Currently, practices need to develop their own protocols for implementation and operation of
online services covering:

      Promotion to patients
      Registration and authentication of patients
      Configuration of services

4.3.1 Promotion to Patients
Approaches vary from proactive promotion campaigns: using posters, prescription forms,
letters and information leaflets, to simply dealing with requests to sign up with minimum
awareness raising.

Many practices have either been unaware of the materials provided by system suppliers, or
where these have been provided as part of an implementation package, they have
subsequently run out and not been re-ordered. Some supplier materials were found to be
out-of-date, e.g. EMIS have only just produced new materials for Patient Access, although
the name was changed from EMIS Access several months ago. Practices felt that
professionally produced promotion materials would help engage patients, instill confidence
and reduce the burden on practices.

Many practices, after an initial launch campaign had been disappointed by low levels of
uptake. They had also been disappointed by problems with system use and high levels of
queries. As a result practices had failed to continue with proactive campaigns. However, it
was recognised that practices need to attain a “critical mass” of usage before they could
change the way they work and reap real efficiency benefits. One practice visited estimated
this critical mass would be between 15-20% of the total practice population.



                                              32                                       15/07/13
Moreover, practices commented that the lack of easy to use audit reports made it difficult to
target support and promotion to patients who were not registered or not active users.

4.3.2 Registration and Authentication of patients
The RCGP document “Enabling Records Access”27 says
“it is essential that the correct patient has access to the correct record. Robust assurance of
identity is a prerequisite to registration for a Record Access service. Until such time that a
suitably robust online registration and authentication method is available, registration should
include sight of photo-ID plus appropriate household bills and other documentation that
between them confirm full name, residential address and date of birth. The extent of identity
checks can be supplemented by, or combined with, the healthcare organisation’s existing
knowledge and relationship with the patient.”

Consultation with practices has revealed a variety of approaches have been taken to register
patients for transactional services, and that in a significant number of practices no checks of
patient identification were being carried out before registration details were issued. A
common approach among Vision practices is to accept either an email request for the
service, or an unsigned form from the applicant and also on behalf of family and friends.

This makes it easy for login details for online services to be supplied to someone other than
the patient. This is especially true where email is used to request access as there is no
requirement for any face to face interaction. Using the online account, a person could book
appointments and make repeat requests in the name of the patient, and also send a
message to the practice on the repeat order form, e.g. requesting additional medication. In
addition the person with the login details could also see information on existing appointments
booked with the practice and the patient’s repeat medication.

Although the amount and sensitivity of data viewable via transactional services is far less
than for Records Access, there is still significant data which can be accessed, and a
transactional services account may be given records access privileges without further check
being made. In future, it is planned that online services are expanded to allow test result
viewing (possibly 6 months away in Vision), online consultations via messaging, and
ultimately access to the patient’s medical record.

Some practices (mainly InPS ) have admitted that they have already registered thousands of
patients without any authentication. The IG risk this presents was acknowledged, but
practices felt this had not been pointed out in training. Indeed, the patient registration form
currently supplied by InPS, has no place for a patient signature and does not prompt for ID to
be checked. The EMIS training documentation and system screens do however prompt for
ID to be checked and registration details to be handed to the patient in person.

All practices attending the workshop have been advised to introduce patient ID checks and
ensure that registration credentials are given to applicants in person. Where practices have
previously registered patients without checks they have been advised to check account
holder details opportunistically and ensure that no further extension of access is provided
without an ID check taking place. Practices were concerned that introducing ID checks would
put off or annoy patients and would increase practice workload.


27http://www.rcgp.org.uk/clinical-and-research/practice-management-resources/health-informatics-
group/~/media/Files/CIRC/Health%20Informatics%20Report.ashx



                                                33                                          15/07/13
4.4 Guidance
Guidance on the implementation, use and access to online services is continuing to develop.
This section looks at currently available guidance in terms of:

        Guidance for health professionals
        Guidance for practices
        Guidance for patients

4.4.1 Guidance for health professionals
The RGCP’s document “Enabling Records Access”28 is the prime source of guidance for
General Practice. However there was very low awareness of this document, and its
relevance for transactional services. It establishes a set of broad principles encouraging the
free provision of records access on the basis that it can improve patient care and safety. It
provides guidance to practices on security processes, how to inform patients and the training
required. Advice is given about writing records with the patient in mind, whilst still keeping
them clinically relevant and fit for purpose.

Key concerns commonly raised by clinicians are addressed, including; the patient sharing
the record with someone else, sharing under coercion, access to third-party data, potential to
do harm, access for parents / guardians for those who lack capacity. However, the guidance
commonly requires clinicians’ individual assessments of potential risks and benefits. There
are few areas for which definitive rules or limits can be applied e.g. age of access or explicit
links to existing processes for obtaining consent e.g. Lasting Power of Attorney (LPA).

The RCN have produced guidance on “Personal Health Records and Information
Management”29 which states that, “the RCN believes that all people, including children and
young people, should be support to control and manage their own health information
according to their preferences and needs.” Although this guidance does not attempt to offer
practical advice to professionals implementing access and looks at issues related to personal
health records rather than specifically GP Records Access, it very concisely and usefully sets
out:

        What a patient should be able to do with personal health records e.g. maintain a
         health diary, use information to make decisions about health
        Potential patient and service benefits
        Barriers to implementation, including the potential for worsening inequalities for
         patients who chose not to / cannot engage with in their own health management or
         use IT
        Recommendations to create the right environment for personal health records

4.4.2 Guidance for Practices
Although there are now approximately 40% offering transactional services, there is very little
practical guidance on implementing and operating online services beyond that offered by

28http://www.rcgp.org.uk/clinical-and-research/practice-management-resources/health-informatics-
group/~/media/Files/CIRC/Health%20Informatics%20Report.ashx
29

http://www.rcn.org.uk/__data/assets/pdf_file/0005/465458/16.12_Personal_Health_Records_Briefing_
-_18_July_2012.pdf



                                                34                                          15/07/13
system suppliers. Many practices have developed their own protocols and materials and
would be willing to share these. However, there is currently no single point of reference for
these resources, forcing practices to develop their own protocols, and “re-invent the wheel”.

EMIS have produced a useful document called “EMIS Access Medical Record Viewer and
Implementing Record Access” which sets out issues for practices to consider around their
approach to records access. It also provides advice on how to manage and administer this
access.

NHS led access projects (notably in the North West, where a team of Patient Access
facilitators have been engaged) have produced “Practice Information Packs”, which includes
guidance on approach and materials to use with patients. The PARTS project has
developed these resources and combined them with good practice examples from early
adopter practices to produce a set of resources which have been made available to
demonstrator sites. These resources are referenced at Appendix 8.4 available on the
PARTS section of NHS Networks.

4.4.3 Guidance for Patients
The BCS, Chartered Institute for IT and the Department of Health have recently published
guidance on keeping electronic patient health records safe. The guide is intended to help the
public understand how to maximise the benefits of online health resources and manage
risks. The guidance explains what health records are, how to protect them, and how to
share them should individuals wish to. There is also advice on protecting computers, mobile
devices and how to access records using a public computer.

Some practices have produced their own guidance for patients in the form of information
leaflets, consent forms and web-sites. A good example is the support provided for patients
on the Haughton Thornley Medical Practice web-site30.




30   http://www.htmc.co.uk/pages/pv.asp?p=htmc28




                                                   35                                  15/07/13
5 Lessons from Demonstrator Sites
The project worked with 16 demonstrator GP Practice sites from across Kent, Surrey and
Sussex:

   System Type             Transactional            Transactional              Records
                             Services                 Services              Access and TS
                           Existing Users            New Users                New Users

        EMIS                                               1                       5
        InPS                       6                       2
         TPP                       1                       1


The learning objectives for working with these 3 categories of practices are set out below.

Transactional Services Existing Users
Implementing Transactional Services is the first step towards offering Records Access;
building trust, confidence and developing safe processes. Practices / patient perception of
the success (or otherwise) of these services will influence their willingness to expand into
Record Access

Therefore the project needed to:

       Understand whether expected benefits were being realised.
       Identify problems and inhibiting factors.
       Work with practices and suppliers to suggest work arounds /fixes to address
        problems.
       Identify and share good practice.

Cases studies A1-A4 in Appendix 8.1 document findings from this category of practice.

Transactional Services New Users
All practices approached by the project were offered support to implement Records Access.
Some practices decided they were not ready for this step (or their system did not offer the
facility) but nevertheless they wanted to start the process of offering online services.

The lessons learned from these practices were:

       How suppliers support new practices and what more support is required?
       What choices did practices need to consider in configuring the service and promoting
        it to patients?
       How long before benefits are realised?
       Could some of the problems encountered by our existing TS users be anticipated /
        avoided?

Case studies C1 and C2 document findings from these practices.




                                              36                                        15/07/13
Records Access and TS New Users
Records Access pilots were intended to be the main focus of our work with practices. The
project followed up expressions of interest from 12 EMIS31 practices to pilot Records Access,
however only 5 practices decided to proceed with the pilot.

The lessons from these practices:

         Why did some practices feel they could not proceed with records access (system, IG,
          workload issues)?
         What issues did practices need to consider about their approach? (Free text viewing,
          parental access, impact of data recording etc.)
         What support do practices require to implement and promote RA?
         What good practice and materials can be developed and shared?
         What benefits do practices / patients hope to see?

All practices which piloted Records Access chose to proceed with invited patients only.
These patients were either invited from the PPG or selected by the GP on clinical grounds.
By the end of March is it expected that there will be between 60-70 patients with Records
Access across the 5 practices.

Case studies B1-B5 document findings from these practices.

5.1 Practice Approach
The demonstrator sites exemplify the choices practices need to make when offering online
services

Configuration of services offered: With InPS, practices have some choices about the
messaging which appears to patients on the online services screen. These messages can
alert patients to services available and the way the practice will respond to their request /
message. InPS users can choose whether to set text message and email reminders for
online transactions. However, the main configuration choices relate appointment booking:
the number of appointments bookable at any time, choice of clinics, choice of clinicians, and
how far in advance appointments can be booked online. Some practices concerned about
potential abuse of the system and limited online booking to one appointment per patient, but
most practices allow 2-4 bookings at time. Until functionality allows for patients to choose
from a menu of appointment slots or reasons for appointment, most practices restrict online
booking to routine GP appointments.

Parental /carer access: Most practices allow parents to have access to their child’s
record for transactional services, although one practice only offers an account to patients in
their own right from the age of 18 onwards. Many practices have not yet considered when
this access needs to be withdrawn and do not have mechanisms in place to do this.
However, new implementations have clear policies for withdrawing access when the child
turns 12 (or whatever age is agreed locally).

As far as the record access pilots are concerned, on the recommendation of the Advisory
Board, no practice has given parental access to a child’s record. One practice is planning to



31   At the time no other system was able to offer records access.


                                                    37                                   15/07/13
set up access for carers at residential establishments with permission from the resident or in
conjunction with the person who has Legal Power of Attorney.

Promotion to patients: Initially, practices introducing the service have tended to be
cautious about promoting services to patients, preferring to let it grow organically and give
practice staff an opportunity to get used to the new ways of workings and processing online
transactions. Other existing users felt that active promotion was important because until a
critical mass of uptake was reached (15-20%) the practice would not see perceivable
benefits.

Online services were promoted via the practice web-site, in new patient packs, on repeat
script forms, practice leaflets, posters / flyers in the waiting room and waiting room TV
displays. Many practices did not know that they could obtain professionally produced
promotional material from their system supplier.

Patient registration and authentication: All demonstrator sites now have processes
in place for patients to register in person, so that their identification can be verified. Some
sites have developed or are using the PARTS consent forms to ensure patients are informed
about their responsibilities and aware of the risks involved. These forms also ensure that
necessary contact details (such as email and mobile numbers) are collected and updated on
practice systems. Some InPS practices use very brief forms developed by the system
suppliers or, in one case, accept verbal consent from the patient. As more functionality
becomes available, practices have acknowledged that they will need to re-authenticate
patients where their identity was not previously checked before further access is granted.

Records Access - Free Text viewing: All practices offering Records Access have chosen
the default setting for free text viewing to be disabled. However most GPs felt that the free
text would be very helpful to patients and some sites were considering enabling free text
viewing on a case by case basis.

Records Access - GP check: All of our demonstrator sites have invited specific patients to
have records access, and have also restricted free text viewing. Sites agreed that if / when
they start offering records to the wider practice population they will need to consider
protocols to ensure that Records Access is in the patients’ best interests, and whether there
is any sensitive or 3rd party information on the record that should be restricted. This would
normally entail a GP checking each application for Records Access and if necessary
conferring with colleagues (e.g. Mental Health specialists working with the patient) before
granting access.

5.2 Benefits

5.2.1 Records Access
The demonstrator sites enabled their first patients for Records Access in January and
February 2013. Therefore it is too early for these practices to provide any evidence of
potential health gain.

Demonstrator sites have all been asked to seek consent from their pilot patients to follow-up
with them about the benefits of Records Access. Although newly enabled patients have been
in touch with practices to feedback comments about usability / technical errors, no one has




                                              38                                          15/07/13
yet had sufficient experience of Records Access to comment on its potential to support great
engagement and better decision making.

The sites which are offering Records Access are being given a patient questionnaire (see
appendix 8.4) to enable them to capture and evaluate patient experience of using Records
Access.

5.2.2 Transactional Services
A survey of practices offering transactional services showed the three key objectives for GP
practices in offering online access to patients were, being able to:

A. Offer patients greater choice and convenience
B. Increase practice efficiency and effectiveness
C. Improve communication between practice and patients

20% of respondents felt that expectations of achieving greater choice and convenience had
been fully realized. However, the remaining practices felt benefits had only been partially
realised for A, B and C above. Clearly, realisation of benefits is dependent on the time
services have been offered for. Survey responses suggest that appointment services need to
be in place for at least a year before practices notice an impact on practice efficiency,
whereas repeat requests online often deliver benefits almost immediately.

Practices were asked to complete audit sheets to try and measure the impact on the
practice. This looked at: number of calls received, number of DNAs, number of repeat
requests, number of complaints and requests for information. However, only two practices
managed to complete this audit:

             %             appts       % appt        %                repeat    % repeats
             population    available   booked        cancellations    requests requested
             who are       for         online        online           available online
             active                                                   for
             online
             users
Practice     5.9%          12            1.9          23.3             2 months 2.9
A3                         months
Practice     4%            2             0.9          3.8              2 months 1.6
A4                         months
The significantly higher % of cancellations made on line, compared to bookings made online,
suggests that patients may be more likely to cancel an appointment if the online service is
available. This could have potential for reducing DNAs, however the time period was too
short to measure this impact.

A more pragmatic approach to measuring benefits of online services is to attribute an
efficiency saving to each online transaction carried out. The following assumptions have
been made to calculate these savings: administrative time costs £10 per hour, time saved
processing online repeat request saves on average 6 minutes, and time saved from online
appointment / cancellation saves on average 4 minutes. The figures below were taken from
practice audits or from audits carried out by the project team.




                                             39                                       15/07/13
                      Appointments / Cancellations            Repeat Requests
           Practice   Average      Estimated Time             Average    Estimated       Time
           population number       efficiency   offered       number     efficiency      offered
                      online per   savings                    online per savings
                      month        per month                  month      per month
                                   £                                     £
Practice       4,600            10         6.66      18                1             1        1
A1                                                   months                               month
Practice        7,600            250        166.66       18          333           333       12
A2                                                   months                              months
Practice       14,250            102            68       18           53            53        2
A3                                                   months                              months
Practice       11,160             48            32       13           56            56       13
A4                                                   months                              months



Some practices have also suggested that online requesting may help reduce script wastage
by enabling patients to re-order more easily themselves rather than allowing community
pharmacists to do these on their behalf. The implication is that patient would be more likely
only to order drugs they actually require, rather than everything that is authorised.

Although no detailed work has been done to calculate savings to patients from online
transactions, it is estimated that patients wait on average 3 minutes for their call to be
answered. Call holding time for all patients should be reduced leading to better access and
time saved for all patients.

5.3 Barriers

5.3.1 Lack of Clear Professional and Legal Guidance
The lack of guidance available during the lifetime of the project led to some Records Access
pilot practices either strictly limiting the scope of their pilot, or in some cases withdrawing
completely from the project. There were particular concerns around safe-guarding and
confidentiality issues relating to access for parents / guardians and carers. In the end,
although several practices could see the benefit of parent / carer access, only one pilot site
now plans to offer this for Record Access. Other sites have offered this access but only in
relation to transaction services (see practice case studies at appendix 8.10). One site
decided that no accounts would be set up for carers / parents and registration would only be
allowed for patients themselves when they reach the age of 18.

The Advisory Board concluded that demonstrator sites should avoid offering parental access
or carers' access (unless there was a strong clinical argument to do otherwise) until further
professional guidance was received.

5.3.2 Practice Capacity
Although demonstrator sites were keen to get involved and agreed a set of project
deliverables, many were in practice unable to complete the work in the time available or
make as much progress as they had hoped. This was due in part to the impact of NHS
transition on practices, other competing initiatives and changes (such as CQC registration,
changes to QOF, and implementation of EPS2 / SCR) and the fact that systems needed
more management than anticipated. A key risk for the future roll-out of patient access is that
many practices simply do not have the capacity, or in some cases, the capability to take on


                                               40                                        15/07/13
the work required for implementation. This is true even where reimbursement of staff time
was offered. Practices acknowledged that short-term investment of time and effort would
potentially reap longer term benefits for the practice and patients but had no way of freeing
up more time to undertake the initial work.

5.3.3 System Issues and Usability
Section 4 above details problems with existing system solutions including feedback from
demonstrator sites. Many demonstrator sites felt these problems undermined confidence in
online services for practice staff and patients and which inhibited further, more proactive
promotion to patients. However, both TPP sites did feel that thier solution was easy for
patients to use, and easy for practices to implement and manage. The most commonly
reported barriers from our demonstrator sites were:

    1. Clunky registration process
    2. Patients frustrated with not being able to order all repeats due to them not being re-
       authorised
    3. No simple guide available for patients to support trouble shooting
    4. Dealing with complaints from patients when they lose access to the system
    5. Very little support and communication from supplier

5.3.4 Costs
All demonstrator sites were asked to consider the costs involved in implementing and
running online services. The following grid was used to collect information. Practices were
asked to considered start-up costs and running costs against these categories.

Area                          Task
Practice Engagement,          Agree practice implementation approach and plan
Planning and Training         Staff attend training
                              External trainer costs
Patient awareness and         Web-site setup and maintenance
communications                Materials (e.g. leaflets, forms etc.) design and printing
                              Patient drop-in sessions
System administration         Data quality checks (for Patient Access to Records)
                              Introduce and maintain new protocols for data recording / processing
                              Appointment books reorganised
                              Configure system for appointments
                              Configure system for repeats
                              Configure system for patient access
                              Checking workflow / maintaining appointments
                              Checking workflow / maintaining repeat requests
                              Checking workflow / maintaining repeat requests
                              Audit uptake and usage
Register patients             Agree and set up new processes
                              Invite new patients / carers
                              Carry out ID checks and issue login credentials
                              GP to check patient application / check record where applicable
Support patients and carers   Deal with patient contacts about registration and technical processes
                              Deal with patient queries about practice offering
System supplier costs:        Licensing / annual support (where applicable)
licensing etc.


                                                 41                                          15/07/13
Information returned from demonstrator sites showed that set-up costs for transactional
services were in the region of £1,500- £2,000 per practice. The key variables were training
costs; whether the practice paid for a system trainer and the also the number of staff (clinical
and non-clinical) involved in training.

Running costs for Transactional Services were estimated at £200-300 per month (depending
on size of practices) excluding supplier licence costs. InPS sites pay annual support fee of
£325. There is no support fee for EMIS or TPP sites. The main costs for practices resulted
from processing registrations (estimated at £10-15 per patient) and dealing with patient
queries (estimated at £15-25 per query). Practices reported receiving 4-7 queries a week
from patients about on line services, depending on the size of practice.




                                               42                                        15/07/13
6 Critical Success Factors for Patient Online Access
This section sets out what elements need to be in place for a successful Patient Online
Access strategy to be delivered and the benefits to be realised.

Critical Success Factors are considered here from the point of view of the following
stakeholders:

     1.   All Stakeholders
     2.   The Public and Patients
     3.   Health Professionals and GP practices
     4.   NHS and Health and Wellbeing Partners.
     5.   System Suppliers

6.1 What do all stakeholders need?
The first step is to agree what strategic needs are being met with this initiative and then
develop a consistent set of measurable benefits which can be evaluated by a coordinated
early adopter programme.

Some attempts of measuring benefits have proved inconclusive because different projects
have taken different approaches. The evidence has been difficult to compare or simply too
small scale to be statistically significant.

It may take years to evidence the benefits, however, engaging partners such as patients,
carers and professional groups in the design and specification of benefits work will ensure
that they buy-in to the process.

As benefits and objectives for online access are clarified, it will be very important to
communicate with those who are tasked with making it happen. This will include Area
Teams, CCG, practices, system suppliers, individual health professionals and patients.

All stakeholders need to understand the benefits of online access. There needs to be:
     more work to evaluate the benefits, and
     better communication of the benefits (potential and actual).

6.2 What do the Public and Patients need?
A London Connect project survey32 of the public, showed respondents felt a number of things
could be done to encourage patients to make more use of their records online. The most
commonly mentioned solutions included:

     • encouragement: receiving an invitation and encouragement from doctors and nurses
       to use online records
     • utility: presenting information without jargon or providing explanations of medical
       terms
     • support: having an accessible telephone helpline
     • privacy: being reassured about the confidentiality and security of records




 http://www.lhib.org.uk/attachments/article/123/London%20Connect%20-%20survey%20-
32

%20summary.pdf


                                              43                                        15/07/13
6.2.1 Awareness of what services are available and how they can be used
Transactional online services are increasingly becoming part of everyday life e.g. online
banking and booking of tickets have become routine. Consequently the public and patients
are comfortable and reasonably confident with using transactional services to communicate
with their GP practice. It is clear how these services can improve both convenience and
choice for patients. If systems are patient friendly and reliable these services will grow
because they are demand led.

On the other hand, Records Access is different. It is not simply task related, but requires the
patient to be proactive about how they use the facility. If patients are to benefit from Records
Access they will need education and support to explain what information is available and
how they can use it support decisions about their health and care.

Records Access is trying to fulfill a need which many patients are not yet aware they have.
However, if their GP or Practice Nurse was to recommend Records Access as a tool to help
manage their condition then patients would be much more likely to sign up and use it.

Records Access needs to be at the centre of a wider programme of health literacy and self-
care to ensure that patients know what information is available and how to use it to improve
their health and well-being.

6.2.2 Services which are easy to use
EMIS and InPS have both acknowledged the requirement to improve the patient interface to
reduce the level of patients “dropping-out” but also to reduce practice workload. In particular,
online help and the registration / login screens for patients need to be improved. If patients
cannot sign-in or find the information they need within a few minutes, many people will not
use the service again. For example, it may be that the service is down but no guidance is
offered about when it will be restored. Confidence can be easily undermined and therefore it
is essential that the patient interface for transactional services be improved if these are to be
used to prepared the way for Records Access.

6.2.3 Health information which is easy to use and is relevant
Being able to view information and being able to use it are very different things. The RGCP
guidance on “Enabling Records Access”33 for health professionals makes it clear that GPs
should “write as accurately, clearly and honestly as possible” and “always assume that the
patient will have access to what you write”. However, this good practice does not change the
fact that the records currently accessible to patients are written and structured from a
clinician’s perspective and not built with the patient in mind.

It is certainly helpful if abbreviations and “jargon” can be avoided, but the prime purpose of
the record is to support clinical care and decision-making. Clinical time for record-keeping is
very constrained. Even if record-keeping can be made more patient friendly without
impacting adversely on clinical utility / time, this alone is unlikely to make Records Access
engaging enough or sufficiently relevant to impact on the way most people think and act
about their health and care.



33http://www.rcgp.org.uk/clinical-and-research/practice-management-resources/health-informatics-

group/~/media/Files/CIRC/Health%20Informatics%20Report.ashx



                                                44                                          15/07/13
GP systems currently present the online record to patients as a list, or filtered lists of
chronological data. What should be done with the information is left to the patient’s
expertise. There needs to be development of better decision-support tools for patients in the
form of dashboard or traffic light style displays. This may include health diaries with test
reminders linked to care plans, and applications which track progress against targets. The
London Connect project34 has highlighted the sort of functionality patients would find most
useful and engaging.

Unless information and systems are easy to use and relevant there is very real risk that
Patient Access will exacerbate health inequalities by putting patients with low health / IT
literacy at a disadvantage. If online health records are to make a difference to patient care,
they must align with self-care protocol and wider health education programmes.

Many practices have expressed an opinion that SMS is a very effective way of
communicating with patients and argue that this functionality should be completely integrated
with online services. Reminders for appointments can already be set via SMS in some
systems, rather than Records Access being simply passive, SMS could be used to alert
patients when new information such as diary dates and health promotion messages are
added to their record. Commercially work is being done to develop web-based interactive
patient interfaces which support patients with specific Long Term Conditions or care
packages. These products aim to improve compliance and understanding by presenting
patients with what they need to know, when they need to know it. It is early days for some of
these products which currently rely on data being input by the patient, however significant
research has gone into to clinical efficacy of design ideas, and companies developing these
solutions are keen to explore integration with GP systems. Further consideration needs to be
given to making Records Access an interactive tool using existing SMS or new mobile
applications.

An online access strategy needs to consider whether Records Access should be targeted at
patients who would benefit most. This would not necessarily be only those with Long Term
Conditions, but also include potentially hard to reach groups. Records Access may help
them to better understand their health risks and more easily access appointments e.g. for
NHS Health Checks.

6.2.4 Assurance that services are safe
The biggest concern among patients was security and confidentiality. Many patients happily
use online banking and shopping but have concerns about their health records being online.
There is also confusion about where records are held and what is done with their
information. Some patients assume Record Access Online is linked to the Summary Care
Record and that their records are being transferred to a central system. Other patients are
concerned that the system suppliers may use their information for commercial purposes. We
need to provide patients with information which allows them to assess the risks involved but
also give them confidence that these systems are assured by the NHS.

Patients are already asked to consent to various forms of electronic information sharing and
e-communication, including use of SMS, the Summary Care Record and locally shared



 http://www.lhib.org.uk/attachments/article/123/London%20Connect%20Public%20Event%20-
34

%20Summary%20Report.pdf


                                               45                                        15/07/13
records. A single menu of options about how patients access and control their information
would be less confusing and more efficient for the NHS.

The commercial system supplier branding (which appears on patient forms, letters, log-in
screens and confirmation emails) has no clear association with a patient’s practice or the
NHS. A common front-end portal for patients with NHS branding or clearer links to their own
GP practice may help build trust and eliminate confusion about who is responsible for looking
after their information. Similarly, a common NHS process and documentation for obtaining
consent and checking patient identification may also help provide assurance.

Patients and The Public
Recommendations:
1. Priority should be given to improving technical usability and reliability of Transactional
   Services.
2. Wider health education and literacy programmes should cover the availability, use and
   relevance of online access.
3. Patients need to be supported by their GP / Practice Nurse to use information.
4. The structure and presentation of online health records must align with self-care
   protocols.
5. Further consideration needs to be given to making Records Access an interactive tool
   using SMS or mobile applications, to help address health inequalities and benefit hard to
   reach groups.
6. Patients and the Public need information which allows them to assess the risks involved,
   and also gives them confidence that these systems are assured by the NHS.
7. Common front-end portals and process for registering patients with NHS branding or
   clearer links to their own GP practice may help build trust and eliminate confusion.
8. There should single menu of options for patients to state their preferences about access
   to and control of the health information which the NHS holds about them.


6.3 What Health Professionals and GP Practices need?
We need to show that online services can help address the pressures faced by health
professionals and not add to them. Our consultation with health professionals and practices
show that most accept the principle of access to online, but that there is concern about the
pace and resourcing of change.

6.3.1 Systems that can be locally configured and introduced in a step-wise
      fashion
Practices have fed back that systems and functionality need to be tailorable to meet the
needs to their local population, the services they provide and the way the practice works.

Many practices would initially like to offer discrete elements of Records Access, in particular,
test results viewing, rather than commit to opening up the whole record.

Systems need to be designed in a modular way which allows practices to develop Records
Access at their own pace, in response to local patient needs: enabling features, configuring
screens and messages to fit with practice protocols, and allowing more control of what the
patient sees when for example, in respect of sensitive data and new test results.

6.3.2 Support to introduce new ways of working
Our workshops with practices showed that there was much more to being able to use
systems effectively than simply having one-off systems training. Change management


                                               46                                        15/07/13
support is required to ensure that practices effectively promote services to patients, have
robust systems for authenticating patients, and ensure clinical staff understand their role in
maximising the potential health benefits for patients and the practice

Practices are working at the limit of capacity. Even keen volunteer demonstrator sites have
found it very difficult to find the time to introduce changes required to implement online
services. New adopter sites should be provided with a standard pack of materials which
practices can be adapted to suit their requirements. They also need a local facilitator who
can be a point of reference to trouble-shoot issues and guide practices through local
configuration and policy choices.

6.3.3 Better technical support with online systems
Practices feel that they are taking the brunt of problems with systems and that suppliers are
not effectively communicating new developments, fixes or planned changes.

Practices have reported a high level of technical queries from patients when offering
transactional services. Improvements in systems and better training for practices should help
mitigate this workload issue, but ultimately practices would prefer patients to be referred to a
dedicated helpline provided by suppliers. Although this would require new funding it is likely
to be much for more cost-effective than each practice fielding the calls as at present.

Suppliers need to be more transparent about problems with systems and include GP
practices (users and patients) at an earlier stage in the development and trialing of systems.

Full training packages, user guides and a dedicated helpdesk for practices should be
developed for all operational products. These products should also take account of
professional and legal requirements regarding security and confidentiality.

Practices and project managers / facilitators working on their behalf need a responsive and
central point of escalation, especially where products are still essentially in development.
System issues and enhancements should be managed nationally as part of the GPSoC
contract. Although both suppliers are now engaging to address fixes and other urgent
enhancements, progress could be achieved more quickly and effectively if coordinated at a
national level.

Systems need to allow usage and uptake to be readily auditable by practices so that they
can see the benefits accruing and know where to target support for patients or change
practice processes.

6.3.4 Guidance about professional and legal responsibilities
Some practices are very happy to open up records and believe that there is “nothing to fear”
from complete transparency. In fact, they argue that the patient will help them carry out
important assurance work. However, many practices have been wary about offering Record
Access without further definitive guidance about the potential professional / legal risks
involved and how to mitigate these. Guidance is need to:

      Ensure standards are consistent and universally applied
      Reduce the risk of unauthorised disclosure
      Reduce the risk of litigation
      Protect patients’ rights, particularly with regard to confidentiality and access to
       records


                                               47                                            15/07/13
      Ensure safeguarding concerns in respect of children and vulnerable adults are
       addressed.

Project work with practices has identified a number of risks and issues relating to
safeguarding. Pending advice from the RCGP, these issues were discussed by the PARTS
Advisory Board, in order to provide some local guidance to support demonstrator sites.
These issues are included at Appendix 8.5. A key recommendation was that GP Practices
should be sign-posted to local specialist advice from safe-guarding nurses and GPs.

Currently, practices are using their discretion about such safe-guarding issues, for example
about whether / how to provide access to carers. Whilst some local discretion will always be
appropriate it should be within a national advisory framework, otherwise there is a risk of
establishing too many local variations which will not make sense to patients and could lead
to practices becoming isolated from emerging best practice.

Health Professionals and Practices
Recommendations:
   1. Systems and functionality needs to be tailorable to meet the needs of local
      populations, the services they provide and the way the practice works. Systems
      should be modular and capable of being implemented in a step-wise fashion.
   2. Change management support is required to ensure that practices effectively promote
      services to patients, have robust systems for authenticating patients, and ensure
      clinical staff understand their role in maximising potential health benefits for patients
      and the practice
   3. Practices need to have dedicated local support with switching on access, recruiting
      patients and maximising the benefits for themselves and their patients.
   4. A dedicated helpline for patients to deal with technical queries is likely to be more
      cost-effective that practices dealing with these.
   5. Suppliers need to be more transparent about problems with systems and include
      users at an earlier stage in the development and trialing of systems.
   6. System issues and enhancements should be managed nationally as part of the
      GPSoC contract to ensure compliance with patient safety and security requirements.
   7. Systems need to allow usage and uptake to be readily auditable by practices so that
      they can see the benefits accruing and know where to target support for patients.
   8. Definitive professional and legal guidance is required about the potential professional
      / legal risks involved and how to mitigate them.
   9. Practices should be sign-posted to local specialist advice from safe-guarding nurses
      and GPs.


6.4 What do NHS and Health & Wellbeing Partners need?

6.4.1 An understanding of the strategic fit
We need to reverse the current position whereby we are asking the NHS to champion a
solution to a need, when we have not yet clearly defined the need itself or demonstrated the
connection between the two.

Online access to records is potentially a significant enabler for some core health strategies.
However there is an issue in that is online access is perceived as an end in itself, and
dismissed as a political gimmick. It maybe regarded as irrelevant to the key challenges faced
by the NHS and even a potential distraction from the real work of improving care:




                                              48                                        15/07/13
“I think this is a politically-motivated waste of time that could be damaging to patients' well-
being as well as damaging to the doctor-patient relationship. Let us get on with our job,
including cutting costs and commissioning, not to mention running the practice, without
imposing yet more unevidenced initiatives! You will lose your committed family doctors at this
rate. “
GP quote November 2013

Online access needs to be explicitly embedded within health improvement and
transformational change strategies for shared decision-making, moving care closer to home,
improving health literacy and supporting self-care. More work needs to be done nationally
with networks such Directors of Public Health, Health and Well-being Boards to describe a
vision for the enabling role of online access and to ensure that it is embedded in Joint Health
and Well-being Strategies (JHWB) as a priority for commissioners.

If online access is to be used as a clinical tool, benefits should be considered by NICE so
that ultimately its use (if evidenced as being effective) will be mandated in clinical guidelines
and care pathways.

6.4.2 Understanding of the fit with wider informatics agenda
The core informatics themes of a paperless NHS, digital by default, records sharing and
integration mean that the NHS IM&T environment is changing fast and that an increasing
amount of electronic information will be available from within the GP Record. Information
that was previously only available on paper (or as poor quality scanned images) will now be
an integral and coded part of the structured GP electronic record.

In particular, the following initiatives link closely with Online Access:

       Summary Care Records: Will patients be able to use Records Access to see a
        view of their SCR content (as this is no longer available via HealthSpace)? Will
        patients be able to view / select data from their GP record which they would like
        included on their enhanced SCR?
       Electronic Prescription Service Release 2 : Will patients be able to use Records
        Access to check / change their nominations, or monitor progress of an electronic
        script?
       Electronic Palliative Care Co-ordination Systems and other systems to share
        Advance Care Plans: will patients / carers be able to use Records Access to check
        what their current plan is and access it easily from with the GP record?
       Telehealth: Will patients able to exchange information (for example, depression
        diaries, blood pressure monitoring and medication reminders) with their health care
        professional against a background of improved understanding of their health and
        condition because they have access to their record?
       Choose and Book: Will there be any potential for integration with Records Access
        to allow viewing of diary dates and managing appointments in one place?
       Digital Public Services Online: Will there be a central government solution to the
        issues of citizen / patient authentication for online services?

If Record Access is going to be fit for the purpose and for the future, then we should be
designing Record Access solutions which fit with the IM&T environment of 2015-18.




                                                 49                                        15/07/13
6.4.3 Clarification of responsibilities and resources to take forward online
      services
Due to transition, lines of accountability and communication have been disrupted across the
NHS and these will take time to re-establish. It still remains unclear where future
responsibility for this agenda lies, and what the performance management and funding
mechanisms will be.

Locally, this project might sit with NHS Commissioning Board Area Teams and / or with
CCGs. These organisations will need to understand their role relative to any national roles
(being taken forward by NHS CB centrally and / or the HSCIC), and the resources required
and available to support them.

Online records access requirements need to be clearly defined and resource implications
clarified. Online access is still ill-defined in terms of scope, benefits and resource
requirements and is subject to further significant change. The 2011/12 Operating
Framework requirements have been largely ignored by outgoing PCTs and SHAs.
Consequently, there has been scarce provision locally for implementation or resourcing in
CCG Annual Operating Plans.

Local commissioners will need to know:

• How the online programme will be supported nationally? Whether there will be co-
   ordinated pilots? Packages of training and change support? Communications support?
• How GP practices will be incentivised to offer online services? (A Directed Enhanced
   Service has recently been confirmed for 2013/1435, but not details are known.)
• What costs / support will need to be picked up locally?
• Will online services will be included in the core GPSoC36 requirements?
• What degree of local choice and flexibility there be about type / pace / focus of online
   services?
Until these questions are answered it will be very difficult for local commissioners to make a
robust business case for local implementation.

6.4.4 Local clinical support and clinical champions
Emerging CCGs are currently focused on building their organisations, balancing budgets,
and exercising their prerogative for local decision-making. If online access is to be
supported by CCGs and their members:

          There needs to be greater public / patient awareness and demand
          Evidence of clinical and productivity benefits
          Explicit links to health improvement goals and clinical targets
          A programme of support for practices
          Local pilots and clinical champions which CCGs / practices can refer to
          Robust and reliable information systems
          Achievable incentives in the GP contract




35   http://www.dh.gov.uk/health/2012/10/gp-contract/
36   http://www.connectingforhealth.nhs.uk/systemsandservices/gpsupport/gpsoc


                                                 50                                     15/07/13
Clinical leadership is essential to change the prevailing GP / Practice view that records
access is more of a risk, rather than an opportunity. Demand must be promoted from within
the local GP community.

NHS and Health and Wellbeing Partners
Recommendations:
   1. Online access needs to be explicitly embedded within health improvement and
      transformational change strategies
   2. More work needs to be done with networks such Directors of Public Health, Health
      and Well-being Boards to describe a vision for the enabling role of online access
   3. Clinical benefits should be considered by NICE so that use of online access as a
      clinical tool can be incorporated into clinical guidelines and care pathways.
   4. Record Access solutions need to be designed for the Paperless NHS / Digital by
      Default environment of 2015-18 and beyond.
   5. Local commissioners need to understand their roles with relation to Online Access,
      and the resources required / available to deliver it
   6. Clinical leadership is essential to change the prevailing GP view that records access
      is more of a risk, rather than an opportunity. Demand must be promoted from within
      the local GP community.


6.5 What do the System Suppliers need?
All three main systems suppliers are planning to develop their online services in line with the
Government’s targets for online access. However, some developments will require significant
work and investment and the existing GP system suppliers may not be best place to deliver
the whole solution by themselves.

6.5.1 A clear mandate for development and investment
We are grateful to suppliers for their co-operation with this project and for working with us to
identify and take on board suggested fixes and enhancements to their systems.

However, the development of online services to date appears to have been regarded as a
low priority for the GP system suppliers. Consultation with GP practices at visits and
workshops revealed there were known and long-standing issues with the existing
functionality which were inhibiting roll-out of both transactional services and records access.
Practices felt suppliers were slow to respond to complaints and requests, and support desks
were not well informed about the topic.

Systems have so far been developed in a largely ad hoc fashion, as a commercial response
to customer requirements, unbound by GPSoC standards or accreditation.

To ensure online access systems are fit for purpose and well supported, the suppliers need
the confidence to invest in their development. A detailed and prioritised specification of
functional requirements is needed.

If all GP practices are to be expected to offer online access it should be considered as core
GP system functionality. The GPSoC contract (or its successor) needs to provide a
commercial framework for these developments, which allow for different supplier models,
potentially involving 3rd party suppliers who can bring expertise around developing the
patient interface. Central management of suppliers under the GPSoC framework should
ensure that systems are accredited, operated and supported to a common set of standards.




                                               51                                         15/07/13
Suppliers also need clear codes of conduct concerning the use of:

       advertising on patient access screen, where this is used to subsidise the cost on
        online service provision,
       aggregate patient data gathered from patients signing up to online services.

Terms and conditions and privacy policies which apply to these services should be subject to
NHS specification and scrutiny.

Supplier
Recommendations:
1.   Suppliers need a detailed and prioritised specification of functional requirements
2.   GPSoC needs to provide a commercial framework for these developments, allowing
     for different supplier models, potentially involving 3rd party suppliers
3.   GPSoC management of suppliers to ensure that systems are accredited, operated and
     supported to a common set of standards




                                             52                                        15/07/13
7 The Next Stage
Nationally the online access strategy is continuing to evolve, informed by the recent RCGP
report “Patient Online: The Road Map” and work from regional projects, including as PARTS.

Meanwhile the NHS Commission Board Area team, CCGs and CSUs need to maintain the
momentum created locally by PARTS project and work together to:
Support practices to extend and improve online services and deliver benefits
now
A new DES to incentivize general practice to offer transactional services is being introduced
from April. Whilst 99% of practices are technically capable of offering Transaction Services,
local facilitation and support is needed to ensure safe, effective and consistent
implementations which provide a sound basis for progression to Records Access.

Local System User Groups should be supported to work with GP system suppliers to resolve
issues, deliver enhancements, and maintain good communications and support for practices.

Continue learning about Records Access
Existing pilots should be given support to deliver benefits to patients now. They will also
need help and guidance to sustain and grow pilots. These pilots supply need to be
systematically evaluation to provide robust evidence of benefits and true costs of offering
access. Lessons learned must be captured and used to inform future strategy and solutions.
Ideally each CCGs would have a local demonstrator site from which local clinical champions
could be developed.

Horizon scan for new solutions
New solutions and technologies which would allow the development of an integrated
personal health record will need to be appraised and exploited. Patients and clinicians must
be central to the process.

Raise awareness of benefits
Evidence of the benefits of patient online access must communicated to patients, the public
and NHS leaders. Local clinical champions for online access should be supported from
within primary care and other sectors or specialist and urgent care. Public awareness should
be addressed as part of wider health education programmes.

Produce a shared vision of what Patient Access could achieve
Online Access represents significant cultural, organisational and technical challenges.
These will only be tackled if there is a clear and shared vision of what “good access” looks
like and how it could be used to change behaviours and deliver better outcomes.
Commissioners, patient groups and Health and Well-being boards need to consider how
patient access benefits (see attached matrix) could support the delivery of strategic
objectives, and from this analysis, develop detailed user case scenarios which will in turn
inform information strategy and solution requirements.




                                              53                                        15/07/13
   8 Appendices
   8.1 Demonstrator GP sites case studies
The Practice        Approach                                   Benefits                          Barriers                              Conclusion
Practice A1 – Transactional Services – Existing Implementation
System              Objectives                                Actual                              System issues. Many queries         Lessons
InPS Vision (LAN)  Reduce time spent on telephone for         So far benefits have not           from patients due to password       • Need to check patients ID on
                      patients / staff.                         outweighed costs / effort of       problems and log in failures (at      registration for VOS and hand
Practice             Improve communication between             deployment.                        least 2 per week), putting people     credentials to applicant in person.
Population            patients and practice                    Limited benefits from online       off from using the service.          System should have been robust
• Approx. 4600                                                  appointments only 48               578 patients have signed up for       before implementation
  patients          Services offered                            booked / 13 cancelled in last      VOS, but only 42% are active         There should have been a national
• Higher than        Online appointments since June 2011.      6 months = approx. £82             users.                                approach with guideline.
  average number      10% of GP routine appointments are        efficiency savings p.a.           Patients happy using existing        Active promoting is essential
  of retired          bookable on line.                        Web-site service for online        repeat order service on web.        Next steps
• Affluent area      Online repeats since December 2012,       repeats has improved              Patients say there are not enough    Release more appointments online
• Broadband           using in parallel with web based (non-    practice efficiency and            appointments available online.        for trial period
  readily available   integrated) facility for repeat orders.   patient satisfaction – 1,000      Patients often book the wrong        Promote VOS in articles, website,
  in the area        Promotion. Services advertised on         requests every month.              doctor when using online              dispensary bags
                      repeat scripts & practice website.       Too early to comment on            appointments
Audit data           No parental access. Patients can use      VOS repeats.                      Practice can’t use online booking
 Data collected      online services from age 16.              4 online VOS repeats in last       for nurse appointments as
  January 2013                                                  month.                             duration depends on the nature of
                                                              Expected                             the consultation.
                                                               In future online access to the    InPS Helpdesk lacked
                                                                record could improve data          understanding of VOS.
                                                                quality.                          Tips re practice setup had not
                                                                                                   been shared with practice.


                                                                                                    .




                                                     54                                          15/07/13
The Practice       Approach                                  Benefits                         Barriers                               Conclusion
 Practice A2 - Transactional Services – Existing Implementation
System              Objectives                              Actual Benefits                   Barriers                                Lessons
InPS Vision (LAN)  Offer greater choice and                 Fewer patients kept waiting      Clunky registration process           Advise doing a “soft roll-out”
                        convenience and improve               on hold.                         Patients frustrated by only being     Communicate widely to patients
Practice                communications with patients         Commuters and parents              able to order authorised repeats     Support all staff through changes.
Population           Improve online service for patients,    have better access to              (when other system would allow         It is a steep learning curve.
• Approx. 7,950         leading to reduction in complaints    appointments.                      them to order any meds.)             Communications back to patients
  patients              and requests for support from        Patients can order scripts at    No simple trouble-shooting              are still a problem, sometimes
• Young                 patients.                             any time.                          guide for patients.                    difficult to resolve patient
  population, IT     Help inform the development of         Increases patient choice of      Usage reports can be obtained           misunderstandings
  literate.             future online services, initially     available appointment times.       but trends are difficult to          Online access very popular with
                        focusing on test viewing.            Average 250 appointments           monitor.                               patients – the elderly in particular.
                    Services offered                          booked / cancelled online        Patients often require               Next steps
Audit data           Online appointments available since     p.c.m. = approx. £2,000 p.a.       passwords to be reset. 30%           Next steps are dependent on
 Data collected      mid-2011 All GP pre-bookable slots      efficiency savings (exc.           patients who apply do not              system improvements and
  March 2013          are available online. Over 800 slots    clinical time saved from           activate accounts.                     funding / support being made
                      normally available at any time.         potential DNAs saved.)           Appointment page is not patient         available.
                     Online repeats available since early   Average 330 repeat requests        friendly – leads to complaints       Demand from patients to see
                      2012                                    p.c.m =approx. £4,000              that no appointments are               have online test results. Practice
                     Website facility for patients to book   efficiency savings p.a.            available.                             would consider piloting if viewing
                      appointments and order repeats via a                                     Records Access: Clinicians              restricted to results which have
                      non-integrated system has been                                             would need to change the way           been seen by GP and patient
                      available 6 years.                                                         they maintain records, this could      only sees GP’s interpretation /
                     Promotion to newly registered                                              take extra time, devalue clinical      action advised and not the actual
                      patients, also via message on scripts                                      usefulness of record                   result.
                      and web-site.                                                            Records Access: Patients may          Practice must be able to
                     57% patients have VOS accounts                                             misinterpret clinical information      configure the type of tests
                      created, 37% have activated accounts.                                      and become distressed /                available to view, and
                                                                                                 confused, consequential                improvements needed to
                                                                                                 increase in workload.                  reliability and usability of
                                                                                                                                        systems.




                                                                                                 .




                                                   55                                         15/07/13
The Practice        Approach                                    Benefits                             Barriers                               Conclusion
Practice A3 - Transactional Services – Existing Implementation

System              Objectives                                  Actual                                57% patients who are registered      Lessons
InPS Vision (LAN)    Preparing to pilot for online test         2% of appointments booked            have not completed the process       • Patient registration process needs
                      viewing - high priority for practice        online. Approx. £680                 online.                                to be face to face to allow patient
Practice             Improve uptake and use of online            efficiency savings p.a.             VOS only shows authorised              ID to be authenticated.
Population            services                                   Improves patient                     repeats – some patients think        • Online access very popular with
• Approx. 14,500     Improve service to patients                 satisfaction.                        other drugs are no longer              patients.
  practice           Improve efficiency for practice            Provided incentive to re-            required.                             Investing in VOS face to face
  population        .                                             organise appointment books          Patients report VOS emails going       training has been worthwhile.
• mixed age         Services offered for over 12months           More appointments                    into junk mail boxes.                 No longer use appointment slots
  structure          6% of patients have created online          cancelled on day (fewer             Patients home security                 for “administrative purposes” – as
• no socio-           accounts, but registering at rate of 10     DNAs) as people on the               sometimes interferes with logon        patients can view messages in
  economic issues     per day.                                    move e.g. via phone. 23%             process                                these appointment slots
• IT / health        Online appointments live for over a         cancellations are online.           VOS does fall over occasionally
  literate            year – 2 slots bookable per patient.       Online Repeats -                    Concerns about potential             Next steps
  population          Bookable on the Day available via           administrative savings from          safeguarding issues around            Practice is interested in piloting test
                      phone only.                                 sorting and processing fewer         granting parental access for older     result viewing
Audit data           Online repeats live Nov. 2012               paper scripts. So far 3% of          children who may attend the GP        Other priorities for access when
 Data collected     Practice also offers automated              repeats are online = approx.         independently.                         these become available are
  February 2013       telephone booking / cancellation /          £640 efficiency savings p.a.        System forces email                    immunizations, patients letters and
                      checking service and web-form for          Test Result Viewing -                synchronization with PDS. If           ability for patients to update
                      repeat ordering                             approx. 60% of telephone             email is changed then VOS              demographic details online
                     Parents offered accounts for their          calls are for test results,          account stops working.
                      children up to 16 years                     therefore potential to reduce      Records Access concerns:
                     Patients apply online via link on           telephone traffic significantly.    Free text entries could include
                      practice website. Practice used to                                               sensitive / 3rd party data.
                      email password to address provided,                                             Concern that clinicians may
                      so that no face to face contact                                                  withhold important but sensitive
                      required. However this protocol has                                              information from records.
                      been reviewed in light of security
                      concerns.
                         .




                                                      56                                             15/07/13
The Practice        Approach                                    Benefits                           Barriers                                Conclusion
Practice A4 – Transactional Services – Existing Implementation

System              Objectives                                  Benefits                           Barriers                                Lessons
TPP SystmOne         Increase uptake of online services with    SystmOnline works very well       Lack of information from              • Need to offer as many
                      target of 15-20% register users             and is easy for the practice        supplier about setting up service      appointments on online as
Practice             Further promote online repeat               and patients to use                 – actually easier than                 possible, hence extension of
Population            requesting service and increase            The service is providing            anticipated                            booking period from 2 to 4 weeks
• Approx.             uptake.                                     worthwhile benefits for the       Practice not aware of: training         in advance.
  7,300patients     Services offered                              small percentage of patients        and support available, patient        Need to ensure mobile numbers for
• mixed ages,        SystmOnline has been enabled since          that use it                         promotional materials to               teenagers are checked as many
  16% over 65,        December 2011 in response to PPG           Online repeats in particular        download, how to audit online          originally have parents numbers
  31% “employed       requests.                                   offers an alternative service       activity for practice as a whole.      recorded.
  unable to take     354 registered users for online             to patients and is therefore      Patients have to contact surgery       Online services take time to catch
  time off to see     services, approx. 5% of practice            useful in complaints                to get their passwords reset.          on. Need proactive promotion.
  GP”, 9% are         population. 66 of these registered          management                        Messages displayed to patients
  carers, some        patients are aged 60+.                     Unlikely to notice efficiency       via SystmOnline need to be           Next steps
  areas of high      All pre-bookable appointments               benefits until at least 20% of      practice configurable.                Higher profile promotion of
  social need.        available online up to 4 weeks in           patients are registered.                                                   SystmOnline in new patient packs,
                      advance.                                                                     Barriers to Records Access                on right hand side of scripts,
                     2 appointments can be booked at a                                             SystmOnline now offers                  possibly event in waiting room,
Audit data            time with the usual GP to ensure                                                Records Access but no flexibility      sending information via text
 Data collected      clinical continuity.                                                            to select which elements are           message etc.
  January 2013       Promoted via waiting room screen,                                               offered to patient. Only option is    Practice considering switching to
                      and practice website.                                                           to restrict free text comment and      notification of normal test results by
                     Pre-registration online not offered as                                          sensitive record entries.              text message. (Already used for
                      there are lengthy new paper forms                                             GPs hold range of views but             appointments.)
                      which have to be filled in at the                                               concerns around implications          Practice might consider offering
                      practice                                                                        for workload with queries from         access to limited clinical
                     Patients must register in person and                                            patient not understanding the          information if this was an option i.e.
                      always provide photo ID, verbal                                                 way information is recorded.           the summary record, medication,
                      consent for is given by patient–no                                            Risk that Insurance Companies           vaccinations and immunisations, as
                      consent forms are used.                                                         might use records access to            a first priority
                     Parental access is withdrawn                                                    obtain data from patient directly.
                      automatically by the system when                                                .
                      children reach 12.




                                                    57                                             15/07/13
The Practice        Approach                                    Benefits                         Barriers                                   Conclusion
Practice B1 - Records Access and Transactional Services – New Implementation

System              Objectives                                  Actual                             Barriers                                 Progress
EMIS Web             Improve service to patients and            “Very easy” to process          Initial concerns among some               150 patients signed up for
                      patient satisfaction                        online scripts, GPs doing        clinical staff about potential for         Transactional Services, registering
Practice             Improve practice efficiency; fewer          themselves.                      patients to misinterpret results /         at rate of 5-10 a day.
Population            phone calls (currently average 20 an                                         clinical information.                     50 patients invited for Medical
• Approx. 5,700       hour), fewer reception desk visits                                          No facility to audit usage of              Records Viewing, 10 enabled.
                                                                 Patients like the
  patients and        (currently average 40 an hour), less                                         Transactional Services                   Lessons
  growing quickly                                                 transactional services and
                      processing of paper.                                                        Competing demands from QOF                Few queries for practice to deal
• 50% are over 65                                                 find them easy to use.
                     Help inform development of online                                            etc. made it difficult to find time to     with.
                      services                                                                     promote Records Access.                   Lots of patients over 65s using
Audit data                                                      Expected: Records Access
                    Approach                                                                      Patients with Apple computers              repeat requesting
 Data collected     December 2012 practice web-site            Patients will validate own       needed help (from GP) to set up.          Patients use message box with
  March 2013                                                      records. Practice has
                      launched, practice enabled for “Patient                                     Username potentially confusing             repeat requests appropriately.
                      Access”                                     nothing to hide.
                                                                                                   for patients – could it be an email       Audit of numbers using Patient
                     January 2013 Repeats ordering live         Improve communication            address of something familiar?             Access can be obtained via “Bulk
                     February 2013 Appointment booking           increase patient ownership      EMIS training / documentation did          Patient Update”
                      of all routine GP slots (up to 4 at a       of care / treatment plans,       not cover everything required e.g.        Items marked as “sensitive" are not
                      time, 2 weeks in advance)                   compliment “My Wishes”           how to set global viewing so staff         viewable by patient.
                     Secure messaging enabled                    advanced care plan register,     can see medication requests.              Need to set up appointment
                     March 2013 Medical Records Viewer           SCR and EPS2.                                                               templates in advance to avoid
                      50 patients with mix of demographic /                                                                                   editing existing sessions.
                      clinical backgrounds invited               Support carers of patients                                                Next steps
                     Records Access                              with dementia, and children                                                High profile promotion of online
                      All free text viewing disabled                                                .                                         service, all staff now confident.
                                                                  with complex / long term
                     Promotion. Posters in waiting room,                                                                                    Evaluate progress with PPG in
                                                                  conditions.
                      web-site.                                                                                                               April
                     Parental access up to age 12.                                                                                          Promote online access via “EMIS
                      Patients can use online services from                                                                                   app”
                      age 16.                                                                                                                Offer Records Access to patients
                     Consent forms and leaflets adapted                                                                                      (carers) in Residential Homes
                      from PARTS examples.                                                                                                    (Learning Disability and Elderly)
                                                                                                                                             Review free text viewing




                                                     58                                          15/07/13
The Practice         Approach                                    Benefits                          Barriers                                  Conclusion
Practice B2 and B3 - Records Access and Transactional Services – New Implementation
System               Objectives                                  Actual Benefits                     Barriers                                Progress
EMIS Web              Improve service to patients by offering    Too early to say                 Initially cautious about                 20 patients signed up for
                       great choice and convenience.             Expected: Records Access            introducing online repeats given          Transactional Services.
Practice              Improve practice efficiency                Records viewing has the           issues with Medicines                    8 patients enabled for Medical
Population                                                         potential to support patients     Management in EMISWeb.                    Records Viewing.
• 2 practices with   Approach                                      with long term conditions        Risk of patient seeing 3rd party        Lessons
  shared              February 2013 Practice C enabled for        with decisions about their        information / sensitive information      Need to ensure Clinicians set up to
  management           “Patient Access” and appointments,          care, sharing records and         / bad news – would like option to         allow online access to their
  team                 repeats and change of address               information with other            delay viewing of results until            appointments before setting up
• Practice B2 =       Appointments bookable for GP routine        agencies (e.g. social care)       clinician has discussed with              templates.
  Approx. 10,800       1 at a time, 3 > 40 days before             and supporting improved           patient.                                 EMISWeb practices are enabled
  high % retired,      appointment.                                compliance with treatment        Read codes are not always used            for Patient Access by default.
  mainly affluent     Medical Records Viewer offered to           plans                             consistently or at correct level.         Patients were able to apply online
  area.                PPG patients following system                                                 Hiding free text could impact on          for online services before the
 Practice B3=         demonstration at meeting.                                                     interpretation by patient.                practice had decided to offer them.
  Approx. 4,700,      Records Access                                                               Concern that Records Access             Next steps
  high %               All free text viewing disabled                                                could affect practice insurance          Practice D – Start roll-out of
  unemployment        Promotion. Start slowly. Posters in                                           cover.                                    Transactional Services to any
  transient            waiting room, web-site.                                                      Test results – need to be able to         patient requesting them service
  population, low     Registration Patients invited to make                                         show clinicians advice /                  and Medication Records Viewer to
  income               an appointment to register to avoid                                           interpretation instead of                 invited patients.
                       queues at reception.                                                          automated comment.                       Evaluate progress and feedback
Audit data                                                                                          No test patient to help train staff /     with PPG members and selected
                      Patients must be over 18 to use online
 Data collected       services. No parental or carer access                                         trouble-shoot patient queries             patients using Medical Records
  early March          is permitted.                                                                “Patient Access” not robust;              Viewer.
  2013                                                                                               patients report problems "Internal
                      Consent forms and leaflets adapted
                       from PARTS examples.                                                          error" when attempting to view
                                                                                                     results. The "i" information
                                                                                                     buttons don't work.




                                                      59                                           15/07/13
The Practice         Approach                                     Benefits                           Barriers                                 Conclusion
Practice B4 - Records Access and Transactional Services – New Implementation
System               Objectives                                   Actual                              Some patients appeared to              Progress
EMIS LV               Improve service to patients by offering      Too early to say                  already have PINs issued before         6 patients from PPG signed up for
                       great choice and convenience.              Expected: Repeat Ordering            the practice was enabled. When           Transactional Services.
Practice              Improve practice efficiency                 Reduce practice                    this couldn’t be explained this         6 patients from PPG enabled for
Population            Help prepare the practice for the             administrative burden and         undermined practice confidence.          Medical Records Viewing.
• Town centre          future roll-out of online access.             improve patient satisfaction.    EMIS training support and
  main site with                                                   Improved patient safety.           documentation not sufficiently         Next steps
  village branch     Approach                                        Correct medication is             comprehensive.                          Use patient survey to evaluate
  site                January 2013 Practice enabled                 automatically selected for       Risk of patient accessing 3rd            progress and feedback with PPG
• Approx. 10,400       “Patient Access” for repeat ordering          practice staff to process.        party information / sensitive            members using Medical Records
  patients, mixed      and Medical Records Viewer.                Expected: Records Access             information.                             Viewer and repeats ordering.
  demographic,        Appointments will not be enabled as         Regarded by practice GPs          Online access could affect way          Update web-site to promote new
  higher than          practice is operating Doctors 1st triage      as having potential to            clinicians keep records                  online services, put message on
  national average     system                                        support patients with long       Could result in extra workload as        repeat order forms.
  retired. IT         Medical Records Viewer offered to             term conditions.                  patient queries increase.
  literate             PPG patients and those                                                         Repeat requesting does not force
  population                                                                                                                                   May consider using online
                       recommended by GPs on clinical                                                  patients to specify which site they      appointments for nurse
                       grounds only.                                                                   want to collect script from,             appointments when functionality
Audit data            Piloting repeats ordering with PPG                                              doesn’t allow practice staff to sort     allows patient to selected reason
 Data collected       before rolling-out to whole practice.                                           online requests by site.                 for visit and book time accordingly.
  March 2013          Records Access                                                                 Login process for patients is
                       All free text viewing disabled                                                  “clunky”.
                      Patients must be over 16 to use
                       transactional services and over 18 for
                       Medical Records Viewer. No parental
                       or carer access is permitted.
                      Consent forms and leaflets adapted
                       from PARTS examples.




                                                       60                                            15/07/13
The Practice        Approach                                  Benefits                         Barriers                                Conclusion
Practice B5 - Records Access and Transactional Services – New Implementation
System             Objectives                               Actual                              EMIS training support unaware         Progress
EMIS PCS            Improve practice efficiency              Too early to say                  that Patient Access could be           2 patients signed up for
                    Offer greater patient choice and        Expected: Transactional             used with EMIS PCS.                     Transactional Services.
Practice             convenience                             Services                           Online repeats could not be            2 patients enabled for Medical
Population          Help inform development of Records      Reduce practice                    viewed in workflow when practice        Records Viewing.
• Operates across    Access.                                   administrative burden and         enabled. EMIS took two weeks          Lessons
  2 urban sites.                                               improve patient satisfaction.     to resolve this “bug”.                 Protected time needs to be made
• Approx. 2,700    Approach                                 Expected: Records Access            Staff annual leave and bug with         available for staff training and
  patients.         February 2013 Practice enabled          Improved patient trust and         repeat requests viewing has             implementation (e.g. tailoring
  Turnover less      “Patient Access” for appointment          confidence.                       prevented online access being           materials etc.).
  than 10%.          booking (all routine GP slots up to 2   More effective consultations.      rolled-out.                            Test patient is very useful for
  Higher than        weeks in advance), repeat ordering                                         Difficult to find time to implement     training and working our practice
  average levels     and Medical Records Viewer.                                                 new services and promote to             protocol.
  of                Medical Records Viewer enabled for 2                                        patients.                              Once patient materials are agreed,
  unemployment /     patients with long term conditions                                                                                  service can be offered to patients
  depravation.       invited by GP.                                                                                                      and will grow slowly without
                    Records Access                                                                                                      dramatic change on practice ways
Audit data           All free text viewing disabled                                                                                      of working.
 Data collected    Patients must be over 16 to use                                                                                   Next steps
  March 2013         transactional services and Medical                                                                                 Roll-out transactional services to all
                     Records Viewer. No parents or carers                                                                                patients who want it.
                     will be given access.                                                                                              Set-up practice web-site
                    Change of Address decided not to                                                                                   Evaluate Records Access pilot with
                     enable initially, but reassured that                                                                                2 selected patients.
                     practice would be able to accept /
                     reject and that patients would not be
                     able to move of area without informing
                     practice.
                    Consent forms and leaflets adapted
                     from PARTS examples.




                                                   61                                          15/07/13
The Practice        Approach                                   Benefits                          Barriers                                Conclusion
Practice C1 - Transactional Services – New Implementation
System             Objectives                                 Actual                             Barriers                                Progress
EMIS LV             Improve service to patients and patient  Much easier to make sure           Concerns discussed re patient          52 patients signed up for
                     satisfaction                                patients get the right             seeing potentially distressing         Transactional Services.
Practice            Improve efficiency for practice freeing     medication.                        information before practice has
Population           up admin time for other work              Expected: Transactional              been able to contact them.           Lessons
• Operates across  Ensure practice is ready for new ways      Services                                                                   Need to allow more than one
  2 rural sites.     of working                                Free up phone access for            Potential for patient to see          appointment at a time so that
• Approx 9,600                                                   patients who are not using          things in their past history they     patient can have nurse and GP
  patients. High   Approach                                      online services.                    may have been unaware of or           appointment outstanding.
  levels of IT /    January 2013 Practice enabled             Reduce DNAs                          forgotten.                           Book on Day slots are available to
  health literacy,   “Patient Access” for appointment          Replace email repeat                                                       web when embargo time has
  relatively         booking (all routine GP slots up to 6       requests (grown dramatically       Issues regarding parental / or        passed.
  affluent           weeks in advance, limited to 1              recently) with safer, more          carers access need further           Will take time to grow as patients
  population.        appointment at time), repeat ordering       secure, more efficient              guidance.                             have to physically come in to
  Migrating to       and change of address.                      process.                                                                  complete registration process.
  EMISWeb in                                                                                        Patient login process is             Primary use seems to be for
                    Medical Records Viewer enabled for        Reduce medication wastage
  2013.                                                                                              cumbersome and off-putting.           prescriptions and little use at this
                     test patient only. Practice wish to wait    by enabling patient to order
  Dispensing         for outcome of RCGP report and              directly rather than via                                                  time for appointments.
  practice.                                                                                         Some features of Medical
                     development of system functionality         community pharmacist.
                                                                                                     Record Viewer e.g. links to         Next steps
                     before proceeding.                         Administrative savings as           Patient Information sources are
Audit data          Patients must be over 16 to use             processing less paper.                                                   Update practice web-site to explain
 Data collected                                                                                     not working properly.
                     transactional services in own right.      Expected: Records Access                                                   and promote online services
  February 2013                                                                                     Still quirks in system e.g. past
                     Parents may have access when child          Potential to reduce                                                      Consider use of text messaging for
                                                                                                     appointments count against
                     <12, and with child’s consent over 12.      telephone calls, improve                                                  reminders and informing patients of
                                                                                                     patients allowance when
                     Carers may have access where                patient communications,                                                   results. Consent to use text
                                                                                                     patients tries to book another
                     Lasting Power of Attorney.                  support patient compliance,                                               messaging could be incorporated
                                                                                                     after attending the surgery.
                    Practice protocol, consent forms and        improve quality of healthcare                                             with online consent form.
                                                                                                    No audit of usage.
                     leaflets adapted from PARTS                 experience, and improve
                                                                                                    Patients should be blocked from
                     examples                                    data quality.
                                                                                                     re-ordering medication too soon
                    Promotion via posters in reception,        Secure messaging: could
                                                                                                     / multiple times.
                     email patients who submit requests via      replace cumbersome and
                     email, via repeat script request forms.     insecure email.




                                                     62                                          15/07/13
 Practice C2 – Transactional Services – New Implementation
System              Objectives                                 Actual                                  GPs are concerned that VOS           Progress
InPS (LAN)           Improve service to patients by offering    Patients are providing                only allows patients to see           28 Active Users
                      greater choice and convenience.             information when they book            medication that is authorised.        All routine GP appointments are
Practice             Improve practice efficiency                 online which helps GP                 They believe this has patient          offered online (except Bookable of
Population           Improve patient safety - processing         prepare for the consultation          safety implications.                   the Day).
• Urban surgery       scripts                                     and saves time.                      Registration and authentication of    Not live yet with repeat requesting
• Approx. 4,700                                                Expected: Repeat Ordering                patients has workload                  via VOS. Plan is combine this with
  patients, some                                                Would like to be able to               implications.                          introduction of EPS2 and GP
  socio-economic    Approach                                      switch off web-site repeat           Cost of annual VOS license.            carrying out re-authorisation of
  depravation        January 2013 Practice enabled VOS           order system. Practices              Further guidance is required           repeats themselves.
                      (Vision Online Services) for repeat         processes approximately               about when it is appropriate to      Lessons
Audit data            ordering and appointment booking for        400 scripts per week at a             offer / withdraw parental access      Online Appointments take time to
 Data collected      the first time.                             cost of approx. If 25% were           to transactional services.             gather pace.
  January 2013       “Web-form” repeat requests have             received via VOS this could                                                Next steps
                      been offered to patients for some time.     deliver approx. £4,800 in                                                   Switch on VOS repeats in April
                      During 2012 over 3,000 requests were        efficiencies.                                                                2013 and switch off non-integrated
                      received this way. Patients can use       Before offering online                                                        service for ordering repeats
                      this service to request any medication      appointments the practices                                                  May consider offering online
                     Patients must be over 18 to use             was taking an average of 20                                                  appointments for booking
                      transactional services. No parental /       telephone calls for                                                          telephone slots but would need to
                      carer access is currently allowed.          appointments per hour.                                                       inform patients that there is no
                     Promotion of service to patients via        Reducing these calls by 25%                                                  guarantee of actual time of call.
                      surgery web-site, posters in waiting        could achieve efficiency                                                    Practice would be willing to
                      room. When repeat requests via VOS          savings of approx. £6,000.                                                   consider pilot of test result viewing,
                      go live note will be added to right hand Expected: Appointments                                                          if results could be released after
                      side script                               Reduce DNAs where                                                             GP has viewed them. Currently
                     Practice protocol, consent forms and        patients find it difficult to get                                            the practice receives 6-8 calls an
                      leaflets have been adapted from             through on telephone to                                                      hour for test results, therefore
                      PARTS examples.                             cancel appointments.                                                         potential for substantial efficiency
                                                                  (Practice has approx. 4-6                                                    savings for the practice, and better
                                                                  DNAs) per week.                                                              telephone access for all patients.




                                                       63                                             15/07/13
8.2 Glossary
Term / Acronym   Explanation
CCG              Clinical Commissioning Group
DH               Department of Health
DNA              “Did not attend”
GPSoC            GP Systems of Choice
HSCIC            Health and Social Care Information Centre
IG               Information Governance
IM&T             Information Management and Technology
LINKs            Local Involvement Networks
LMC              Local Medical Committee
PALS             Patient Advice and Liaison Service
PARTS            Patient Access to Records and Transactional Services
PCT              Primary Care Trust
PPG              Patient Participation Group
PRIMIS           Provides consultancy, training and support in health informatics.
QIPP             Quality, Innovation, Productivity and Prevention
RA               Records Access
RCGP             Royal College of General Practitioners
RCN              Royal College of Nurses
SEC              South East Coast
SHA              Strategic Health Authority
TS               Transactional Services
VOS              Vision Online Services




                                    64                                        15/07/13
8.3 References
An Information      http://webarchive.nationalarchives.gov   DH            October 2010
Revolution          .uk/+/www.dh.gov.uk/en/consultations/
                    liveconsultations/dh_120080

A Guide to          http://www.pifonline.org.uk/new-pif-     Patient       September
Records Access      guide-to-health-records-access/          Information   2012
                                                             Forum
Enabling patients   http://www.rcgp.org.uk/clinical-and-     RCGP          September
to access           research/practice-management-                          2012
electronic health   resources/health-informatics-
records             group/~/media/Files/CIRC/Health%20I
Guidance for        nformatics%20Report.ashx
health
professionals
It's Your Record:   http://www.myhealth.london.nhs.uk/sit    London        January 2013
A guide to          es/default/files/u3246/ItsYourRecord.p   Connect
accessing health    df
records online
Keeping your        http://www.bcs.org/upload/pdf/social-    BSC Health    October 2012
Health and Social   care-records.pdf
Care Records
Safe and Secure.
London Connect:     http://www.lhib.org.uk/information-      London        March 2013
Information         transparency/resources                   Connect
Transparency to
Drive
Improvement and
Health
Operating           https://indicators.ic.nhs.uk/download/   DH            December
Framework           GP%20Practice%20data/Specification                     2011
Technical           /PHF10%20-
Guidance 2012/13    %20Technical%20Guidance.PDF
Royal College of     http://www.rcgp.org.uk/clinical-and-    RCGP          March 2013
GPs Patient         research/practice-management-
Online Access       resources/health-informatics-
Project             group/patient-access-to-records.aspx
Information         https://indicators.ic.nhs.uk/webview/    HSCIC         January 2013
Centre GP
Indicators
Personal Health     http://www.rcn.org.uk/__data/assets/p    RCN           July 2012
Records and         df_file/0005/465458/16.12_Personal_
Information         Health_Records_Briefing_-
Management          _18_July_2012.pdf
Haughton            http://www.htmc.co.uk/pages/pv.asp?      Haughton      Current
Thornley Medical    p=htmc28                                 Thornley
Practice Patient                                             Medical
Access site                                                  Practice




                                            65                                       15/07/13
8.4 Index of PARTS resources
Resources Name              Description                                    Available from
Patient Consent Forms       Template patient consent forms for both        NHS Networks:
Records Access:             Records Access and Transactional               PARTS
   i.      Patient          Services.
   ii.     Parent/Carer
Transactional Services      Forms for both patients and parents/carers.
   i.      Patient
   ii.     Parent/Carer
Patient Information         An information leaflet designed for patients   NHS Networks:
Leaflets                    about online records access and                PARTS
   i.      Records Access   transactional services.
   ii.     Transactional
           Services
Practice Protocol for       An example protocol setting out roles and      NHS Networks:
Online Services             responsibilities within a practice             PARTS
Audit Toolkit               Excel spreadsheet comprising of separate       NHS Networks:
                            resources and benefits sheets to be used       PARTS
                            by practices to log cost (actual / time) of
                            implementation and operation of online
                            services, and quantity benefits based on
                            measurable changes in practice activity
                            (e.g. reduction in DNAs etc.)
Practice Planning toolkit   Step by step plan of preparation required      NHS Networks:
                            to implement online services.                  PARTS
                            Guidance to help practices decide on their
                            approach to implementation
Instruction sheets for      Guidance for patients to support               NHS Networks:
patients                    registration and logging in to Patient         PARTS
                            Access.
InPS VOS Hints & Tips,      Compiled from workshops held with users        Embedded in
Enhancements & Issues       and suppliers throughout January 2013          Appendix below
EMIS Hints & Tips           Compiled from the workshops held with          Embedded in
Enhancements & Issues       users and suppliers throughout February        Appendix below
                            2013
Patient Survey              A survey designed to identify the hopes        Results are
                            and fear patients have for online services,    incorporated in
                            and current levels of usage.                   the report.
                                                                           Survey analysis
                                                                           embedded in
                                                                           Appendix
                                                                           below.
Primary Care Health Team    A survey designed to identify what services    Results are
Survey                      are offered by practices, benefits             incorporated in
                            anticipated and issues experienced /           the report.
                            perceived which would inhibit further roll-    Survey analysis
                            out/                                           embedded in
                                                                           Appendix
                                                                           below.
Practice Review Survey      This survey is used to obtain anecdotal        Results are
                            feedback from practices about the benefits     incorporated in
                            / costs of implementing online services        the report.
Patient Evaluation          A short survey designed to be used by pilot    NHS Networks:
Questionnaire               practices to evaluate patient experiences      PARTS
                            and gather feedback about the process.


                                          66                                       15/07/13
8.5 Safeguarding Issues and Recommendations
PARTS Advisory Board discussion 7th January 2012 (following a briefing from Trish
Dabrowski, NHS South of England, Strategic Lead for Children and Young People):

Parental Access to Childrens’ Online Record

• Age 16 should be considered the minimum age for medical records access or access to
  online services to automatically be granted to patients.
• Access could be granted to children under 16, if on a case by case basis, they were
  considered Gillick competent.
• Parental access should normally be withdrawn when the child reaches 11 or 12 (precise
  age to be agree by practice policy taking into account local considerations), unless the
  child does not have competency to consent.
• There is a risk allowing parental access with a child’s consent between the ages of 12-16,
  may put the child under pressure to consent. There is a risk that children may not seek
  the correct medical attention, because they aware of parental access.
• Child protection issues may arise if children disclose information to the GP that is later
  viewable on their record by the online account holder.
• Risks related to the use of social media must be considered, particularly in relation to
  young people and the risk that they may be targeted online for information / login details.
• Granting parental access to one parent only when parents separated may cause conflict.
  In these cases a practice would be advised to withdrawn parental access completely.
• There are concerns about establishing whether an individual has parental rights in
  respect of a child. The suggestion is that practices should only grant access where
  parent and child are both know to and registered with the practice. The same rules should
  apply as when a parent is asked to consent in respect of clinical treatment.

Adult Safeguarding

• Guidance is required on when and on what basis can access be granted to informal or
  formal carers. For example, can legal power of attorney be taken as consent and are
  forms of verbal / written consent valid? Also under what circumstance professional carers
  e.g. Nursing Home staff be given access should and what arrangements should be in
  place to review or remove this access?
• There may be pressure put on vulnerable patients to grant access to the record and this
  must be considered.
• There should be protocols developed to enable carer assessment and authentication
  before access is granted.
• Consideration should be given to whether carers need retrospective access, allowing
  prospective access only would support their current role but avoid past history being
  shared inappropriately.




                                             67                                       15/07/13
8.6 Survey analysis


Primary Care Attitudes

A survey was designed and distributed among primary care staff in order to gauge levels of
awareness and attitudes towards Records Access and Transactional Services. Survey
analysis included responses from 212 respondents, 19% of which identify themselves as
clinicians, and 71% as Practice Managers.

Full survey analysis can be accessed below or on the PARTS NHS Networks website.



03 12 12 GP Survey
    Analysis.pdf


Patient Attitudes

In order to find out what patients thought about Records Access and to understand levels of
awareness about services offered, a survey was promoted at patient PPG meetings, on GP
practice websites and via the PARTS project Twitter page. As of early February 2013 it had
received 86 responses.

Full survey analysis can be accessed below or on the PARTS NHS Networks website.



 07 02 13 Patient
Survey Analysis.pdf




                                             68                                      15/07/13
8.7 GP Systems Workshops

8.7.1 Hints and Tips

A series of workshops were held for practices using Vision Online Services to share hints
and tips. These have been collated below.



  VOS Hints and
    Tips.pdf


This document is also available on the PARTS NHS Network website.

8.7.2 Issues and Enhancements


The project had been working to identify known system issues and requested
enhancements. A number of these were collated and discussed at practice workshops and
are available below.



VOS Enhancements        EMIS Issues and
 and Issues.docx      Enhancements v3.docx




                                             69                                       15/07/13
8.8 Advisory Board

8.8.1 Membership and Terms of Reference

The membership of the Patient Access to Records and Transactional Services Advisory
Group:

            Chair and Clinical Lead – Dr Christopher Markwick (GP)
            Chief Information Officer – Tad Matus
            GP practice representatives – Alison Turner IM&T Manager West Byfleet
             practices (InPS), Angela Ballard Practice Manager Witley Surgery (EMIS)
            Public Health representative – Anne Morrison
            Lay representative – Laurie Beed (Informatics Committee, Carers Forum, Royal
             College of Psychiatrists)
            LMC representatives - Surrey and Sussex LMCs (Tracey Amatt) and Kent LMCs
             (Dr Mike Parks)
            Self-Care / Long Term Conditions Lead – Karen Devanny
            Communications representative - Michelle Kane
            Benefits Lead – Lynn Smith
            Health Informatics Project Manager – Becky Gayler
            Health Informatics Programme Support Officer – Isabella Davis-Fernandez
            Strategic Lead for Children & Young People – Trish Dabrowski
            Sustainability Lead – Dr Caroline Jessel




TOR PARTS Advisory
  Board V1.0.docx




                                            70                                     15/07/13
   8.8.2 Advisory Board Benefits workshop


Stakeholders:
Key questions            PATIENTS                  GENERAL PUBLIC                   CLINICIANS                  GP PRACTICES                  PUBLIC HEALTH                     WIDER NHS
to consider:
                                                                                Access to information to
                   Better understanding of
                                                                               improve clinical decision-                                   Improved data quality.
                      condition/health.
                                                  Greater transparency.                 making.                                              Enables health advice        Improved health literacy.
  Why is          Proactive partner in care.                                                                   Cost and efficiency
                                                    Improved trust &         Improved relationship/trust                                 /messages to deliver directly    Integrate with other NHS
                   Share record with those                                                                  savings; using admin and
  patient              caring for them.
                                                   confidence in NHS /               with patient.
                                                                                                               clinician time more
                                                                                                                                                 to patients.                     services.
  access                                                clinicians.                 More informed                                          Improves health literacy.     NHS sustainability strategy.
                  More accessible services.                                                                         effectively.
                                                                              conversation with patient.                                     Reduces inequalities?         Improved transparency
important?         Patient empowerment.
                                                                              Improved compliance with
                    Increased confidence.
                                                                                treatment / care plans.
                    Be more prepared at
                       appointments.                                         Write notes with patient in
                 Carers able to care better if                                          mind.
                   armed with knowledge.                Take greater            Prescribe “access” to
What would             Less DNAs, less             responsibility for own     patients to help improve      Offer patients a choice re   Use access as a mechanism to    Encourage patients to share
   you do              appointments.                       health.              their understanding /        accessing services and       reach to communicate with       records directly with other
                   Make better decisions.         Help support family and      adherence to care plan.            information.                 patients / public.               care providers
differently if       Ask more questions.         friends who are receiving   Encourage patients to refer       Deployed freed up          Encourage public to access     Better coordination of care
 the service     Check information recorded          care / treatment.       to record to support day to      resources to improve        records and take proactive         between providers.
     was                  is correct.               Make better lifestyle       day decision-making.         other patient contacts.        interest in their health.                  .
 available?         Help co-ordinate care.                choices.
                   Share information with                                                 .
                  other health / social care
                          providers
                      Increased patient                                                                                                                                  Decrease in the number of
                                                                                Improved compliance.         Fewer subject access
                         satisfaction.                                                                                                                                         investigations /
                                                                              Increase in the number of            requests.
                         Fewer DNAs                                                                                                        Improvements in health         unnecessary procedures.
                                                                               patients accessing their     Fewer complaints about
                   Fewer inappropriate /            Public confidence                                                                               literacy.              More appropriate care
                                                                                        record.             contacting the practice.
How would        unnecessary consultations              increases.                                                                       Greater awareness of health /       delivered / quicker.
                                                                                 Patient better able to          Fewer DNAs
success be           Fewer phone calls /           Public awareness of
                                                                             contribute to discussions re     Fewer phone calls.
                                                                                                                                         care and treatment options /       Reduction in adverse
measured?          requests just to access       health options increases                                                                       consequences.                events / litigation.
                                                                                         care.              Fewer requests to print
                         information                                                                                                      Improved lifestyle choices.    High patient / public levels
                                                                             Decrease in the number of           information.
                  Less need for patients to                                                                                                                                     of satisfaction.
                                                                                    appointments.             Better data quality
                    repeat information.

                                                               71                                                  15/07/13
8.9 Acknowledgements
We would very much like to acknowledge and thank the following for their contribution to this
project:

Adam           Rogulski      Associate Trainer       KCMS
Phillip        Abbott        Practice Manager        Seaford Medical          Demonstrator
                                                     Practice                 site
Tracey         Amatt         Director of Liaison     Surrey and Sussex LMC    Advisory Board
                             and LMC Finance &                                Member
                             Development
Angela         Ballard       Practice Manager        Witley Surgery           Advisory Board
                                                                              Member /
                                                                              Demonstrator
                                                                              site
Laurie         Beed          Patient                                          Advisory Board
                             Representative                                   Member
Yvonne         Bennett       Patient                 Haughton Thornley
                             Representative          Medical Practice
Penny          Blackbourne   Patient                                          Patient
                             Representative                                   Reference
                                                                              Group Member
Tracey         Burgoyne      Practice Manager        River Lodge Surgery      Demonstrator
                                                                              site
Anna           Burns         Project Co-ordinator    myRecord
Dawn           Chalcraft     Practice Manager        Beaconsfield Road        Demonstrator
                                                     Surgery                  site
Sue            Challinger    Practice Manager        Riverside Medical
                                                     Practice
Trish          Dabrowski     Strategic Lead for      NHS South of England     Advisory Board
                             Children and Young                               Member
                             People
Tim            East          Product Manager         EMIS
Bruce          Elliott       Health Informatics      Department of Health
                             Development
                             Programme Manager
Dr Brian       Fisher        GP / Project Lead       myRecord Project,
                             Director                PAERS Ltd
Dr Amir        Hannan        GP / Clinical Lead NW   Haughton Thornley
                             PATRS Project           Medical Practice / NHS
                                                     North West
Eleanor        Haslam        Systems Analyst         TPP
Heather        Heatley       Practice Manager        Holbrook Surgery         Demonstrator
                                                                              site
Terri          Holcroft      NPfIT Primary Care      NHS North West
                             Lead
Richard        Ince          Project Manager         myRecord
Dr Caroline    Jessel        Sustainability Lead     NHS Kent & Medway        Advisory Board
                                                                              Member
Dr Awadh       Jha           GP                      Tunbury Avenue           Demonstrator
                                                     Surgery                  site
Lynne          Jones         Practice Manager        Cropredy Surgery,        Early adopter
                                                     Banbury                  practice
Rick           Jones         Practice Manager        Mile Oak Surgery         Demonstrator
                                                                              site
Michelle       Kane          Communications          NHS South of England     Advisory Board
                             Officer                                          Member
Howard         Leicester     Patient
                             Representative
Christopher    Lewis         Practice Manager        Sandgate Road Surgery    Demonstrator
                                                     & Folkestone East        site
                                                     Family Practice

                                              72                                       15/07/13
Debra         Little       Practice Manager         Preston Park Practice
Nicky         Macdougald   Practice Manager         Westgate Surgery
Dr            Markwick     Clinical Lead            Highcliffe Med. Practice   Advisory Board
Christopher                                                                    Member
Tad           Matus        Chief Information        NHS South of England       Senior
                           Officer                                             Responsible
                                                                               Officer /
                                                                               Advisory Board
                                                                               Member
Sol           Mead         Patient                                             Patient
                           Representative                                      Reference
                                                                               Group Member
Valerie       Middleton    Patient                                             Patient
                           Representative                                      Reference
                                                                               Group Member
Ray           Morgan       Patient                  Sandgate Practice          Demonstrator
                           Representative           Folkestone                 Site
Ray           Morgan       Patient                  Sandgate Medical
                           Representative           Practice
Anne          Morrison     Public Health            NHS South of England       Advisory Board
                           Programme Lead                                      Member
Joanne        Palmer       Regional Account         EMIS
                           Manager
Nin           Panjit       Project Director         London Connect
Henry         Pares        Head of Informatics      Department of Health
                           Planning
Dr Mike       Parks        Medical Secretary        Kent LMC                   Advisory Board
                                                                               Member
Scott         Pashby       Regional Business        InPS
                           Manager
Gill          Peters       Trainer                  InPS
Dr Inram      Rafi         Chair of the Clinical    RGCP
                           Innovation and
                           Research Centre
Dr Venkat     Reddy        GP                       Mocketts Wood Surgery      Demonstrator
                                                                               site
Neil          Reynolds     Associate Trainer        KCMS
Margaret      Shorland     Patient                  Sandgate Medical
                           Representative           Practice
Barbara       Smith        Change and Benefits      NHS North West
                           Realisation Manager
Caroline      Smith        Product Development      InPS
                           Manager
Chontelle     Smith        Admin Team Leader        Sheppy Community           Demonstrator
                                                    Hospital                   site
Christine     Smith        Implementation           Eastern & Coastal Kent
                           Manager                  PCT
Lynn          Smith        Benefits Lead            NHS South of England       Advisory Board
                                                                               Member
Julia         Taylor       Practice Manager         The Cedars Surgery         Demonstrator
                                                                               site
Eddie         Thomas       Practice Manager         Bird-in-Eye Surgery        Demonstrator
                                                                               site
Alison        Turner       IM&T Manager             West Byfleet               Advisory Board
                                                    Healthcentre               Member
Dave          Wellbelove   Patient                                             Patient
                           Representative                                      Reference
                                                                               Group Member




                                               73                                       15/07/13

								
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