Pharmacy has been lobbying for access to patient records for several years, but there has been an indication from the secretary of state that ministerial approval could be given in the future. While this is by no means secured, this would be a significant step for pharmacies and patients if it comes about. In reality the agenda looks set to be driven by software suppliers rather than professional bodies and it seems that work is already under way. Some pharmacists using Rx Systems’ software will have limited access to GP records early this year and those employed by a multiple are already accessing patient-held records on a trial basis. Any further delays are likely to be about politics rather than technology.
Health Secretary Jeremy Hunt announced at the end of October that pharmacists would be able to access GP records ‘so that they can make sure that they give people the correct medicines and know about their allergies’. But his predecessor, Andrew Lansley, promised patients the power to control their own records as far back as 2010. The issue is predominantly political and it is striking that the discussion is around pharmacy’s access to the GP record, says Simon Driver, managing director of software supplier Cegedim Rx. ‘They are neither the GP’s nor the pharmacist’s – they are the patient’s records!’
Founder and chief executive of the Patients Know Best (PKB) patient-held records system, Dr Mohammad Al-Ubaydli is confident that plenty of patients want to grant pharmacists access to their records. He is working on a trial with HIV patients using his system and they are asking for pharmacists to be given access to their records. This is significant because HIV consultants are not obliged to share information about their patients with GPs, so even many GPs are unaware which of their patients are HIV positive.
PKB is also working with a pharmacy chain that is using the system for medication review. Patients can consent to share their records with the pharmacist, but also to stop that access whenever they like. It is being used in secondary care by institutions such as Great Ormond Street Hospital and South Devon Healthcare NHS Foundation Trust.
A number of other groups, such as social workers, patient charities and pharmaceutical companies running clinical trials are ‘locked out’ under the current system. But patients are keen to give many of these groups access to their records, says Dr Al-Ubaydli. He believes that a top-down approach calling for GP records to be integrated with pharmacists’ is ‘flat impossible’ because of the privacy requirements, however. This type of approach has failed in every other country where it’s been tried. Although PKB is currently the only patient- held system available, Dr Al-Ubaydli hopes that other companies will develop patient-held options. As long as patients control the data and anybody can use it, the various systems should not clash, he says.
Record sharing is not difficult from a technological aspect, says Mr Driver. In fact Cegedim, through its sister company INPS, is a partner in the Healthcare Gateway, which has already developed the Medical Interoperability Gateway (MIG) that allows GPs and other clinicians to share a patient’s records. ‘This is a political hot potato, not a technical one,’ he says.
It is ‘essential’ that pharmacists have this access if they are to take on more clinical roles, says Heidi Wright, RPS practice and policy lead. It will also allow the profession to play a bigger role in the delivery of unscheduled care. ‘Access to the patient’s health record, with their consent, will allow pharmacists to make more informed clinical decisions, in partnership with patients and GPs, about the pharmaceutical care of the patient. It will improve medicines safety and adherence and help address some of the drug bill inefficiencies which currently exist within the NHS.’
PSNC has discussed the subject with MPs while giving evidence to the Health Select Committee. Alastair Buxton, its head of NHS Services, told politicians that the advantages of pharmacists’ contribution to medicines management, public health and other clinical services would only be fully realised if they could share information about the services they are delivering securely with other healthcare professionals.
Of course, patient consent and confidentiality are the main issues to consider when it comes to record sharing. The Royal College of GPs published guidance earlier this year, ‘Patient Online: The Road Map’, highlighting the information governance issues. ‘It all boils down to patient consent, respecting patient confidentiality and developing a workable system that is safe for patients and helps them to manage their own health,’ says Dr Imran Rafi, Chair of the RCGP Clinical Innovation and Research Centre. ‘There will be patients who do want their pharmacist to access their records, and patients who don’t, but it’s important to stress that the patient will be able to choose and that only limited information will be available to community pharmacy staff.’
Adequate IT systems will need to be in place in order to allow partial – not full – patient records, such as allergy status, to be safely accessed online by pharmacists, says Dr Rafi. It is also important that patient permission is granted for other members of the pharmacy team, such as technicians, to access their records.
Pharmacists using Rx Systems’ software, including Proscript and AAH Link, will be among the first to access GP-held records. In the first quarter of 2014, probably February, provided there is the appropriate GP and patient consent, these pharmacists will have access to a limited data set via Rx Systems’ secure connectivity from GP practices that use EMIS software. Accessible data will include prescribed medicines, drug allergies and limited information around blood pressure readings.
Pharmacist access will be reliant on consent from both GP and patient, but will also depend on geography because they can only access records kept on EMIS software. This connection has been made possible because Rx Systems is part of the EMIS group. But, with around 4,700 pharmacy customers and about 50 per cent of the GP market, Rx Systems’ managing director Ian Taylor is confident that this new service could potentially be available to a ‘significant percentage of the pharmacy population’.
Records are neither the GP’s nor the pharmacist’s – they are the patient’s records
Records access is going to be part of a ‘bundle of services’ that Rx Systems will be supporting. Its repeat prescription request system will be rolled out at the same time, enabling pharmacists to put repeat requests directly into the GP system. These facilities will be all about GPs and pharmacists working together, so GPs must want to work with their local pharmacy. Some GPs may allow the repeat prescription request function but not access to patient records, for example.
‘It’s very important that we do this in the correct manner. I think there needs to be a bit more work done by the professions on how they can support the patient together. Of the GPs we’ve spoken to – there are areas where they’re extremely supportive of this. Some people will be hesitant, but others are fully embracing this.’
Mr Taylor predicts that these IT links will become more widespread as pharmacists and GPs become more used to working together and are an important element of service development. ‘We will not be able to embrace more of a service agenda without service providers being able to share information.’
And that sharing of information between primary and secondary care will be made easier by EMIS’s recent purchase of Ascribe, the hospital pharmacy software supplier used by 75 per cent of NHS secondary care organisations.
As part of this, the company is considering how to make discharge summary information available to community pharmacies. ‘From a pharmacy profession’s perspective there will need to be something more structured. But as a system provider we are keen to move the agenda on at a faster pace than the profession are doing.’
Pharmacy software systems are fundamentally focused on prescription fulfilment and from this perspective there’s ‘not a massive difference’ between existing systems, says Mr Taylor. But the wider connectivity required for pharmacists to embrace more services will be difficult to implement unless they come under a large stakeholder umbrella. So, while EMIS has a foothold in GP practices, pharmacy (through Rx Systems) and now secondary care via Ascribe, Cegedim owns INPS, supplier of GPs’ Vision software.
Organisations such as EMIS and Cegedim are driving this connectivity, with no other large-scale method of linking systems currently available. Pharmacy’s connection to the NHS, for example, is driven through the NHS Spine, which was designed for electronic prescriptions and the profession has not driven forward a broader reason for interconnectivity. Systems suppliers that are not in this type of partnership arrangement will fall behind, warns Mr Taylor. In terms of sharing information between pharmacies, the profession could use the same MIG as GPs, suggests Mr Taylor.
Not everybody thinks pharmacists should have access to patient records. An online discussion on the GP website, Pulse, threw up the following comments from both doctors and patients:
John D’Arcy, managing director of Numark, is confident that pharmacists will achieve widespread access and that it will improve patient care. ‘There’s a compelling case saying that you can help patients better if you know what’s wrong with them.’ Ministerial approval is often the first step towards implementing such initiatives. And now that has been granted, it is up to the profession to drive it forward, says Mr D’Arcy.
Questions remain about how much information pharmacists should have access to, because much will not be relevant and some patients will not want to share all their records. And while pharmacists already have a general understanding around confidentiality and information governance, it is clear that ethical guidelines will need to be agreed, says Mr D’Arcy.
Widespread access is likely to take some time, but this will allow time to resolve the practical and governance issues. ‘You don’t get something without there being a downside or extra governance requirements. The price of progress tends to be greater admin.’
Issues such as data security all point to the fact that pharmacies need to have ‘as a given’ a robust IT system. ‘Pharmacists need to recognise that they’re sitting on a goldmine in terms of information. When EPS comes in, if your IT system fails, you’re out of a job.’
As well as read patient records, pharmacists should be able to input information, which would keep them in the ‘information loop’ with other healthcare professionals involved in a patient’s care, says Mimi Lau, Numark’s director of pharmacy services. They could input information such as blood pressure measurements and flu vaccination details. Any concerns over information governance and patient consent should not be seen as a barrier. ‘Pharmacists have already got good processes and governance procedures in place which can be extended where necessary.’
Patient-held health records may sound good in terms of patient empowerment and choice, but there will be challenges around how freely accessible the information is to those who are elderly or vulnerable, how the patient reads and interprets the medical information without causing alarm, and the security of the information, says Ms Lau. Patients have been able to read their records since the 1990s but very few choose to do so. ‘Maybe that’s a telling message that this is not what the majority of patients want!’