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ANNEX F - NHSSCOTLAND PERSONAL HEALTH RECORDS MANAGEMENT STRATEGY FOR NHS BOARDS

Please note - this annex was developed by a subgroup of The Health Records Forum, and has been the subject of a recent consultation. It has been included in this overarching Code of Practice to provide further advice and support to NHS Boards in the development of their local health record strategy. It is recognised by the Scottish Government eHealth directorate as a useful tool for Boards in helping them meet their records management obligations.

1. Introduction

This document directs the principles and practice for managing health records at the Health Board. The organisation uses a hybrid of computer and paper records to support patient processes. This strategy sets out how all patient records will be managed and replaces and supersedes any previous health records management strategies.

Health records management falls within the remit of the health records service. The aim of the health records service is to ensure that procedures are in place to bring together the health professional and accurate, relevant patient information/documentation at the correct time and place to support patient care. The service comprises of 6 main elements:

• control and maintenance of patient appointment systems;
• initiation, retention, safekeeping and production of patients' records;
• registration and recording of all patient encounters;
• compilation, validation and submission of all Scottish Morbidity Records and statistical returns;
• provision of an administrative service to respond to medico-legal and data requests made under the relevant "Acts";
• provision of clerical, administrative and reception services to support clinicians in the delivery of clinical care.

Records management is a key component of the health records service.

The strategy details the aims, aspirations and targets of what we aim to achieve with our health records management programmes. It provides direction for what we want to achieve within the organisation and also defines what resources are required in future to deliver effective records management programmes.

Records management is the field of management responsible for the efficient and systematic control of the creation, storage, retrieval, maintenance, use and disposal of health records, including processes for capturing and maintaining evidence.

Proper management of information and a strong records management programme requires adequate resources: sufficient funding, facilities, technologies and knowledgeable experienced people. Consideration of health records management principles requires timely inclusion into service objectives, plans and developments to ensure appropriate resource allocation and implementation of good practice.

The strategy is based on the requirements of the Scottish Government Records Management NHS Code of Practice (Scotland). This document covers management of all types of NHS health records throughout their lifecycle, from their creation and use to their final disposal.

This strategy also takes into account the recommendations and standards set by:

• Public Records (Scotland) Act 1937;
• Medical Reports Act 1988;
• The Computer Misuse Act 1990;
• Access to Health Records Act 1990;
• Data Protection Act 1998;
• Human Rights Act 2000;
• Quality Improvement Scotland - Standards for Record Keeping;
• Scottish Government Records Management NHS Code of Practice (Scotland);
• Scottish Government Health Department (Health Department Letters, Circulars and Policies);
• Patient Records and Information Management Accreditation Programme ( PRIMAP);
• Information Governance Standards;
• National eHealth Strategy;
• ISD Data Definitions and Standards.

The strategy will be updated to include future developments such as new health records management guidance or changes in legislation as necessary.

The Health Records Management Strategy should be read in conjunction with the Health Records Management Policy.

2. Scope

2.1. This strategy relates to all clinical operational records held in any format by the Health Board as set out in The Management Retention and Disposal of Personal Health Records.

• within the strategy the terms 'Health Record', 'Patient Record' and 'Case record' are synonymous and includes:
  • records created and maintained by all health care professionals
  • records for all specialties
  • records for private patients treated on NHS premises

2.2. Health Records may be held in many formats, for example:

• paper records, reports, diaries and registers etc;
• electronic records;
• x-rays and other images;
• microform ( i.e. microfiche and microfilm);
• audio and video tapes.

3. Aims

The aims of the Health Board Health Records Management Strategy is to ensure:

• a systematic and planned approach to health records management covering health records from creation to disposal;
• efficiency and best value through improvements in the quality and flow of information, and greater co-ordination of health records and storage systems;
• compliance with statutory requirements;
• awareness of the importance of health records management and the need for responsibility and accountability at all levels;
• appropriate archiving of non current health records.

4. Key Elements

The Health Records Management Strategy comprises the following key elements:

4.1. Responsibility and Accountability

The Chief Executive has overall accountability for ensuring that Health Records management operates correctly/legally within the Board. The Chief Executive may delegate responsibility for management and organisation of health records services to the Chief Operating Executive who is responsible for ensuring appropriate mechanisms are in place to support service delivery and continuity.

The Head of Health Records Services/Senior Health Records Manager has strategic and operational accountability for the creation, retrieval, storage, archiving and disposal of all health records within the Board. The Board has in place a documented Health Records Management Policy and supporting documented procedures.

4.2. Quality

The Health Records Management Strategy aims to ensure that policies and procedures are in place to bring together the patient and health professional along with accurate, relevant reliable patient information and documentation at the correct time and place to support effective and safe patient care. The Health Records Management Policy and appendix of policies and procedures provides further detail concerning standards for the management of health records. Health records are managed in accordance with the recommendations and standards detailed in the introduction of this strategy.

4.3. Management

All health records are subject to the standards and legislation detailed at the Introduction of this document and the Board is responsible for ensuring that health records are managed accordingly. The Board has a detailed inventory providing details of the location and current status of all health record types. The Health Records Management Policy details procedures for the storage, retrieval, archiving and disposal of each record type. This procedure is in accordance with the minimum retention periods detailed in the Scottish Government Records Management NHS Code of Practice (Scotland). The Board is responsible for ensuring that adequate resources are made available to support effective records management, including making adequate provision for records growth and technological developments which enable records to be stored or transferred to other media.

4.4. Security

The Board provides systems which maintain appropriate confidentiality, security and integrity for all health records including their storage and use.

Health records in any form are highly confidential documents. The Board is responsible for ensuring that adequate physical controls are put in place to ensure the security and confidentiality of all patient identifiable information, whether held manually or computer. Policies and procedures can be found in the Boards Information Security Policy and local departmental procedures.

4.5. Access

Access to all patient identifiable information is on a strict need to know basis in accordance with the Caldicott principles, Data Protection Act 1998 , Information Governance Standards and various codes of professional conduct. Polices and procedures governing access to patient identifiable information are in accordance with these principles.

4.6. Legislation

Health records and associated clinical information are released to patients, their representatives and legal bodies in accordance with relevant and current legislation. The Head of Health Records Services /Senior Health Records Manager is responsible for the processing and release of clinical information in accordance with documented procedures.

4.7. Audit

This Health Records Management Strategy will be audited on a bi-annual basis for compliance against the actions outlined within the Health Records Management Policy.

4.8. Training

As the volume and complexity of clinical information increases, we demand the highest standards of probity in the way it is gathered, recorded, stored and transmitted. These requirements are set out in the Introduction of this strategy.

In implementing the strategy, the Board will put in place training and guidance on legal and ethical responsibilities for all NHS staff involved with the creation, maintenance and ongoing management of health records. In addition to complying with legislation, this training will follow the HORUS principles :

• holding information securely and confidentially;
• obtaining information fairly and efficiently;
• recording information accurately and reliably;
• using information effectively and ethically;
• sharing information appropriately and lawfully.

Whenever possible nationally recognised training material which is referenced to appropriate publications will be used.

Ongoing workforce education plays a major part in preparing NHS staff to deliver effective, high quality services. There are numerous reasons for providing education and training in information handling, including maintenance and improvement of services, respect to patients as well as the need to comply with legislation in respect of data collection, storage and use. NHS Education for Scotland and NHS National Services Scotland ( NSS) are working in partnership to develop a framework of educational support for Information Governance. Information Governance in NHS Scotland Planning for Workforce Education (currently in draft) will be a key tool to assist NHS Boards with the planning and implementation of local workforce development initiatives. This document will include an Information Governance competency framework describing the learning outcomes for each of the HORUS standards. Competencies will be grouped into levels Foundation, Intermediate 1, Intermediate 2 and Advanced in order that these can be applied to specific occupations, staff groups, professions etc.

4.9. Development Programme

All health records managers or those with a particular responsibility for the administration and management of health records will be able to access appropriate information and guidance concerning record keeping standards. Whenever possible national standards will be employed to manage all health records throughout the Board. A rolling programme of audit and performance indicators will be developed to enable assessment of individual records system against these standards. An improvement plan will be formulated taking cognisance of the development needs within each of the designated areas.

4.10. Improvement Plan

A documented health records management improvement plan that identifies prioritised activity to support the implementation of the Health Records Management Strategy can be found within (A5) of the Health Records Management Policy. This improvement plan identifies resources (human, financial and organisational) required to ensure that all NHS health records of all types are properly controlled, readily accessible and available for use when required and then eventually archived or disposed of in an appropriate way, regardless of the media on which they are held.

5. National Strategic Direction

'Partnership for Care' states:

"Our goal is to deliver an Integrated Care Record jointly managed by patients and professional NHS staff with in-built security of access governed by patient consent". In addition:

"integrated care records will take time to reach, but each step in their development will bring immediate benefits to patients, carers and health care professionals by enabling:

• service redesign and the shift in the balance of care provided in different settings;
• faster exchange of information between professionals;
• quicker efficient access to patient records for patients and health professionals (with built in patient confidentiality);
• continuous improvement through routine monitoring of quality standards set by external bodies.

The new Scottish Government are due to consult on the priorities for health and wellbeing and will announce their key objectives for the next few years.

Better Health, Better Care announced:

That a revised eHealth Strategy would be published in spring 2008. At time of writing the process of developing this strategy is underway, however the final document following consultation has not yet been agreed by the eHealth Strategy Board. In the meantime there are several relevant sections in the former (draft) Strategy, and these are shown below.

The Electronic Health Record is an electronic and structured set of health information based around an individuals' health and care status and encounters across all healthcare sectors and settings. It is:

• brought together from diverse clinical settings with their individual electronic patient records via a single patient identifier - the Community Health Index ( CHI) number;
• accessible from a wide variety of locations by the patient or care professional, given appropriate security and access rights;
• organised primarily to support continuing, efficient and quality care across the complete patient journey;
• protected by secure profiles which will ensure that access is on a 'need' basis and that the patient is aware of who can see what information;
• secure, with an audit trail of all individuals who have accessed the record and their interactions with it;
• added to both by health professionals and patients themselves;
• a replacement for existing paper records and used as a medico-legal record as well as a health record.

For the short to medium term the goal of EHR will not be achieved by a single all-encompassing software application. Such a product is not available on the market at this time. Our strategy, therefore, is founded on an iterative and incremental approach rather than 'rip and replace'. ' EHR' is an umbrella term used to describe all the clinical information about a patient which is held electronically and which can be brought together from the data repositories maintained by key software applications. EHR will be achieved through incrementally putting in place and connecting the necessary software and ICT infrastructure components.

Currently health records are mainly maintained as paper based documents, however with the progression of eHealth projects and electronic solutions the service will move to a hybrid model of paper based and electronic records both active and passive. Health records staff are critical to the successful delivery of these goals. The challenge of moving from manual to the vision of electronic integrated care records built on modern technology will require the application of the skills and experience of health records practitioners and personnel.

The National eHealth/ IM&T Strategy further states:

"The single patient record is a holistic patient record that is accessible to those who require the information including patients and carers. Currently professional staff in many settings hold fragments of the record, but none have access to the whole record".

The key elements of the eHealth high level plan for a single patient record endorse the move to one patient, one record jointly managed by patients and professional NHS staff with in-built security of access governed by patient consent. Reliable and consistent authentication of patient demographic information is vital when assembling different "fragments" into the same record. The Community Health Index ( CHI) number is the unique patient identifier in all NHS Scotland systems, which will unite patients' records irrespective of where they have been created. Whilst departments currently have a plethora of different hospital numbers which are used to identify manual patient records, the relevance of these will diminish to that of a case record filing number as CHI becomes established throughout all healthcare settings. Work is ongoing across NHS Scotland via the CHI Programme to ensure that the CHI number is ubiquitously used across all sectors of NHS Scotland for patient identification and all clinical communication.

Patient Management System ( PMS)

Currently across NHS Scotland there are multiple Patient Administration Systems ( PAS) employed operationally in secondary and community care. PAS systems are used to administer patient record systems and are pivotal to effective records management in secondary and community hospital environments. All but one existing commercial PAS contract is due to expire between 2008 and 2010. NHS Scotland eHealth Strategy Board has agreed that a national approach should be taken to re-procurement of secondary and community care PAS. An outline business case has been prepared and circulated to Boards for consideration.

Features of the solution will include provision of 24/7 core PAS business functionality:

• patient identification;
• electronic referrals workflow management;
• scheduling;
• bed management;
• case record tracking;
• clinic attendances and in-patient management;
• document production;
• clinical coding;
• management reporting tools.

In addition the required solution is expected to include:

• integration with order communication and results reporting;
• integration with HEPMA electronic drugs prescribing, medicines administration and pharmacy modules;
• integrate with or interface to a number of other clinical modules;
• provision of facilities to users of locally and nationally managed accredited business systems;
• conformance to interoperability and data standards;
• future interface with IPACC ( e.g. primary health care record, scheduling, mental health).

Clearly the move to a single patient management system across Scotland will provide the foundation for the creation of a national electronic patient record through the authentication of patient demographic data and records linkage.

6. Review

This strategy will be reviewed every two years (or sooner if new legislation, codes of practice or national standards are to be introduced).

The Scottish Health Records Forum acknowledges the effort of the sub-group in drafting this strategy for use across NHS Scotland. It is hoped the document will provide a framework which can be customised for use at individual NHS Board level.

Mr Robert H Bryden, NHS Ayrshire & Arran (Chair)
Miss May McConnell, NHS Ayrshire & Arran
Mrs Marilyn Horne, NHS Glasgow & Clyde
Ms Dorothy Ireland, NHS Forth Valley
Ms Elizabeth Lothian, NHS Forth Valley

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