BMJ Feature: Flipping the model for access to patient records

Lots of questions are being asked about NHS England’s initial promise back in 2012 to make full medical records accessible online to patients. The project has since slowed down and the NHS is carefully evaluating the best way forward. This article featured in The BMJ describes where the NHS is now but also in contrast looks at how Patients Know Best, which is a private company that is providing patient-controlled medical records, has been successful in partnering with NHS Trusts and providing patients with digital medical records. The success is best described by “flipping the model for access to patient records.”

Mohammad Al-Ubaydli, PKB CEO:

When you digitise [medical records] this happens by institution: first via GP practices, then the laggards— which is the hospitals—but each just takes care of its internal silo and forgets the patient. Patients usually don’t go through the neatly organised care route that the government has created for them—they may go to a private GP in London, then a supermarket pharmacist in Surrey, then a hospital in Cheshire, then have a Marie Curie nurse visit.

So you can say: ‘let’s have a central database’ or you can say ‘what’s the common theme here?’ Well, it’s the patient, so why don’t we follow the patient and not the institutions.

The full article can be found here.

Flipping the model for access to patient records

By Ben Adams freelance healthcare journalist, Chichester, UK

Lack of progress in NHS England’s efforts to provide universal access to medical records has led to the development of independent initiatives, reports Ben Adams

In 2012, amid growing pressure for patients to be allowed to participate more in their own care, NHS England promised to make full medical records available to patients in an easy, online format by 2018. But four years on, little progress has been made. Some patients can now register with their GPs to look at their records online but they find only partial information.

Yet while the NHS has struggled to overcome issues of confidentiality and security as well as technological challenges, a small and nimble company has jumped into the void. Patients Know Best, which was set up in 2009, has created a simple online tool that relies on patients to pull together all the health information that they and their carers need to see. Initially designed for patients with complex medical conditions, Patients Know Best reports that it is now the patient record system of choice for 60 NHS organisations, including leading hospitals such as Great Ormond Street.

With the threat of competition, can NHS England still deliver on its promise to provide a universal medical record system that people can trust? Or will the job ultimately be done by patients using their phones and tablets and technology designed and run by organisations the NHS does not control?

Why has the NHS failed so far?

Since its launch in 2012, care.data, the project to overhaul NHS England’s information technology and infrastructure has run into myriad problems and embarrassments,1 including concerns among patients and GPs about confidentiality 2 and security. It has also struggled to identify IT systems that could cope with the complexity of the NHS, the largest employer in Europe with over 1.3 million staff.3

The project became so embroiled that last September the government announced a review. The man in charge of care.data, Tim Kelsey, has since left his position as NHS England’s national information director and his replacement has yet to be appointed. The findings of the review, led by Fiona Caldicott, the national data guardian for health and care, are expected to be published shortly.

A spokesperson for NHS England told The BMJ that there was now no end date for the care.data programme: “We have not committed to artificial timescales as we want to get this right for patients and continue with our preparations,” she said. However, she added, “We have committed to giving patients full access to their entire digital health record in real time by 2018”—this is separate from the main care.data programme, which aims to upload data from GP records to a national database for access across all NHS institutions.

But in practical terms, opening up medical records depends on general practices making it happen, and their progress in this has varied enormously across the country. Some practices have been working to make patient records even more accessible than required by current schedules for care.data (box). Others have barely informed their patients that they can now register to see their records. There is also little in the way of punitive action for practices that don’t comply.

Patients who ask for access currently have to be given only a summary of their records with most elements coded. The summaries exclude letters, documents, and free text entries, and how far the information dates back depends on how much data practices have managed to upload.

Under schedules set out by care.data, more detailed (but still coded) medical records— including diagnoses, symptoms, and test results—should be made available by April of this year, but the review may push this deadline back.4

Many GPs have misgivings about opening up medical records to patients. Some have expressed concern that this could cause undue anguish for patients, misunderstandings, or additional work for GPs dealing with queries or complaints from patients about what they have read.

Patients Know Best

Patients Know Best has meanwhile forged ahead in this area by putting patients at the heart of the process. The business has been working with NHS trusts to obtain agreement for patients to access their medical records through its platform, using a secure code. What patients see looks much like Facebook, with a wall showing a list of current medications and other data and messages from doctors or nurses to view. Patients can invite other healthcare professionals, carers, and family members to join and input information or comments; they can also remove people from the group if they no longer want them to have access.

The project was founded by Mohammad Al-Ubaydli, who says he created the business because he has a long term illness and found managing his complex care difficult without him, his family, and his doctors all having easy access to his records.

The company began by focusing on records for patients with specific diseases in hospitals but now works with patients across England and eight other countries. The numbers of patients using the PKB platform is difficult to assess, the company says, but more than 30 NHS trusts (out of the 220 total) are using it in some form across 60 sites in the UK, including some general practices.5 Trusts have to pay to use the service but it is free for patients.

The company’s approach is diametrically opposed to that of NHS England, which started by trying to allow access to nearly all the 53 million people living in England in its first two years but has ended up drip feeding limited data in a phased roll-out.

Al-Ubaydli says: “When you digitise [medical records] this happens by institution: first via GP practices, then the laggards— which is the hospitals—but each just takes care of its internal silo and forgets the patient. Patients usually don’t go through the neatly organised care route that the government has created for them—they may go to a private GP in London, then a supermarket pharmacist in Surrey, then a hospital in Cheshire, then have a Marie Curie nurse visit.

“So you can say: ‘let’s have a central database’ or you can say ‘what’s the common theme here?’ Well, it’s the patient, so why don’t we follow the patient and not the institutions.”

Patients Knows Best will also allow third parties to have access to patients’ medical records if the patient consents. “In our partnership with [the charity] Cancer Research UK, patients can consent to open up their data to both CRUK and its research partners,” he explains. “They would consent the patients to use this for enrollment in clinical trials and for big data applications.” Although only focusing on charity deals so far, Al-Ubaydli says drug and insurance companies are asking for the same opportunities to access records.

Al-Ubaydli says he could envisage working with NHS England in future but the NHS England spokesperson had not heard of Patients Know Best and therefore did not want to comment on compatibility.

Will patients benefit?

There is no formal research on whether open electronic health records create better patient outcomes in the UK. Patients’ views vary on how useful they are.

Marilyn, a 66 year old patient from Manchester, says that when she first signed up with her GP to see her records online, she didn’t have any major conditions or diseases. “I just wanted to make myself familiar with the process. One thing I did do, however, was to look up some test results; I then researched them and understood what they meant and then had a very constructive conversation with my doctor about them. I now don’t take a certain medicine I was taking prior to this as my results were borderline, but both myself and my GP thought this was the best decision.”

An anonymous patient from London who has been diagnosed with health anxiety and clinical depression said having access to his health records caused more harm than good. I now can’t help but look at medical records every day and research every detail I see in case something has been missed” he told The BMJ.

Keeping the focus on the patient is what GPs are keen to do when it comes to opening medical records. Amir Hannan is a general practitioner in the practice in Hyde, Greater Manchester, where the serial killer Harold Shipman worked. He began creating a website designed to help his local patients gain access online in 2007, long before the concept of care.data, in the hope it would help rebuild trust among those registered at the practice.6

He tells The BMJ that having a complicated and confusing system like care.data imposed on patients—among other things, it puts the onus on people to opt out, rather than asking them to opt in after educating them about the programme—was a poor decision by NHS England.

He also argues that giving every patient complete access to their medical records is not necessarily going to create better outcomes for everyone, especially those with anxiety or who do not speak English as a first language.

“The government thinks everyone just wants access to data—that data are the answer to care. But you need data plus knowledge to gain understanding, and this comes with the need for better health literacy and, most importantly, trust between a patient and their GP.

“This is why I ask patients who want to look at their electronic patient records at my practice to fill in a short survey7 beforehand in order to assess how they will deal with this information.”

So far 5155 (43%) of his practice’s patients have access to their electronic health record.8 This compares with 1262 (11%) patients who said they wanted to opt out of the future care.data programme in May 2014.9

Notes

Cite this as: BMJ 2016;352:i722

Footnotes

Competing interests: I have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.
Provenance and peer review: Commissioned; not externally peer reviewed.