A hazard identification approach was used in this report. It was not intended to be comprehensive or to allocate levels of risk, but to draw attention to these hazards in order that they can be discussed more widely, and their inherent risks better mitigated.
The themes which come out in the hazards are as follows.
Many of them rely on education and training of the users to mitigate the risk. Generally, there was felt to be lack of education - and of educational resources & best practice agreement on the use of EPRs and that this needed to be addressed at all levels of medical and other user education. It was also felt that where there was training in the use of clinical systems it was often only at the deployment of the software or induction of new users and restricted to use of the software, not its use to enhance patient care, and was not followed up on a regular basis to enable users to enhance their use of the tools.
Better and more thorough training would mitigate the issues around terminology, using the structure of records correctly and curation of the records to maintain high quality, as well as issues around the use of third-party data and appropriate access to and use of safeguarding information.
The design of shared care records. Ensuring high levels of usability by involving users in the design and ensuring it supports the workflow will lead to better quality use of the systems. There are issues around specific data types and how they are managed, such as safeguarding data, and legal data, including subjects such as retention dates. Taking these into account in the design of Shared Care Records is vital, as is ensuring the context and provenance of the data is preserved to ensure that the data becomes usable information. Given the variance in data structure in contributing systems this is a challenge, but it is essential to make sure that the record can be viewed from a variety of aspects, such as a problem list or an encounter view and not just as a flat list under section headings. Where possible all the relationship links of a data item should be preserved, and the data viewed in the same structure as the contributing system.
For shared records to make sense de-duplication of data items needs to take place. But it was felt to be important that where this had occurred the fact was obvious and the discounted data items could be seen if required, to retain the integrity of the record.
In a socio-technical model these design issues are the "Informatics layer", the level where it is agreed how things will behave and how data is stored and accessed.
The "Conversational Layer" in this model is around agreeing the processes and how they will be used. Several of the hazards above can only be mitigated by ensuring this is undertaken. A solution to this would be for shared record systems to have an executive group who can gain agreement from users on how the system will be used. They should own the ultimate risk. This would enable issues around responsibility for care, hand overs of care, for prescribing, and record curation to be clarified, as well as issues where data was disputed or felt to be erroneous.
The top layer of the model is around socio-cultural matters. These are issues outside the systems themselves, such as the data governance laws. But it could also be seen as concerns that need to be dealt with once, subject to ongoing scrutiny and /or action by the professions. Getting education into the training curriculums, providing input into creating, monitoring, and maintaining the necessary standards and providing on-going training in keeping high quality EPRs cannot be addressed at system level only and need a national approach. Taking a high-level view of the data models needed in clinical systems to serve the new purpose of sharing data would also mitigate several of the hazards arising from the different data structures in/ of contributing care record systems.
The PHCCSG recognizes the huge benefits to patient care of having comprehensive and up to date information about them and their care, and the roles of shared care records in achieving this.
This report highlights problems which we have been talking in creating and managing shared records and suggests proposals that the Group believe would mitigate them. The group has been discussing many of them since 2008.
We would like to see this report used as the basis for a safety case to justify the work needed to resolve them. However, some of the most serious hazards - for example the lack of education in record keeping, and agreement about clinical behaviour in certain situations - need urgent resolution at a professional level, to create norms for the use of all shared records.