Your electronic health record

Please read this resource carefully. It will give you information about how your data is shared for the purposes of direct patient care.

Today, electronic records are kept in most of the places where you receive healthcare, for example at your GP surgery or out of hours clinic.

This care service uses the clinical computer system SystmOne, which enables your full electronic record to be shared to anyone involved in your direct care, across different healthcare services. A full list of the care services that use SystmOne is below.

You have choices about whether or not your information is available to other providers who care for you.

Why is sharing my health information important?

Your electronic health record contains lots of information about you, including your medical history, the types of medication you take, any allergies you have and demographic information like your home address and your next of kin.

In many cases, particularly for patients with complex conditions, the shared record plays a vital role in delivering the best care. Health and social care professionals can ensure a coordinated care response, taking into account all aspects of a person’s physical and mental health.

Whilst some patients have extensive knowledge of their conditions and care requirements, this is not true for everyone. Many patients are understandably not able to provide a full account of their care. The shared record means patients do not have to repeat their medical histories at every care services, or make guesses about their previous care.

A shared record ensures care providers always have the most accurate, up to date information. They can rely on their colleagues, sharing accurate and relevant data in a timely way, to provide you with safe and efficient care.

Which care services could I go to that could access my patient record?

• GP practices
• Community services such as district nurses, rehabilitation centres, telehealth and diabetes services
• Child health services that undertake scheduling of treatments such as vaccinations
• Urgent care organisations such as Minor Injury Units and Out of Hours  services
• Community hospitals
• Palliative care hospices and community services
• Offender health – care providers within the health units
• NHS Mental health trusts
• NHS Hospital trusts
• Accident and Emergency departments
• Care Homes
• Pharmacy
• Social Care – registered and regulated professionals within social care organisations coordinating care (not social care providers)

If you would like more information on how your data is shared please talk to your healthcare professional.

Sharing your record

To provide the best care, we want to be able to share your electronic health record to other services involved in your care. In order to do this we will ask your permission. If you give your permission then the information recorded will be available for other organisations to view.

Until you are registered for care at one of the care services on the previous page, no information from your record will be shared to them.

If you do not want your information to be shared, you can ask your care professional for this option to be switched off. This will mean none of the information recorded here will be visible at any other care service. The only exceptions where your data can still be accessed are:

• When you visit another care service, you give your permission to override your previous dissent, allowing them to view your record including any items marked as private.
• If your clinician has concerns regarding your wellbeing related to safeguarding, for example concerns about domestic abuse.

If you would prefer that the override option is never made available, you have the ability to request that this is prevented. However, this means your data will never be available at other care services.

Can I choose what is made available?

To give you the most personalised care, it is recommended that you share your whole patient record with every service that cares for you. However, you have control over your record and have the choice to specify specific elements of the record you don’t want to be shared.

For example, if you have had a consultation about a particularly sensitive matter, you can ask for this section of the record to be marked as private. That way, even if you consent for another service to see your record, that consultation will not be shown. If the consent override option above is used, then consultations marked as private will be accessible.

What choices do I have?

When thinking about how your information is shared, you as the patient can specify 3 main controls:

• Do you enable your record to be shared at all? If you have said ‘yes’ to sharing out from this organisation, for every care setting you visit you still get to decide if they can view your record. You do not have to make the same choice for every organisation.
• You can specify entries in your record that you want to remain confidential. These can only be viewed by the care service they were originally recorded at (unless the consent override is used for the reasons stated above). You can then decide if the rest of your record is shared at each care setting you visit.
• Saying ‘no’ at this stage means no other care service can see any of your record. If you do not want your record to ever be viewed by anyone you have a further choice to request that consent override is prevented.

Providing consent to view

When you start receiving care from a care service (that uses SystmOne), you have the right to either agree or disagree that they may view your SystmOne record. The health or social care professional seeing you should ask your permission for them to view your electronic record.

If you answer yes: That care service will be able to view information recorded on your electronic record by other care services (excluding any data you have requested to keep private (see below)).

If you answer no: That care service will not be able to see any information recorded anywhere else (even if your record has been set to share from any other care services). As a patient, you have control over who can see your health information. Even if you give permission on one occasion, you can still change this at any time.