Curiously, there is no comment or guidance on the lab's position. Can we
stop printing and issuing paper reports if requested to do so by GP
surgeries?

Chan Seem
Chemical Pathologist

	-----Original Message-----
	From:	Jonathan Kay
[SMTP:[log in to unmask]]
	Sent:	23 May 2000 11:42
	To:	[log in to unmask]
	Subject:	Paper reports and computer communications

	I previously posted a note about the need for paper reports.
I've had a
	reply from Nigel Bell, Chief Executive of the NHS Information
Authority.

	Comments please.

	Dr Jonathan Kay
	Chairman, Standing Committee on Informatics, Royal College of
	Pathologists

	......................

	Nigel Bell wrote:


	Colleagues in the Information Policy Unit have provided me with
the
	following guidance on the status of electronic reports from
laboratories
	to clinicians:
	"The GP terms of service as set out in paragraph 36 of Schedule
2 to the
	NHS (General Medical Services) Regulations 1992 requires that
the
	medical records of a patient should be kept on forms provided
for the
	purpose by the health authority.

	That paragraph further requires that this record is an adequate
record
	of the illnesses and treatment of patients.

	To remain strictly within this regulation the computer records
should
	consist only of a duplicate of the medical record plus any
additional
	information that the doctor wishes to store which he believes is
beyond
	the scope of the record required by his terms of service.

	It is known that some GPs rely more extensively on computer
based
	records.

	The Department is in consultation with the GPC to legitimise the
	practice of maintaining electronic patient records. Draft
regulations
	have been prepared which would allow those GPs who wished to
keep
	electronic patient records to do so. However, conditions would
be
	applied the principal ones being discussed with the GPC are:-

	- Health authority permission is required;
	- The computer system to be used must be accredited to RFA99
standards;
	- The audit trail facilities must be enabled;
	- The health authority must be given access to the audit trail
on
	request.

	In addition it is proposed that it would be a breach of the
revised
	terms of service to disable or attempt to disable the audit
trail.

	Our discussions with the GPC are ongoing and no agreement has
yet been
	reached on introducing this amendment to the terms of service.
Their
	main objection is that to gain business benefits from this
change
	requires the separate ability to transfer the record
electronically from
	GP to GP, NHS standards for this type of electronic interchange
do not
	exist.

	Scottish regulations have already been changed to allow GPs to
maintain
	electronic patient records with the agreement of the Scottish
GPC. Their
	resolution is very similar to the proposals put to the GPC in
England."


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