ࡱ> @B;<=>? bjbj qhhzF,P P 8 ||a(dl8|||||||~5 | t"  ||""" j|" |""ry L4r |uHx||0|u?H!?yyP?(zP  "     ||H"   |    ?         P Y:  PRIMARY CARE DEVELOPMENT 4.1.3 ENHANCED SERVICES SPECIFICATION FOR INFORMATION MANAGEMENT AND TECHNOLOGY 1 SERVICE OUTLINE 1.1 This Directed Enhanced Service (DES) is designed to facilitate Information Management and Technology (IM&T) adoption to support the delivery of the National Programme for Information Technology (IT). It requires Primary Care Trusts to pay providers specified, non-recurring payments following successful preparation for and adoption of IT systems and processes. There will be variations in the timing of roll out of these systems across the country. 1.2 This enhanced service has been extended for a further year into 2008/09 to allow for the work on the outstanding components to be completed. Providers were required to complete the first element of this two year DES during 2006/07 to remain eligible for payment for the remaining components. 2 SERVICES AIMS 2.1 This DES will support providers to become properly equipped for the innovative new Information Technology approaches to patient service delivery. This will include: active implementation of the key national initiatives outlined above ensuring that all provider staff, clinical and non-clinical, receive adequate training to equip them to adopt new methods and systems; and that staff receive sufficient skills development to ensure that the provider can function effectively in the new IT-intensive environment that will prevail in primary care recognition of and resources for the successful installation and implementation of new technologies. Providers will benefit from increased efficiency once these programmes are embedded in the provider, but it is recognised that the initial installation and training has workload implications provision of adequate support to ensure smooth service delivery during installation of new systems and the providers adaptation to new ways of working accreditation of the quality of the electronic record keeping of providers which record their consultations in the surgery setting contemporaneously through their computer systems, otherwise termed paper-light. Appendix 1 provides a copy of the Primary Care Trust paper-light accreditation process 3 SERVICE REQUIRMENTS 3.1 The timing of deployments of programmes across the country will vary depending on the state of readiness of providers and the development of the programmes in those localities. The DES payments will reflect these variations and be made available when the deployment takes place. See Section 9 for more details on payment. 3.2 The elements below are key to successful implementation of the overall programme and the DES provides providers with a contribution to supporting the costs of them: protected time for team members to attend training tailored to their needs and ensure that the provider meets Information Governance, data quality and system operation standards. This does not include the direct costs of the facilitator staff provided by the Primary Care Trust whose training is provided free by the NHS Connecting for Health contract Primis + protected time for new team members, especially clinical, to be inducted to meet the providers information standards time for provider staff to undertake necessary additional work in order to ensure safe and effective implementation provision of additional clinical and non-clinical support to ensure efficient service when providers are learning how to use each new technology to best effect recognition of any adjustments to skill mix that may be required due to the higher technology environment 4 MEASUREMENT OF STANDARDS 4.1 There will be a three part process of accreditation: When a provider applies for accreditation it will submit a plan that includes the suggested letter in Appendix 5 of the Good Practice Guidelines. It will submit evidence of protocols and audits in support of the standards described above A quantitative analysis of provider data will look at a number of areas. Searches are defined with PRIMIS+ CHART to help identify providers whose recording is substandard A visit will be arranged by a team from the Primary Care Trust to accredit the provider. The visit will do qualitative checks of a cross section of notes from every clinician who consults on a regular basis. The team will also explore areas it has identified in the evidence submitted by the provider in its application Accreditation will normally last for three years but the team will be able to give a shorter time of approval if they feel that it is more appropriate due to the special circumstances within the provider 5 BACKGROUND 5.1 NHS Connecting for Health (CfH) is the agency delivering key Department of Health priorities in the National Programme for IT. It is tasked with providing new IT facilities for the NHS to improve patient care in all parts of the health service, by reducing risks, increasing efficiency and enabling more effective ways of working. 5.2. Among these new IT facilities are a number which will initially have significant impact on the delivery of high quality patient services by General Practitioners (GPs) and their provider teams including: Electronic Prescription Service (EPS) Electronic transfer of GP records (GP2GP) Choose and Book The NHS Care Record Service 5.3 Introducing these systems and services to GP providers will result in benefits and increased efficiencies within provider workflows and business processes. New processes and procedures will support the requirements of data quality, data protection and patient confidentiality, system failure recovery, and systems management. With time, as providers move to paper-light status these processes and procedures will become increasingly vital to the security, stability and safety of clinical care. These changes will result in improved patient care and improved provider efficiency and will enable providers to communicate electronic patient information with other parts of the NHS for the direct benefit of their patients and their provider organisation. 6 COMPONENT ONE 6.1 Providers will be required to prepare a plan that demonstrates their commitment to the DES which should include: nomination of a provider lead who will liaise with Connecting for Health nomination of a Caldicott Guardian a training needs assessment and linked training plan for each member of the provider team involved with the operation of IT systems evidence of compliance with good information governance practice including clauses on confidentiality in contracts of employment, training, compliance with the Data Protection Act, Computer Misuse Act and Caldicott Guardianship 6.2 In addition providers should: maintain a log of training undertaken by each member of the provider team linked to his or her training needs assessment and personal development plan maintain a log of in-house training events undertaken including induction of new staff, including locums and relief staff and a signing-off process undertake appropriate training and demonstrate proficiency in information governance standards 6.3 All providers are expected to be connected to the N3 network by the end of this DES. Providers are expected to enable the upgrade of the hardware estate to a nationally specified standard as set by Connecting for Health in consultation with the Joint General Practitioners Committee (GPC) and Royal College of General Practitioners (RCGP) IT Committee. 6.4 Every staff member who is to have access to the computer system must be authenticated and registered with a Smartcard and know how to use it. The provider must have a process in place for staff changeover with regard to the Smartcards. This process will be supported by the Primary Care Trust. 7 COMPONENT TWO PREPARATION OF DATA FOR ACCREDITATION 7.1 Providers will be expected to work towards data accreditation in readiness to upload electronic patient summaries to the spine when appropriate. This includes electronic note summarisation. This accreditation will be for paper-light practices and will require a process of reviewable accreditation. The data standards required for this accreditation can be found in Appendix 2. It is not envisaged that providers will be finally uploading data to the spine in 2006/07 other than in pilot providers. It is not intended that detailed discussions with patients about their spine data would occur under this DES. 8 COMPONENT THREE Maintenance of patients addresses with opportunistic regular validation with patients. 8.1 The provider is the sensible location within the health service for the patients addresses to be maintained and validated for accuracy. This will require administrative effort and new workflows to ensure that address changes are processed accurately. It would be expected that providers will validate a patients address and other relevant details at the point of referral and/or when a provider has received information about a patient that contains a conflicting address. Electronic Prescription Services (EPS) 8.2 Providers will prepare for the EPS programme, including accessing training, and identify changes in working practice and amend standard operating procedures. Providers will be required to utilise EPS Release 1 software. Patient information (via practice leaflets etc) on any local changes for prescription collection arrangements should be available. When available and permissible, EPS Release 2 Software should be utilised. 9 PAYMENT SCHEDULE 9.1 Component one: In order to receive an upfront, first component payment, providers will need to agree a provider plan with the Primary Care Trust. This payment acknowledges the commitment and planning the provider will need to invest ahead of programme deployments, and the work required to fulfil all the elements in Sections 6.1 to 6.4 above. This component is worth 40 pence per registered patient. All providers have received this payment. 9.2 Component two: Providers will receive a further payment following data accreditation, as set out in the standards. This component is worth 44 pence per registered patient. All providers have received this payment. If providers do not comply with the requirements or respond to the actions drawn up on the visits then Section 9.5 of this specification will apply. 9.3 Component three: Providers will receive a further payment for successful completion of the requirements set out in Section 8. This component is worth 27pence per registered patient. All providers have received this payment. If providers do not comply with the requirements or respond to the actions drawn up on the visits then Section 9.5 of this specification will apply. 9.4 Component four: Providers will receive a further payment following migration to a Connecting for Health accredited hosted system. This component is worth 22 pence per registered patient. Where providers wish to express an interest in migrating to a hosted system the next steps should be discussed with the Primary Care Trust. 9.5 If a provider has not made reasonable efforts to complete the elements of a component it agreed with the Primary Care Trust to do, the Primary Care Trust may seek repayment of a proportion of the specific component payment relative to the amount of work done by the provider. If a provider has not been able to fully implement a component of this DES due to circumstances beyond its control (e.g. due to national or regional difficulties), the provider should receive a pro-rata payment for the work that they have completed. 10 VALIDATION 10.1 Connecting for Health will provide Primary Care Trusts on a regular basis with electronic evidence of those providers that have successfully deployed each of the programmes. This will enable Primary Care Trusts to make the specified payments to providers upon receipt of individual claims and supporting evidence from providers. 11 REFERENCES 11.1 Paper-light infers a Provider that uses its computer system as the main place it records its patient records. Providers will not be dually recording that information on paper. They will be using the computer system contemporaneously in the consultation and recording their findings according to the standards set out in the Good Practice Guidelines and will be coding their data systematically against standards to be published. 11.2 Good practice guidelines for general practice electronic patient records (version 3.1). Prepared by: The Joint General Practice Information Technology Committee of the General Practitioners Committee and the Royal College of General Practitioners (29July 2005).  HYPERLINK "http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4008657" http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4008657 Information Governance (IG) toolkit submissions via  HYPERLINK "http://www.igt.connectingforhealth.nhs.uk" www.igt.connectingforhealth.nhs.uk accepted as evidence, linked with the IG Statement of Compliance and any necessary action plan. APPENDIX 1 SOMERSET PRIMARY CARE TRUST DIRECTED ENHANCED SERVICE - INFORMATION MANAGEMENT AND TECHNOLOGY PAPERLIGHT ACCREDITATION FOR PRACTICES 1 BACKGROUND 1.1 Increasingly data about patients is being recorded in electronic health records in general practice rather than in the traditional Lloyd George notes. This information is becoming ever more important, especially in light of the development of the National Care Records Service and projects such as electronic GP to GP record transfer. The Information Management and Technology Directed Enhanced Service is aimed at improving the quality of data and to this end a specific requirement is accreditation as a paperlight provider. The General Practitioners Committee have produced a proposal for a generic process for approval and this document is based on the principles established there. 2 REQUIREMENTS FOR GENERAL PRACTITIONERS 2.1 The new terms of service in the new contract do not place any new requirement on GPs to keep anything other than the equivalent of the adequate records they previously kept on paper. The new terms of service do however, require practices to be aware of, and have regard to, the Good Practice Guidelines for General Practice Electronic Patient Records which contains advice about the content of Electronic Patient Records (EPRs). Paperless providers will need to consider whether the true benefits of holding electronic records can be attained without a more structured approach to the content of their records. 3 INITIATING THE PROCESS 3.1 Under ideal circumstances providers wishing to record most of their patient data on the electronic health records as opposed to the paper records would apply for accreditation before starting to do so. 3.2 The reality of the situation is that many of the providers in Somerset are de facto paperlight already. Very few providers are using a dual system of electronic and paper record keeping, although approval through the process outlined here does not preclude doing so. 3.3 Under the circumstances that currently exist, the Primary Care Trust is not concerned specifically with determining the clinical adequacy or content of the patients records. However, it does have a responsibility to ensure that they are being maintained and are secure. 3.4 The Primary Care Trust has identified a Senior Officer who will have responsibility for approving requests to maintain electronic records. This will be the Director of Primary Care Development. 4 APPROVALS PROCESS 4.1 When a provider has determined that it wishes to become paperless, the following process should be followed and the checklist in Annex A should be completed. The provider makes a formal written request to the Primary Care Trust to be paperless. All the partners (PMS and GMS) must sign the application. (See Annex B for the template letter). The request should be sent to the Primary Care IT Co-ordinator, Somerset Primary Care Trust, Ground Floor Mallard Court, Express Park, Bristol Road, Bridgwater, Somerset TA6 4RN. 4.1.2 The designated person at the Primary Care Trust reviews the application. 4.1.3 Where there is no doubt as to the readiness of the provider to become paperless, based upon the information known to the Primary Care Trust and provided in the checklist, approval will be granted. 4.1.4 Where the Primary Care Trust has any doubt as to the readiness of the provider to be paperless, based upon the information about the provider known to the Primary Care Trust and provided in the checklist, the Primary Care Trust will consult the Local Medical Committee. Following consultation, if there is no doubt as to the readiness of the provider to be paperless, approval will be granted. If doubt remains as to the readiness of the provider to become paperless, an accreditation visit should be arranged, to address any concerns. If the Local Medical Committee and Primary Care Trust are satisfied following the accreditation visit, approval will be granted. If the Local Medical Committee and Primary Care Trust are not satisfied following the accreditation visit, the Primary Care Trust should work with the provider to make any necessary changes to enable it to seek approval at a later date (probably not less than six months). 4.1.5 Once approval has been granted, the Primary Care Trust will write confirming approval. The provider should formally acknowledge acceptance, and agree to inform the Primary Care Trust of any future changes that could affect the approval. 4.2 It should be noted that if at anytime after approval has been granted the Primary Care Trust has reasonable concerns as to the providers ability to maintain adequate electronic patient records, the Primary Care Trust should notify the provider and the Local Medical Committee immediately that it is reviewing approval. The Primary Care Trust advises that withdrawal of approval is an extreme course of action. In reviewing approval, the Primary Care Trust should then address its concerns to the provider and Local Medical Committee and proceed as from Section 4.1.4, second bullet point above. 4.3 Paperlight Accreditation approval is granted for period of three years, at which point the provider will need to apply for renewal. This is to ensure that standards around patient records, coding and information security are being maintained in line with local and national developments. ANNEX A CHECKLIST FOR THE PAPERLIGHT ACCREDITATION PROCESS Please complete the checklist below, adding comments for evidence, and completing the tick box when the item is complete. If a provider finds it is not possible or relevant to fulfil one of the criteria, please include reasoning in the comments box or at the end of the checklist. E - Essential D - Desirable 1. Hardware requirements E/DComments1.1. RFA 99 accredited clinical system.E1.2. Support/maintenance agreement in place to ensure maximum availability of the system.E1.3. Workstations in place in all consulting rooms.E1.4. Workstations in place in treatment rooms.E1.5. Workstations in place for administrative staff and community nursing rooms.E1.6. Data storage capacity to meet medium term requirements (12 months) taking into account any increase in demands eg scanning. The provider will have a regular review of capacity to predict level of need.E1.7. Back up media to meet requirements (see 1.6).E1.8. Sufficient number of printers to allow for printing letters and patient records in addition to those needed to print prescriptions. At least one printer to be networked allowing shared access to all users.E1.9. LAN in place to support availability of records throughout the practice.E1.10. Connection to NHSNet expanded to all PCs on LAN and to include branch surgeries. This should be the strategy of the provider.D1.11. All equipment complies with Health and Safety requirements. The practice is to use its Health and Safety Policy and undertake regular reviews. E1.12. UPS on all servers.E1.13. Data rated fire safe for storage of magnetic media on site and/or data stored securely off-site. E1.14. Additional security measures (such as lockable boxes for main processors, core equipment in non-patient areas, etc ).D 2. Incident Management Comments2.1. Formal Procedure established for reporting and investigating suspected or actual breaches of security (To be detailed in Practice Security Policy.) E 3. Control of AssetsComments3.1. Inventory of assets maintained and updated to include copies of software licences. Assets marked as appropriate e.g. number/barcode. To be carried out annually. E3.2. Areas requiring restricted access (e.g. computer rooms, non-public office) are identified and access controls established. E3.3. Where terminal equipment is on view in public areas VDUs are positioned to prevent disclosure of patient data. Viewing of patients own data in consultation permitted (Data Protection Act). The use of flat screens may assist with this issue. E 4. Security Comments4.1. Signed undertaking to have regard to Good Practice Guidelines for General Practice Electronic Patient Records (Document available).E4.2. Data entry restricted to trained and authorised personnel.E4.3. All users have a unique user ID and password. Any third party access to be authorised and recorded (Practice Security Policy). E4.4. System configured to restrict access following a definable number of logon failures (RFA99).E4.5. Password management policy in place. E4.6. Encryption policy in place for transferring patient identifiable information electronically. (part of Information Security policy). D4.7. Risk assessment and management programme in place.E4.8. All passwords changed at frequent intervals with default to a maximum of 90 days.E4.9. All users should use password-protected screensavers. Screensavers should automatically activate within 10 minutes in all public areas.E4.10. All staff must log out of workstation when tasks completed. All new users must log onto system using own User ID and password.E4.11. Clinical System audit trail enabled.E4.12. Information received is filed in the computerised record of the patient to whom it relates. E4.13. All reports/correspondence received from external sources must be viewed by a clinician prior to filing in patient record. E4.14. Amendments to previously entered information are clearly shown. E4.15. Appropriate physical security measures in place to prevent loss or failure of the system. E4.16. Virus checking software installed on the system and configured to automatically update in line with Security Policy. All files/disks/downloads received from external sources should be virus checked. E4.17. One or more member of provider team has sufficient IT competence to deal with minor problems and to liaise with support staff.E4.18. Back ups using systematically labelled media and logs reviewed in accordance with GP Supplier recommendations and GPC Guidelines. A 10 tape strategy is the minimum recommendation; the most robust back up solution is one using 42 tapes. E4.19. All back ups verified by checking integrity of data on a regular basis, minimum six monthly.D4.20. Policy in place for disposal of old equipment and magnetic media (via SHI, under WEEE Directive).E4.21. Approved information security policy held reflecting statutory requirements.E4.22. Practice Disaster Prevention and Recovery Policy to be revised annually using the provider review policy. E4.23. IT users aware of and accept their responsibilities as to security and data ownership. To be included in staff induction and handbook. E4.24. Member of Provider nominated EDI AdministratorE4.25. Member of provider nominated as Information Security ManagerE 5. Record Transfer and Retention Comment5.1. Data Protection registration must be up to date. (The register can be checked on line at www.dpr.gov.uk)E5.2. Information sharing agreements in place where data is exchanged with other organisation E5.3. Patient consent to access data recorded. Health care professionals should be recording in the patients notes that they agree (with possible exemptions) to their information being shared with those that are providing care. (Data Protection Act 1998).E5.4. Copies of all records for patients previously registered are retained and can be printed on request.E5.5. Records relating to patients removed from the list can be printed in full and forwarded to the PPSA (may change to electronic transfer as technology progresses).E 6. Migration Plan Comment6.1. Registration Links in use.E6.2. IOS Links in use.D6.3. Pathology Links enabled. E6.4. Electronic practice appointments system. D6.5. All clinicians have access to the Electronic Patient Record.E 7. Training Comment7.1. IT Security Training and Awareness forms part of the Provider training / Electronic Patient Record Development Plan and staff induction and training. E7.2. Staff with specific security responsibilities to receive task specific training.E7.3. All staff within provider to acquire basic IT competencies with at least one member of the practice team working towards ECDL. All staff responsible for coding to receive Read Code training. D ANNEX B TEMPLATE LETTER TO APPLY FOR PAPERLIGHT ACCREDITATION To: Somerset Primary Care Trust From: Provider Electronic Patient Medical Records in Primary Care I /we the undersigned wish to apply for consent to keep our NHS patient medical records in electronic format. I /we have familiarised myself /ourselves with the new terms of service as specified in the National Health Service (General Medical Services) Amendment (No.4) regulation 2000 SI 2383 and Directions to Health Authorities and Primary Care Trusts concerning the implementation of pilot Schemes (Personal Medical Services) amendment to paragraph 20 of Schedule 1. I /we confirm that: The computer system on which the electronic records are maintained is accredited to RFA99 standards The computer security measures and audit functions are enabled and will not be disabled I /we am/are aware of, and undertake to have regard to, the Good Practice Guidelines for General Practice Electronic Patient Records prepared by the Joint Computing Group of the General Practitioners Committee and the Royal College of General Practitioners on behalf of the NHS Executive The provider has notified the Office of the Information Commissioner in accordance with the Data Protection Act (1998). I /we agree that a full patient record will continue to be forwarded when requested to the Primary Care Trust with the existing Lloyd George envelope and that the record will contain all relevant paper records including a printout of the entire computer record and including word-processed or scanned documents. I/we am/are aware that compliance with these conditions can reasonably be audited by the Primary Care Trust. Signed by all the GMS list principals or PMS doctors at the provider. APPENDIX 2 EXTRACT FROM THE DIRECTED EHANCED SERVICE SPECIFICATION PUBLISHED BY THE DEPARTMENT OF HEALTH 2006/07 1 DATA STANDARDS FOR ACCREDITATION PROCESS 1.1 The accreditation of providers is required by NHS Connecting for Health. The demonstration of a workable and regularly updated summary of patient records is required in order that another clinician can rapidly comprehend the clinical issues that are pertinent to the patients clinical care. The summary should include repeat medications that are linked to the significant diagnoses/problems that are identified. Allergies and adverse reactions should be included. 1.2 Uploads will be taking place during the year 2007/8 and 2008/09 of patients who are registered with accredited providers. This document outlines the accreditation standards and process. 1.3. The standards that are expected of providers are those already signed up to by the profession and outlined in detail within the Good Practice Guidelines. 1.4 Providers will be expected to be part of the PRIMIS+ facilitated network or equivalent. PRIMIS+ facilitators will support practices with their education and training on data quality issues and information governance. This will help them in providing the evidence of audits required for the accreditation process. 1.5 Providers will be expected to demonstrate compliance with Good Practice Guidelines and the process that has been designed is to enable providers to demonstrate their abilities in the following ways: ORGANISATION NumberStandard e-audit Submission visit1Provider is using the computer contemporaneously in consultation for all clinicians consulting regularly at the provider; or entries are made expeditiously- partial note keeping on the computer is not an acceptable standardxx2There is a process in place to update patients addresses opportunistically (in line with the DES) on the computer systemxx3Locums and people who are unused to the system have a system to support their consultation and data entryxx4Evidence of recording of telephone consultations in the electronic record at an appropriate ratex5Evidence of recording of visits in the electronic record at an appropriate ratex6Referrals are coded and recorded at an appropriate rate, including to secondary care and to other agencies who are not part of the extended provider team, such as counsellors, physiotherapists, community psychiatric nursesx INFORMATION GOVERNANCE NumberStandard e-audit Submission visit7The provider is registered under the Data Protection Act xx8The provider complies with laws on data access including role based access for all terminals, ensuring that no terminals are used by a staff member on another staff member's card xx9The provider has effective, validated data recovery processesxx10The provider has a nominated and trained Caldicott Guardian who performs the role appropriatelyxx11Alleged breaches of data security are investigated promptly and efficientlyxx CLINICAL DATA ENTRY NumberStandard e-audit Submission visit12Prevalence of specified significant, common disease diagnoses, relevant to the provider demographics, within 2 standard deviations of the mean or evidence to explain the variationx13Prescriptions indicative of a major chronic diagnosis not present without an appropriate diagnostic code in the summary recordx14Problems/diagnoses classified as "significant" or "important so that an accurate and complete summary can be createdx15The rate of recording of drug and other important allergies and adverse reactions, is within 2 standard deviations or a valid explanation givenx16Major diagnoses made by secondary care and other health care professional are recorded and prioritised if appropriate in the summaryx  See reference 11.1.  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