Ch 10 e documents

Chapter 10 - Electronic Document Attachments

10.1 Introduction¶

This chapter offers guidance on the principles of safe, consistent handling of attached electronic documents, common document formats, consistent document identification and the secure transfer of attachments between practices.

10.2 Attached electronic documents¶

A normal requirement in GP clinical record systems is to be able to attach an external electronic clinical document to an individual patient record. A wide range of attached document types and technical formats may be encountered and the handling of attachments varies somewhat between GP clinical systems.

'Document attachments' should be distinguished from GP2GP messages, lab results, and other structured 'clinical messages', which contain coded and other computer processable information, and whose contents can be directly imported into the patient record. 'Clinical messages' are discussed in Chapter 8 (Data transfer & inter-operability).

Some clinical communications e.g. Discharge letters, which are currently delivered to practices as word processed documents, and handled as attachments may in the near future be delivered as structured, processable clinical messages. GP system suppliers would normally adapt their systems to facilitate the appropriate handling process, advising practices of any need to change procedures.

10.2.1 Legal status¶

Any attachment to an electronic clinical record should be regarded as having equal medico-legal weight as a note made within the system and should be accorded the same stringencies around audit trail and backup (see chapter 3 'Records Governance'). It should also be possible to extract these attachments and send them to the requesting practice either electronically or as a printout.

Before making use of attachment facilities, a practice should satisfy itself that the system does meet these requirements. Wherever possible all attached data should be stored on the clinical server and not on a separate server. If a separate server is used to store attached data, the practice must ensure adequate and appropriate backup provision to ensure seamless continuity should failure occur on either clinical or attachment serving system.

10.3 Format of attachments¶

Potentially a very wide range of document types and formats may be received or used. Although almost any type of file is viewable with the correct software, when scanning, practices should generally adhere to a smaller subset of standard document types as suggested in Table 10.3.1. This avoids the difficulty of viewing unusual or proprietary formats if the appropriate software becomes unavailable, particularly where the records are transferred to another practice.

Key principles of attachment handling;

Following attachment, any changes made to an editable document must be logged in the clinical system's audit trail.
*Care must be taken that the document can be faithfully viewed after attachment, particularly when documents are scanned. Unusual or proprietary formats should be avoided when scanning. *
*Where a document with an unusual format is delivered to the practice, the practice must ensure that appropriate viewing software is available and that the type of software required is documented within the patient record. *
Picture, image files and especially video files can take up considerable storage space which should be considered when deciding if some types of attachment should be stored in the patient record.
Some formats, particularly JPEG, may result in the loss of image detail and should be avoided where the image needs to be of diagnostic quality. This may become a particular issue if the image is opened and re-saved repeatedly.
When paper documents are scanned, practices should take care to make and save a close facsimile of the original document, retaining colour information where it is important to do so (e.g. highlighted information in a letter). Some image formats such as JPEG, compress the data, losing some image quality in the process, so that the scanned image may not be an adequate facsimile. Image formats such as TIFF and PNG, which do not 'lose information' in this way are generally preferable for scanned images.
When scanning a multi-page document, which it is important to maintain as a single entity for medico-legal purposes, the TIFF format is generally preferred. TIFF can store a number of images/pages in a single file whereas JPEG, in its standard form, can only store a single image per file and, therefore, a multi-page document stored in JPEG format will consist of a number of separate files.
Optical Character Recognition (OCR), which attempts to convert images of type-written text to word-processable formats, is becoming increasingly accurate, sometimes allowing additional semi-automatic processing of document headers. However the accuracy of OCR remains variable and results of the conversion should be checked carefully. Safest practice is always to retain an accurate scanned facsimile of the original document.
*It is possible to password protect some documents, such that the document cannot be viewed without the password. Whilst this may seem an attractive means of adding a layer of privacy to particularly sensitive documents, in practice it can be very difficult to ensure that knowledge of the password can be transferred safely and correctly between practitioners. This can result in documents being 'locked' if the password has become lost through changes of staff personnel or transfer to another practice. In general the use of per-document passwords should be discouraged and other means should be explored for protecting sensitive attachments. Use of native GP system or document management system security and privacy facilities may be helpful, though this may itself cause problems when transferring records to another practice, and ultimately the simplest solution may be to retain highly sensitive documents in a traditional paper 'sealed envelope'. *
NHS England Choose and Book recommends PDF file format for all written text, where practically possible.

Table 10.3.1¶

10.4 Storage of attachments¶

GP systems store attached documents in a variety of ways, and generally provide guidance and user training material on best practise for storing attachments. These instructions should be understood and carefully complied with by practice staff.

In some cases, attachments are simply saved to a specific area on the practice network; in others the attachments are stored directly within the patient record database. A 'Document management package' may be used along with either of the previous options, generally adding more sophisticated handling or 'workflow', of incoming documents, along with detailed document categorisation and labelling facilities. Most Scottish practices now use the NHS Scotland approved 'Docman' package.

Whatever combination of approaches is employed, the practice must ensure that the attachments are treated exactly as other patient records, are backed up securely, are available for transfer to another practice, and are accessible to patients under terms of the Data Protection Act.

10.5 Attachment identification and coding¶

When attaching a clinical document, it is important to name or categorise the document within the local GP system so that its source and clinical significance is readily apparent when the patient record is subsequently viewed, without needing to open the document itself. The attachment should also be correctly attributed and coded to facilitate querying.

10.5.1 Attribution¶

As with any clinical record it is vital that the attribution of the attachment is captured so that date, time and where appropriate clinician or operator are available as well as the date and time and operator making the attachment.

10.5.2 Coding of numerical contents¶

Where a document includes significant numeric data and several values are derived together (Lung Function testing may derive Peak Flow, FEV1, FVC etc.), each value should be stored against an appropriately coded entry to facilitate system functionality and subsequent retrieval.

10.5.3 Attachment identification¶

If an attachment needs to be subsequently identified or 'labelled' within a patient record, a meaningful description such as \'Discharge letter Cardiology Western Infirmary Anytown\' is clearly more informative to the viewing clinician than a bland label such as 'File Attachment', and which would require the document to be opened to ascertain its contents.

Work is progressing at UK level to define standard ways of labelling clinical documents across a wide range of care settings, but at present no such standard has been agreed, other than for Scottish GP practices, which store attached documents within a common set of 'Docman' folders, primarily based on speciality type^1:

A UK-wide clinical document identification standard is likely to include the following elements which offer a minimal but effective way of communicating the contents of a clinical document (see table 10.5.3)

Table 10.5.3¶

Label element Examples

Document type "Clinic letter", "Discharge document" Speciality "Occupational therapy", "General medicine"

This approach, coupled with the use of standard lists of document types and speciality names may, in time, lead to the majority of NHS clinical documents being labelled 'at source', substantially reducing the need to do so within GP practices or any other document recipient.

The method of applying a label or category to the attached document will depend on the GP system used and whether a document management package or other formal categorisation facility is available. Use of such formal categorisation is the recommended approach, wherever possible. Most document management packages allow attached documents to be categorised in a variety of ways, which it would normally be possible to adapt to use the recommended Document type and Speciality categories.

Where formal document categorisation facilities are not available, it may be helpful to use the suggested elements to construct a single label or description for the attachment

e.g. "Discharge document General Medicine"

If the system does not allow a description to be recorded for an attachment, it may be helpful to construct the saved file name in a similar fashion.

e.g. "Discharge document General Medicine.doc"

When creating file names, it is generally best to avoid using any punctuation marks other than the dot character, as these may not be uniformly acceptable across all computer operating systems.

Choose & Book referral attachment names

Choose & Book guidance suggests naming attachments with recognisable filenames such as:

Surname, forename, date of birth e.g. johnsmith23061966** as a basis for ensuring files are easily recognisable and associated with specific patient records.

10.6 Transferring attachments¶

A common issue arises when patients leave a practice and their records require to be transferred to the new practice or other agency.

10.6.1 Legal issues¶

When a patient moves to a different practice, it is legally incumbent upon the original practice to respond to a request to transfer the patient's whole medical record. The legal requirement is that either party may insist on the records being transferred as paper printouts, and of course, in many practices, significant parts of the clinical record will still be available only in paper format. However, when some or all of the clinical record is held in electronic form, the use of some means of electronic transfer of the record is much less time-consuming for both practices, particularly for attached documents which otherwise have to be printed out by the original practice, then re-scanned by the recipient practice (see Chapter 9.7.8).

10.6.2 Modes of transfer¶

Within the UK four nations, there are currently significant differences in approaches to the electronic transfer of GP clinical records, including the transfer of attached documents:

10.6.2a NHS England¶

10.6.2a.1 GP2GP records transfer

When available, the NHS Connecting for Health GP2GP project offers the most safe and practical means of effecting electronic transfer of records between practices. It incorporates the transfer of electronic attachments (with the limitation of a maximum of 100 attachments and a 5MB limit per patient record), generating an attachment file-manifest, which associates attachments with a patient record irrespective of the filename. See Chapter 8b - Data transfer & inter-operability, for guidance on GP2GP records transfer.

10.6.2a.2 CD-ROM based attachment transfer

Although GP2GP rollout continues to progress in England (and is the professionally preferred method of electronic record exchange) it is not yet available for all GP systems. As an interim step, an alternative means of transferring attached documents via CD-ROM disc has been developed by an IM&T Committee consisting of members of the Beds and Herts. Local Medical Committee, GPs, practice staff and PCT staff, working in cooperation with several GP system suppliers.

Detailed guidance on operating this CD-based transfer, including advice from individual GP system suppliers, is available from the project website^2.

The protocol has been operating successfully in a number of PCTs, to the benefit of both sending and receiving practices but the following principles and caveats should be noted;

Formal permission should be sought from the Sending practice's PCO to allow CD-based transfer.
The process should not be carried out until administrative staff have received training in the necessary procedures, as documented at the project website, both to create the outgoing CD and to import attachments from the received CD.
The procedures advised by the appropriate GP system supplier should be closely followed to prevent potential loss of information in the transfer process.
The recipient practice retains the right to receive the record and attachments in paper format if they so desire, but must request this from the sending practice in a timely fashion.
Only non-rewriteable CD-based transfers are acceptable. Other media such as DVD, floppy discs and USB memory sticks have significant risks and drawbacks in comparison.
After importing and checking the data, the CD received must be shredded or destroyed by cutting -- the project website gives further instructions.

10.6.2a.3 CD encryption issues

Dept. of Health information guidance suggests that where clinical documents are electronically transferred outwith the practice, patient privacy should be protected by the use of encryption and passwords, in case of inadvertent loss or interception of the document in transit.

"David Nicholson, NHS Chief Executive, has directed that there should be no

transfers of unencrypted person identifiable data held in electronic format

across the NHS. This is the default position to ensure that patient and staff

personal data are protected. Any data stored on a PC or other removable

device in a non secure area or on a portable device such as a laptop, PDA or

mobile phone should also be encrypted. This is also now a requirement

across all public sector organisations set by the Cabinet Secretary.

It is recognised however that this may take some time to achieve in the NHS

where patient care is our highest priority. NHS bodies will need to make a local judgement on the balance of risk to patient care against risk to personal

data security in determining whether use of unencrypted devices should

continue as an interim measure. Where it is felt that continued reliance upon

unencrypted data is necessary for the benefit of patients, the outcome of the

risk assessment must be reported to the organisation's Board, so that the

Board is appropriately accountable for the decision to accept data vulnerability or to curtail working practices in the interests of data security."^3

This is one rationale for the use of approved NHS mail and messaging facilities such as the Spine and SCI-Gateway, which provide such security automatically for emailed attachments and clinical messages such as electronic referrals and GP2GP record transfers.

To comply fully with the DH directive, a CD used for attached document transfer should be encrypted, but this considerably complicates the transfer process, requiring agreement on the encryption method, availability of the appropriate encryption/decryption software in both practices and communication of the associated password in a secure and timely fashion. If not handled correctly, it may also interfere with patient rights to access records under the Data Protection Act.

In view of such added complexity, the CD transfer project team judged that within this very specific context, encryption adds little to patient privacy protection, given that the CD-ROM is physically transferred via a secure courier service alongside a set of unencrypted paper printouts of other aspects of the clinical record.

Whilst generally acceptable to participating practices, PCOs and suppliers, this advice has not been formally endorsed by practitioner representative bodies, NHS, or medical defence advisers. It remains likely that in due course formal guidance will be introduced, jointly with the Dept. of Health, on standard methods of encryption of CD-based document transfers and associated operating procedures.

Until such time, where encryption is not used, practices should make an individual assessment of the risk of a privacy breach and agree the approach with their PCO.

Full DH Information Security Guidance may be found on their website^4

10.6.2b NHS Scotland¶

10.6.2b.1 Docman Transfer

Almost all Scottish GP practices now use the 'Docman' document management package and associated standardised folder structure. The NHS Scotland Practitioner Services 'Docman Transfer' facility allows the automated transfer of attached documents between practices without the need for the documents to be re-filed in the recipient practice. In addition, an export of the entire GP system patient record to an electronic document may be made, imported to Docman and transferred electronically with the other attachments.

At publication, the 'Docman Transfer' facility was available to 95% of Scottish practices and for these practices represents the simplest and safest approach to attached document transfer. Details of the 'Docman Transfer' process are available online^5

10.6.2b.2 CD-ROM based attachment transfer

The use of compact discs (CDs) to exchange attachments or other electronic records is not currently formally supported by the NHS in Scotland. Any such arrangement would be strongly discouraged where 'Docman Transfer' is available but if necessary it should be agreed on a per-case basis between sending and receiving practices. The protocol used within NHS England for CD-ROM attachment transfer (see above) may be regarded as a robust model on which to base any local arrangement.

10.6.2b.3 GP2GP records transfer

NHS Scotland is examining the possibility of making GP2GP records transfer available. In these circumstances, GP2GP is likely to offer the most safe and effective means of electronic transfer of records (including attached documents).

10.6.2c NHS Wales¶

10.6.2c.1 GP2GP records transfer

NHS Wales have indicated that GP2GP records transfer will be made available as part of National Programme, led by the NHS Wales Informatics Service (GMS IM&T Programme). When it becomes available, it will offer, to Welsh practices, the most safe and practical means of effecting electronic transfer of records (including attached documents).

10.6.2c.2 CD-ROM based attachment transfer

The use of compact discs (CDs) to exchange attachments or other electronic records is not currently formally supported by the NHS Wales. Any CD based transfer would have to be agreed on a per-case basis between sending and receiving practices and seeking prior clearance from a PCO. CDs must be encrypted and transferred via the all Wales secure courier service. The protocol used within NHS England for CD-ROM attachment transfer (see above) could be adapted to provide a model on which to base any local arrangement.

10.6.2d HSC N. Ireland¶

10.6.2d.1 GP2GP records transfer

At the time of writing (July 2010) we have no information on GP2GP records transfer in Northern Ireland.

10.6.2d.2 CD-ROM based attachment transfer

The use of compact discs (CDs) to exchange attachments or other electronic records is not currently formally supported by the Health and Social Care organisations in Northern Ireland. Any CD based transfer would have to be agreed on a per-case basis by the Health and Social Care organisations and between sending and receiving practices. The protocol used within NHS England for CD-ROM attachment transfer (see above) may be regarded as a robust model on which to base any local arrangement.

10.7 e-referral attachments¶

Chapter 9 outlines the use of e-Referral systems (section 9.7.9). Both of the main e-referral packages in use, Choose & Book and SCI Gateway, allow the upload of attachments along with the referral e.g. a scanned document or clinical image. Most of the common file formats listed in Table 9.2.1 are supported but there may be some minor limitations along with restrictions on numbers of attachments and attachment size per referral. These limitations are unlikely to be significant in usual practice and relevant system documentation should be consulted for specific guidance.

10.7.1 Choose and Book attachment limitations¶

It is not possible to add notes or letters from a GP system directly into a Choose and Book 'Advice and Guidance' request. Instead you should copy / paste from a practice system into the body of the advice request or save the additional information in a document outside of the practice system and then add it as an attachment.

¶

10.8 Other documents¶

Practices maintain many different forms and documents about patients that are essential to their day to day operations. Some of these do not form part of the patients' records but carry information about patients, carers and others. Below, we give some examples of these documents and advice about their retention and disposal;

*Notification of infectious disease -- no need to retain counterfoil providing there is an appropriate entry in the relevant EPR. In NHS Scotland, notifications are performed electronically via SCI Gateway. *
*Message books/logs -- ensure any action taken (e.g. phone call/consultation/visit) is recorded in the EPR. It is advisable to retain written message books/logs in line with general medico-legal guidance. *
*Ambulance request logs -- ensure any action taken is recorded (as above) *
*X-ray films. These should be retained in line with the DoH guidance above (see Chapter 3). *

Most of the above are "process" forms but may be important medico-legally. If practices are in any doubt about retaining a document we recommend that they scan and store an image of the document in an appropriate format (see Table 10.3.1) and then shred the original document. However, where any records relate to patients where there are known medico-legal issues (complaints, civil or criminal law) then practices should keep all relevant records pending further advice from their medical defence organisation, PCO or LMC.