Evidence submitted by the British Psychological
Society (EPR 45)
The British Psychological Society welcomes the
opportunity to contribute to the Committee's inquiry into the
development of the Electronic Patient Record and its use.
The Society is the learned and professional
body, incorporated by Royal Charter, for psychologists in the
United Kingdom, has a total membership of over 45,000 and is a
registered charity. The key Charter object of the Society is "to
promote the advancement and diffusion of the knowledge of psychology
pure and applied and especially to promote the efficiency and
usefulness of members by setting up a high standard of professional
education and knowledge".
The Society is authorised under its Royal Charter
to maintain the Register of Chartered Psychologists. It has a
code of conduct and investigatory and disciplinary systems in
place to consider complaints of professional misconduct relating
to its members. The Society is an examining body granting certificates
and diplomas in specialist areas of professional applied psychology.
It also has in place quality assurance programmes for accrediting
both undergraduate and postgraduate university degree courses.
Members of this Society, as Applied Psychologists
work as Clinical, Counselling, Health, Forensic and Educational
Psychologists as well Neuropsychologists. They and other members
also undertake research. Their NHS patients will be directly affected
by the introduction of the Electronic Patient Record. Our comments
reflect our concerns in relation to aspects of electronic records,
particularly in the context of mental health services. We do not
propose to cover the many technical and supply problems that continue
to bedevil this project, as we are sure these will be adequately
addressed by other colleagues.
In submitting our views, we recognise that there
is a strong case for the introduction of electronic health records
in terms of potential benefits for patients, clinicians and management.
This response was prepared on behalf of the
British Psychological Society by its representatives on the British
Computing Society Forum:
Dr Adrian Skinner, Department of
Clinical Psychology, HarrogateMember of the Division of
Clinical Psychology and Associate Fellow, British Psychological
Prof Michael Berger, Royal Holloway,
University of LondonMember of the Division of Clinical
Psychology and Fellow, British Psychological Society.
What patient information will be held on the new
local and national electronic record systems, including whether
patients may prevent their personal data being placed on systems?
At a Local Level
CfH is intended to store patients' medical record,
including all health episodes, centrally. NHS staff with a legitimate
clinical interest in a patient will have access to that record.
The Code of Conduct of the Society requires that the patient and
the psychologist decide who should have access to psychological
records other than under specific circumstances such as a Court
Order. Centralisation of these records will remove this responsibility.
Particular issues arise in relation to mental
health data and data from vulnerable/other groups who may lack
"capacity" to consent to and monitor information about
themselvespeople with dementia, learning difficulties,
acquired brain injury dysfunctions. Such issues need to be addressed.
Associated with this is the complex matter of
mental health patients' access to recordssuch as determining
which parts of records may be potentially harmful if revealed,
dealing with third party information. Currently, such questions
arise when an individual requests access. If all records are to
be subject to individual scrutiny, particular attention will need
to be given to how this process will be implemented.
At a National LevelContents of the summary record
in relation mental health records and those of other vulnerable
groups require specification. Patient access and control remain
issues at this level, again specifically in relation to data for
those with mental health problems and for vulnerable individuals.
Who will have access to locally and nationally
held information and under what circumstances?
The means of determining access to records is
described as "Role Based Access Control". We are concerned
that it will not be possible to produce a satisfactory algorithm,
and that this will result in a far wider variety of people having
access to records.
Information in healthcare covers every aspect
of human functioning and in mental health, it is highly sensitive
and confidential information about diverse aspects of functioning
and relationships, the veracity of some of which may be questionable,
for instance in forensic settings. This information, commonly
essential to treatment, is usually given in the context of a developing
trusting relationship and in most circumstances, is private to
that relationship. The possibility of access by others could block,
impair or distort the information made available, undermining
the treatment efforts of the clinician. Hence special consideration
needs to be given to access and the related issue of protection
of confidentiality in relation to mental health information.
The issues are not just about deciding about
access rights on a spectrum from no-access for anyone other than
the involved clinicians, to unfettered access. They are also about
validating that an individual with access to highly sensitive
and confidential information is a specific individual with the
specific level of access rights. The recent instance of a single
smartcard being left in the card reader to counter the slow response
of the validating system is an illustration of the sorts of issues
involved. This raises the need for the use of biometric smartcards
in certain situations.
What kinds of data are stored?
The lay, and medical, view of a medical record
is of a straightforward collection of bits and bytes of hard information
eg serum potassium levels.
However, for psychology and a number of other
disciplines the information is "soft", ie expressed
in language, variable, and consisting of opinion and conclusion.
We are concerned that the electronic record could both
give spurious authority to transient junior opinion and preserve
erroneous information that could have been corrected in a paper
CfH is aware that patients will not wish all
clinical staff to have access to all records, for instance sexual
or mental health episodes, and propose a scheme of "Sealed
Envelopes" that may be breached only by senior staff under
The problem is that other NHS staff will be
aware of the existence of these sealed envelopes, with sometimes
undesirable consequences. For instance, employers (including the
NHS) may request an inspection of medical records as part of the
Occupational Health Assessment; if such an inspection found sealed
envelopes it is likely that the potential employee might be required
to grant access as a condition of employment.
One solution to this problem is to give every
record a "Sealed Envelope". This way, no individual
will be marked out as having "something they wish to hide".
Those who wish to use this facility would then insert material
that would only be accessible to those with special privileges.
There are two potentially serious consequences
of the above; we stress that, because of existing computerisation,
these consequences already occur.
First, people may avoid seeking treatment for
problems that they classify as embarrassing or threatening to
their lifestyle in some way.
Second, clinicians may be reluctant to record
certain sorts of information for fear of this information "leaking"
to the harm of the patient; an unintended consequence of this
could be the failure to pass on information about someone's care
to a clinician who needed it.
How Data Held on the New Systems Can and Should
Be Used for Purposes Other Than the Delivery of Care eg Clinical
Access to personal health data for research
should be available provided ways of ensuring that usual ethical
principles are followed. However, there should be a formal systematic
review, involving patients and other potential user groups from
within the NHS, medical and other professional training groups,
to assess whether or not electronic records pose special problems
so that supplementary ethical and other guidance can be introduced
In this regard, there will need to be provision
for special informed consent about likely use for research.
Dr Martin Crawshaw
Chair, Professional Practice Board, British Psychological
16 March 2007