A fundamental part of the Hippocratic Oath is keeping secret whatever a doctor sees or hears about their patients.But the oath was written about 2,400 years ago when nobody could have envisaged an age of electronic patient records, email and social networking sites. So how might doctors duty of confidentiality fare in the digital age?
While electronic records are commonplace in most GP surgeries and clinics, it is still relatively rare for GPs to communicate digitally with patients.
Today only 9% of all NHS patients can communicate with their doctor via email to resolve medical questions, and 25% are able to arrange an appointment digitally either by email or by using an online booking system.
The DH's Digital First – The delivery choice for England’s population report recommends that the NHS adopts new initiatives to improve patient access to services, and to save money.
The Digital First initiatives include:
- Greater use of telephone and online consultations in primary care
- Ability to make GP appointments online
- Text message reminders for appointments and to communicate negative test results
- Use of Skype or telephone for post-surgery follow-up appointments.
Whatever new initiatives are adopted, it is important patients confidential information is protected to ensure that trust is maintained in the doctor/patient relationship. Here we look at the confidentiality concerns raised by some of the current uses of technology.
Computerised medical records provide many real advantages over paper records for safe patient care and for confidentiality.
Records are typed and therefore legible, available on computer system whenever needed, often at a different site, and access can be controlled by password protection or similar security systems.
Audit trails also provide details of who accessed the computer record, when, and whether any changes were made.
Some examples of when confidentiality can be breached with electronic records include:
- If passwords are inappropriately shared or the computer is not logged out after use, unauthorised access can occur.
- Badly placed screens that can be read by visitors or passers by.
- If staff are not trained in confidentiality they may be tempted to access records of a patient that they are not involved in treating for example, a relative or celebrity patient.
- When computer systems used for storing confidential data are upgraded, and used equipment is disposed of without cleaning information from the hard drive. The Information Commissioner has imposed heavy financial penalties on healthcare providers involved in such breaches.
Earlier this year the Information Commissioner fined an NHS organisation £70,000 after a consultant emailed a letter to a secretary for typing having misspelled the patient’s name and without including enough information to identify the correct patient. This resulted in the letter being sent to a former patient with a similar name.
Another NHS body that repeatedly sent faxes containing confidential patient data to the wrong person for three months, despite having been informed that they were using the wrong number, was fined £90,000.
In yet another recent case a junior doctor lost an unencrypted USB stick containing details of patients’ conditions and medication that he had intended to forward electronically from home. The NHS trust he worked for was found in breach of the Data Protection Act 1998 after an investigation revealed the doctor was unaware of its data protection policies.
Meanwhile, researchers looking at 84 threads detailing clinical incidents posted on the Doctors.net.uk anaesthetic forum could identify the hospital involved in 38 cases after a Google search on the poster’s name. Five descriptions of cases included the hospital, date, age, sex and further identifying details of the patient.
Fax, email and texts
Digital communications such as faxes, text messages and email allow for rapid communication and can have real advantages for healthcare staff and patients alike. However, as with any message sent containing confidential information, you need to take care that it reaches only the intended recipient.
For more on the pitfalls of emailing and texting patients click here.
USB sticks, tablets and other mobile devices
Many GPs now carry a smart phone or tablet and may be tempted to use them to work ‘on the move’.
If a mobile device is to be used to store or access patient data it will need to have the necessary security installed to protect that information from unauthorised access. Mobile devices are particularly tempting to thieves and easily lost. Also, who is looking over your shoulder when you are reading the patient’s file?
The DH stated in 2008 that ‘the movement of unencrypted data held in electronic format should not be allowed in the NHS’ and 'wherever possible, personal identifiable data should always be stored on a secure server.’
Photographs of patients
Tablets and other mobile devices can be used to take photographs of a patient and to email them to a colleague for almost instant clinical advice.
The GMC has issued guidance about the use of visual and audio recordings of patients. In essence, explicit informed patient consent is needed for a doctor to take an image of a patient. Such images need to be stored securely, with the same level of security as other patient records.
Informed consent will also be required to share identifiable patient images with others, whether for the purposes of clinical care or for secondary purposes such as teaching and training other doctors and students.
Social media and internet blogs
After a hard day it can be tempting to share stories with friends via forums and internet blogs. However, be aware that even seemingly superficial details about patients could be identifiable.
With the rapid increase in doctors using social media, the GMC last year published draft guidance on its use. It states that the same standards are expected of doctors when communicating through social media as when face to face with patients.
The draft guidance advises doctors not to discuss individual patients or their care via social media and warns that once information is online it can be difficult to remove as others may distribute or comment on it.
Principles of confidentiality
These principles remain unchanged despite modern digital technologies and include:
- Medical records should be protected from unauthorised access.
- When transmitting patient data always take care to ensure that you use the correct address for the intended recipient.
- Get patients’ express consent for anything that they would not expect as part of their routine care, such as text messaging and the recording of images.
- Don’t discuss patients on social networking sites and be aware that information can be distributed further than you originally intended.
- Dr Old is a medico-legal adviser at the MDU
Information Commissioner guidance for health organisations