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The optometrist is legally bound to issue the patient with a confirmation of their refractive correction, if any, and a note as to the need for any further medical assessment if the eyes were found to be less than healthy.
This 'prescription' needs to be dated, signed and have details of the prescribing practice on it. It is important to remember that the final prescription might be adapted in some way from the final refractive error measurement, for example:
- Where a patient is used to a slightly overminused correction used primarily for distance viewing and prefers the extra minus
- Where the refractive error is helping to stabilise binocular state (over minus to compensate for an exophoria, maximum plus for an accommodative esophoria state and so on)
- Where a reduced post-cycloplegic correction has been decided upon to improve compliance with an isometric hypermetropic refractive error.
The optometrist should also be able to offer advice (and record such on the notes) about the best methods of correction, whether it be contact lenses or a particular spectacle lens form or design. This may aid the subsequent dispensing, particularly if the advice is verbally relayed to the practitioner carrying out any subsequent dispense.
Communication of findings
The delivery of information based upon the findings is the culmination of all the preceding verbal and practical techniques. If the presenting problem of the patient is to be addressed and perhaps resolved then the recommendations should be delivered in a meaningful way to the patient. To some extent this will depend upon the nature of the underlying problem and the person specific examples will be dealt with later. However, general considerations might include the following:
- The recommendation should be clear and concise. After a lengthy summing up and appraisal of the situation it is quite soul destroying to hear the words 'So, do I need glasses then?'
- The recommendation should be specific. 'You need to wear your glasses for driving'. 'You should make an appointment with your GP in the next two days'
- Non-verbal cues help to reinforce the information given, of particular importance if emphasising an issue with possible health consequences
- Categorisation or presenting information in manageable 'chunks' makes information easier to understand and easier to remember, so improving compliance. 'You do require new distance glasses. Your current readers are absolutely fine to continue with. Your eyes appear to be healthy. There is no significant change in the health of your eyes since the last examination. I shall want to examine you again in one year.' Be very careful not to overload the patient with information as this may decrease subsequent recall of information
- Where there is a greater amount of detail to be imparted, it is a useful technique to repeat any information of particular importance. Furthermore, if a sequence of information 'chunks' is delivered the patient will tend to remember most the first thing said to them (the primacy effect) and the last thing said to them (the recency effect) and this can be exploited by the skilled practitioner in conveying information
- The patient should be given ample opportunity to question or respond to any particular points. This will also have the advantage of signifying their understanding of a particular point, so allowing the practitioner to reinforce by repetition or clarification
- The patient should be made aware of the opportunity for future contact in cases where there may be a problem arising from subsequent consideration of the results
- Some practitioners give written reinforcement in particular situations where advice may be technical or specific, for example with regards to a particular lens material or contact lens solution regime.
The conclusion of the examination may often benefit from a call for commitment from the patient, for example 'So I can rely upon you to consult your GP this week?' or 'Do you agree that glasses may help to alleviate this problem'.
A note about record-keeping and the Data Protection Act
The Data Protection Act (DPA) came into force in 1998. The law was designed to ensure that information held about any party was secure, available to the party and held in accordance with and in the knowledge of a central agency. Optometrists and opticians hold a good deal of medical information about their patients and customers, much of it in electronic form, and therefore it is important for all eye care practitioners to be aware of the implications of and their obligations under the law. It is also reasonably common for practitioners to be contacted by unofficial advisers, offering their services for often inflated fees, promising to ensure that the practitioners are operating within the law. Though it is true that any practitioner may easily be operating outside the law if uncertain about their obligations, it is usually a simple matter of familiarising themselves with these obligations to ensure safe and legal practice and not to give in to some of these opportunistic and clearly out-for-profit fear mongers.
A brief history
The dramatic increase in the use of computers to hold personal information about people led to the introduction of the Data Protection Act in 1984. This Act offered people the right to have some freedom of access to this information and, where there was proof of exploitation of the information, the right to claim some form of compensation. The law was expanded specifically for health records in 1987 (SI 1987/193 Data Protection (Subject Access Modification) (Health) Order). This law also saw the establishment of the Data Protection Registrar, to whom a complainant could apply where a breech of the Act was suspected and with whom anyone holding data was required to register.
The Access to Health Records Act 1990 (effective from 1991 to 1998) clarified the process whereby an individual had the right of access to any health record concerning them held by a health professional (including a registered optician) and the right to amend such records where error could be demonstrated. The definition of records in this case excluded any information as described in section 21 of the 1984 DPA.
The Data Protection Act of 1998 superceded the Access to Health Records Act 1990 and in effect combined the two provisions and applies to information stored both electronically and manually. The 1990 Act still applies to deceased patients where information had been stored prior to 1998 who had passed away before this date. As far as patient access to information is concerned, the newer Act allows patients full access to all health records kept about them, and includes access for applicants acting on behalf of the patient, for example in the case of a parent wanting access to information about their child, someone designated in a written statement as having permission to act on behalf of the patient, or when a court has designated someone to act on the behalf of a patient otherwise incapacitated and unable to act for themselves. Access may only be refused where it is arguable by the professional that information disclosure may present a danger to the physical or mental state of the applicant.
When the newer DPP effectively repealed the older Access to Health Records Act, there were concerns raised at the time by various civil liberty groups. Concerns included the apparent loss of a patient's right to have a note of their concerns about a disputed matter added to the record, the apparent rise in the fee chargeable by the professional for responding to an application from £10 to a maximum of £50, and the extension of the time allowed for the practitioner to respond to a request from 21 days (where access is required to information recorded within the last 40 days) to a standard 40-day limit under the new DPA. Generally speaking, however, the repeal clarified procedure and, as is often the case in law, is adaptable to changing circumstance. An example of how advice regarding a new demand requires a new clarification is with the new requirements of the proposed pre-registration year where a College of Optometrists assessor requires access to records to assess the pre-reg as competent in a certain area. This access will need to be sanctioned by the relevant government body.
The Data Protection Act 1988
The new DPA came into effect on March 1 2000, and covers all data traceable to an individual held either manually or electronically. An individual has the right to expect the information held about them to be accurate and used only for a specific purpose which needs to be made clear to them (for example 'I am going to make some notes so we can properly monitor how your eyes change over the years'). The right to amend information if inaccurate is maintained and also there is offered the right for an individual to object to the use of data if that use causes harm or distress.
Importantly, practitioners are required to register as data controllers with the Data Protection Registrar or more commonly now known as the Information Commissioner. Failure to register, as well as failure to comply with the provisions outlined, constitutes a criminal offence.
A data controller is defined as 'a person who determines the purposes for which, and the manner in which, personal data are, or are to be, processed'. This may be an individual practitioner or an organisation, such as, for example, a multiple group. A data processor is defined as 'a person who processes information on behalf of the data controller' as would be the case in an employee of a multiple or within a registered practice. The patient about whom information is kept is described as the 'data subject'.
In cases where a data controller is deemed to have failed to satisfy their requirement under the DPA, such as in the case where a practitioner refuses access to a record to a patient, the Information Commissioner may issue an enforcement notice. This sets out the actions the practitioner needs to follow in order to comply with the relevant part of the DPA as well as offering a period within which the practitioner might appeal. Failure to comply may result in court action. The Commissioner may also issue an Information Notice (see later).
Electronic data
As already stated, it is the responsibility of the practitioner (data controller) to notify the Information Commissioner's Office of their activities when they are storing (or 'processing') information about a data subject (patient) with some exemptions. Where none of the 'processing' is carried out by computer, there is no need to notify. Computer here, however, is a broad enough definition to include image and data storage in instrumentation, audio and CCTV systems. Administrative records (appointments for example), advertising and staff-related information are exempt from the requirement to notify. As most records relate to healthcare, clinical management and possible treatment, they are not exempt along with the administrative information. In most cases, therefore, practitioners are bound to notify the Commissioner's Office.
The use of an electronic field screener (even if the results are printed out for storage in the record card) would still require notification, and certainly image storage, or topographic data would fall under the DPA requirement. It is surprising how much of a modern optometry practice involves electronic handling of data and therefore notification is the norm.
The electronic optometrist
The patient journey at a modern practice might include the following steps, most of which might be argued as notifiable under the DPA:
- Remote access to a practice website to make an appointment and check information about ocular health and services offered. This might be in response to an electronically generated reminder letter
- CCTV surveillance on entering the practice
- Personalised computerised information slideshow in waiting area
- Autorefraction, lens meter, tonometry data 'hardwired to a central processor unit
- Visual fields data stored and compared with previous results
- Fundus imaging
- Topography and scanning laser topography or interferometry with analysis of previous and current data compared to stored regression analysis data from trial population
- Slit-lamp based external video and image capture
- PDA-based note keeping and download of information about patient medication and systemic health condition
- Automated and variably pre-programmed refraction unit with transfer of result to dispensing unit
- Video facial measurement and photographic representation of frames on face (and cosmetic contact lenses)
- Electronic data transfer to lab for glazing and to GP for notification of ocular health status
- Dedicated and personalised information sheets produced for patient to take away.
Even in the case where a data controller is exempt from notification (no electronic processing of clinical data which could influence the clinical management is proven) the practitioner still needs to adhere to the eight principles of the DPA as follows the data processed must be:
- Fairly and lawfully processed
- Processed for limited purposes
- Adequate, relevant and not excessive
- Accurate
- Kept no longer than necessary (see below)
- Processed in accordance with the data subject's rights
- Secure
- Not transferred beyond the EEA without adequate protection.
With regard for length of data storage (to comply with the fifth rule above), the UK College of Optometrists specifies that data be kept a minimum of 10 years for hospital records, eight years in general practice, 15 years if the data is involved in clinical trials, and up until the 25th birthday of a child (26th if they were 17 at the conclusion of the treatment or eight years after the event of a child's death).
The Commissioner is also responsible for enforcing the Telecommunications (Data Protection and Privacy) Regulations 1999 and the law which superseded this, the Privacy and Electronic Communications Regulations 2003. These include directions concerning the security of information to be transferred electronically, as well as limitations upon electronic marketing and correspondence, applicable where a practitioner may wish to contact patients through an electronic medium which might be construed as generating SPAM. If 'teleoptometry' catches on (the paper-free storage and transfer of clinical material) these regulations will become more significant.
Notification is the process by which a data controller's processing details are added to a register. Under the DPA, every data controller who is processing personal data needs to notify unless they are exempt. Failure to notify is a criminal offence.
Even if a data controller is exempt from notification, they must still comply with the principles.
The Commissioner maintains a public register of data controllers available at www.dpr.gov.uk. A register entry only shows what a data controller has told the Commissioner about the type of data being processed. It doesn't name the people they hold information about.
Freedom of Information Act 2000
The Freedom of Information Act sits alongside the Data Protection Act 1998 and the Environmental Information Regulations as the principal mechanism for access to information held by English, Welsh and Northern Irish public bodies. The Act does not apply to Scottish public authorities, who fall under the Freedom of Information (Scotland) Act 2002 which is overseen by a separate organisation, the Office of the Scottish Information Commissioner. From January 1 2005 it will oblige opticians' and optometrists' practices to respond to requests about the NHS-related information that it holds, and it will create a right of access to that information.
Summary
Many aspects of modern optometric practice mean that most practitioners act as data controllers to some extent and awareness of their responsibilities under the DPA is essential. Details of notification and responsibilities to the Information Commissioner are available from the Office of the Information Commissioner, Wycliffe House, Water Lane, Wilmslow, Cheshire, SK9 5AF (Tel 01625 545740). Do this yourself and avoid paying the less than respectable outfits offering services at an exorbitant fee. ?
Useful references
www.hmso.gov.uk/acts/acts1990/Ukpga_19900023_en_1.htm
www.hmso.gov.uk/acts/acts1998/19980029.htm#aofs
www.hmso.gov.uk/acts/acts2000/20000036.htm
www.informationcommissioner.gov.org
? Andrew Franklin practises in Gloucestershire