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Betsi Cadwaladr University Health Board Board Paper 24.1.13 Item 13/018.7.3

Subject: Minutes of the Information Governance Committee (IGC)meetings

held on 13.12.12 and 11.10.12 Summary or Issues of Significance

Issues of significance 13.12.12 : • Progress has been made with regards to the IT desktop and

storage strategies. • All GP Laptops are to be encrypted and discussions are taking

place with National Programme Groups. • The PACS (digital X-ray) system has been procured and has

been implemented across North Wales. • A Policy Management System was discussed for use in

compliance and alerts monitoring. • Requests for information from the Police has been discussed

and revision to documentation will be agreed and disseminated to all parties.

• Work is ongoing to establish policies and procedures regarding the use of patient administration systems by switch board staff.

• A pilot of digitalising/scanning of patient records is to commence at the end of February/beginning of March 2013.

• The Data Protection Subject Access Requests Procedure for non clinical information was reviewed and approved.

• The MARS system is to be in place with immediate effect for secondary care doctors to use for appraisal and revalidation.

• A single implementation for Myrddin has been agreed and a full business case is to be presented at the next Committee.

• The issues of significance from the Health Informatics Group and the Information Governance Group were accepted.

Approved minutes of IGC held on 11.10.12 are appended for information

Strategic Theme / Priority / Values addressed by this paper

Safe collection, storage and use of information held by the Health Board

Legislation or Healthcare Standard:

Data Protection Act 1998 and Freedom of Information Act 2000 Healthcare Standards 19 and 20

Evidence base or other relevant information to inform decision (e.g risks)

Consultation with others:

Equality Impact Assessment (EqIA)

Has EqIA screening been undertaken?Y / N Has a full EqIA been undertaken?Y / N

Recommendations:

• The Board notes the minutes and issues of significance. • The Board ratifies the decision to approve the Informatics

Operational Plan 2012/13 on 11.10.12. Author(s) Emma Pritchard, Information Governance Co-Ordinator

Presented by Prof Merfyn Jones, Chair Information Governance Committee Mrs Grace Lewis-Parry, Director of Governance & Communications

Date of report 11th January 2013 Date of meeting 24th January 2013

BCUHB Coversheet v3.4 Disclosure: Betsi Cadwaladr University Health Board is the operational name of Betsi Cadwaladr University Local Health Board

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IGC December 2012

Version Draft 0.6 Public

Betsi Cadwaladr University Health Board

INFORMATION GOVERNANCE COMMITTEE

Minutes of meeting held on 13th December 2012

Via videoconference between;

Ysbyty Gwynedd, Wrexham Maelor Hospital, Matthew House,

Abergele Hospital and NWIS.

Present: Mr Keith McDonogh (Chairing) Independent Member Ms Jenie Dean Independent Member Mr Harri Owen-Jones Independent Member In Attendance: Mrs Vera Wilson Community Health Council Representative Mr Dylan Williams Assistant Director of Informatics Mrs Justine Parry Head of Information Governance Mrs Barbara Jackson Assistant Director of Corporate Affairs Mrs Grace Lewis-Parry Director of Governance and Communications Dr Robert Atenstaedt Public Health Wales Mr David Davies Director of NHS Engagement, NWIS Mr Christopher Roseblade Consultant Obstetrician, Assistant Medical Director Mr Clive Sparkes Chief of Staff, Therapies and Clinical Support Ms Tracy Williams Head of Performance & Improvement Ms Anne-Marie Rowlands Deputy Director of Nursing Dr Martin Duerden Deputy Medical Director Mr Markus Hesseling Consultant Paediatrician Mrs Gaynor Gould Information Governance Officer Miss Emma Pritchard Information Governance Co-ordinator Apologies : Professor Merfyn Jones Chairman Ms Marian Wyn Jones Independent Member Mr Mark Scriven Medical Director and Director of Clinical Services

Agenda Item Action

IGC 12/059 Welcome, Introduction and Apologies Mr Keith McDonogh Chaired the meeting in Professor Merfyn Jones absence. He welcomed everyone to the Information Governance Committee (IGC) and introductions were made. Apologies were duly noted.

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IGC 12/060 Minutes of the last meeting held on 11th October 2012 The minutes of the previous meeting were accepted as a true and accurate record, subject to the following amendments:

• Mr Clive Sparkes was present at the meeting.

EP

IGC 12/061 Matters Arising 12/030 - this action is outstanding. The Chair asked for this to be addressed immediately and asked for it to be escalated to the Chief Executive. Dr Duerden commented that although he had not been part of this process he offered his assistance to establish what progress has been made and will take the paper to the next Board of Directors meeting. The Chair thanked Dr Duerden and asked for assurances that someone would take overall responsibility of the Plan in Mr Scriven’s absence. 12/049 – Mr Williams reported that the operational plan has not yet been approved but will be submitted to the next Health Board meeting. IGC 12/054 – Mrs Parry confirmed that the amendments had been made and the final version circulated. All other actions are addressed within the agenda. Mrs Wilson asked if the contractual issues regarding confidential waste and the implementation date of 1st December had been instigated. Mrs Parry confirmed that the process was implemented on 1st December and that the Information Governance Team are working with individual CPGs. After brief discussion Mrs Parry advised members that any issues surrounding the implementation should be directed to the IG team who offer guidance and assistance. Ms Dean asked if any progress had been made with the development of desktop and storage strategies and Sharepoint. Mr Williams reported that there have been technical problems and that there is two systems currently out to tender. It is hoped that systems will be in place by February 2013. He also stated that discussions are on-going with Microsoft regarding desktop and licensing. Ms Dean commented on experiencing problems with access to meeting papers via Sharepoint. Mr Williams offered to discuss these issues with Ms Dean outside of the meeting. It was agreed that Mrs Lewis-Parry and Mr McDonogh would liaise with other Independent Members to establish if they are also experiencing problems with sharepoint.

MD DW JD & DW GLP & Chair

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IGC 12/062 Issues of significance from the Health Informatics Group (HIG) Mr Williams presented the issues of significance from HIG and noted that the last meeting was on 21st November and not 21st September. He highlighted the following issues: Mr Williams confirmed that refresher training and guidance on health records standards has commenced. Further discussions have taken place regarding private practice access to medical notes and discussions have been held around the complexity of dealing with charging for access to health records. Due to the significant costs to the organisation it was felt that this would not be pursued. Safeguarding dividers and issues regarding violence and aggression were discussed in detail. Mrs Parry is to set up a Task and Finish Group to establish what the organisation is working to across the different sites and to ensure that we comply with legislation. It was agreed that specific markers would be removed until further discussions had taken place with the Health and Safety and Safeguarding Team.

JP

ICG 12/063 Issues of significance from the Information Governa nce Group (IGG) Mrs Jackson presented and highlighted: The NetConsent Policy Management system was brought to the Committee’s attention, it was highlighted that this type of system would be a useful tool for compliance and alerts. A Task and Finish group is being set up to develop a business case. Police requests were discussed, Mrs Jackson reported that a new SA3 form has been devised. The IG team are currently seeking legal advice on the content of the form before finalising. A recent issue was highlighted to the IG Team regarding the use of PAS system by hospital switch board staff. The IG Team are discussing the issues with other Health Boards across Wales to establish their processes and procedures, and work is on-going to resolve the issues. The Chair agreed, especially in light of recent events with media and the Royal Family. An initial meeting has taken place and Mrs Parry agreed to feedback from this at the next meeting. The Chair also commented that this issue may well be raised at the next Board meeting, therefore any timescales of any process which may be implemented will be required before the next IGC takes place. The Committee accepted the concerns raised, Ms Rowlands commented that nursing staff are always aware of patients next of kin and would check the identity of a person before releasing any information. She also advised that nursing staff do

JP

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not give out information over the telephone but give a generalised statement. The Committee agreed that staff did not want to prevent the appropriate transition of information to the appropriate people, but it was recognised that this is a very difficult area and that guidance and procedures are required. The Chair asked if any Committee member had any further comments, these could be forwarded to Miss Wendy Hardman, IG Manager. Mrs Parry made the Committee aware of an investigation undertaken by Public Health, who have reported to Welsh Government and the Information Commissioners Office (ICO). Information Governance received a copy of the report approximately three weeks ago, and have made some comments for consideration prior to the final report being published. Dr Atenstaedt confirmed that he was not aware of the report. Mrs Parry informed the Committee that all GP laptops will be encrypted and discussions are taking place with national programme groups to establish who will incur the cost.

IGC 12/064 Issues of Significance from Health Infor matics Group and HIG Report - This item was taken for discussion when Mr David Davies joined the meeting via v/c at 10.26am. Mr Williams presented the issues of significance from the Health Informatics Group, noting that the Group did not meet in December, however work has been on-going. He commented on: The Terms of Reference (ToR) were reviewed and the first exception report was received which was a much simplified report that dealt with exceptions or major changes since the last report. Work has been progressing regarding the Therapy Services system and a meeting with NWIS has taken place to discuss how this system works in Wales. Discussions have taken place with Mr Davies regarding the local approach and he felt that a way forward has been found. PACS (digital X-ray) system has been procured and is now implemented across North Wales. There have been some issues with the system i.e. Patients have been flagged up as appearing in more than one hospital. An SBAR regarding the functionality of the system has and a way of managing duplicate data has been submitted for comment and approval. Mr Williams asked the Committee if they had any questions regarding the exception report, no comments were received. Mr Williams advised that a more comprehensive report will be produced 6 monthly. There are currently no changes to the Health Informatics / IT work plan. Work is currently taking place with procurement to progress the desktop storage strategy. Also, the plan for the Clinical Portal requires finalising

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but good progress is being made on the timescales to resolve issues by February 2013. A single implementation for Myrddin has been agreed and a full business case will be ready for presenting at the next Committee meeting in February 2013. Mr Davies commented that there is a credible programme for North Wales with some sensible solutions, the timescales are now achievable. Mr Williams confirmed that they did not achieve full approval by the end of November and a date is still outstanding. However, the timescale for the roll out of Myrddin is 2 years and the organisation is currently awaiting NWIS capacity to move forward. Mr Davies confirmed that a draft joint proposal is to be drawn up. A discussion ensued, with Mr Hesseling expressing concern regarding the delivery of projects and that timescales have not been achieved. Mr Roseblade commented on his concerns also but believes that Mr Williams and Mr Davies are aware of the urgency on this matter. The Chair asked for a realistic, deliverable integrated plan from both BCUHB and NWIS. Finance is on plan, however the capital schemes are using up lot of resource. Revenue is being managed well in terms of budget but there is a large amount of non-recurring activity, which will be a real challenge for the coming year. The Chair commented that reduced allocation from Welsh Government has been disproportionate and Mr Williams confirmed that there will be a requirement f just under £2 million IT equipment and infrastructure alone. Microsoft licencing is also changing, and will require an additional £750,000 revenue. Mr Williams is meeting with Neil Bradshaw to discuss this the longer terms strategic capital allocation. The Chair informed the Committee that the Finance and Performance Committee have agreed to share the allocation from Welsh Government in a way that positively favoured informatics and medical devices. Mr Williams informed the Committee that an application to the Invest to Save bids would be submitted. He also commented that disaster recovery planning is underway and plans are being implemented to move forward. Mrs Parry asked for an update regarding the transportation of case notes. Mr Williams advised that there is a great demand for records to be transported across North Wales due to patients attending appointments at various hospitals. Mr Williams briefly explained the process for obtaining medical records and that the digitalising of the patient record will help, however 2 weeks’ notice to scan the record is required so initially this will remain a problem. Mrs Lewis-Parry has asked that Mrs Parry work with Mr Williams to resolve the issues. Mrs Dean expressed her enthusiasm for the digitising of medical records. Mr Williams responded that a pilot scheme for the scanning of records is due to take place and Mrs Williams, Head of Performance & Improvement (Informatics), is involved in taking this forward. Mrs

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Williams briefly updated the Committee confirming that the pilot will be ready by the end of February/ beginning of March 2013. The Chair requested an exception report and schedule for a final outcome report be provided. Mr Williams confirmed that he will feedback to the Committee in April.

DW

IGC 12/065 Data Protection Subject Access Request Procedures Mrs Parry presented, and advised that amendments have been made:

• The inclusion of being able to waive the fee charged • Removal of the section that the individual has to state they are

making a request under the Data Protection Act. • A section has been added that a panel can be requested in order

to meet the requirements of the request and to provide assistance to ensure a timely response.

Dr Atenstaedt asked how many requests for information are received from the police per year. Mrs Gould advised that approximately 5 requests have been received over the last 3 months. Ms Dean expressed concern over the complexity of the procedure for enabling staff to view or request a copy of their personal file Mrs Parry informed Ms Dean that staff are encouraged to speak to their line manager in the first instance. However, the procedure is there to provide assistance to members of staff who do not have a good relationship with their line manager and vice versa. Ms Dean asked if this could be incorporated within the procedure as this is currently not clear, Mrs Parry agreed to amend this and provide some additional wording. The Chair asked if these issues had been raised previously, Mrs Parry responded that they had not when the procedure went out for consultation in July 2011. The Committee approved the Procedure, pending the amendments to be made by Mrs Parry. Mrs Parry agreed to circulate the procedure when the amendments had been made.

JP

IGC 12/066 SBAR – Appraisal and revalidation for Secondary Care Doctors in BCUHB Dr Duerden presented, and provided background to the SBAR for Committee members. He reported that doctors are required to go through a revalidation and review process. He advised that BCUHB have 1,300 doctors who will need to be revalidated over the next 3 years and the importance to have a robust system in place to allow annual appraisals to be carried out. This is not an issue for doctors in general practice as they use a system set up by the Deanery. However, it is difficult for hospitals to implement as currently there is a paper system and several electronic systems, and it has now been decided that all hospital doctors will use the MARS system. However, the system will not be in place for BCUHB until late in 2013. Following the hospital doctors concerns a meeting with Mr Chris Jones and the Deanery took place on 1st September and BCUHB insisted that our hospital doctors use the MARS system with immediate effect. Following this the Deanery

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has given assurance that MARS will be available by 1st January 2013. Hospital doctors will require training in the use of MARS and it has been agreed that there will be Revalidation Programme Board, a Programme Lead and Manager at each site assisting doctors. A discussion ensued around the SBAR and the use of MARS where costs were approached. Dr Duerden advised that costs were, at this time, undetermined but will be paid for by Welsh Government. Mrs Wilson asked if there will be a need for revalidation of GPs in line with their extended roles. Dr Duerden confirmed that it is the intention that the system will appraise the most clinical care area of a GP role and each component of work will be included. Dr Duerden also commented on the complexity of the process and advised that changes may be required in the future. The Committee agreed the recommendations. IGC 12/067 Standard Items

• Health Standards • Standards for Health (Star Chambers) - the next meeting is

deferred until January, Mr Williams will report back at the February Committee meeting.

DW

IGC 12/068 Any Other Business Ms Dean asked for clarification regarding the meeting times for 2013 – Miss Pritchard will amend start times to 9.30am and recirculate.

EP

IGC 12/069 Issues of Significance to be identified to the Boar d No items of significance for identifying to the Board.

IGC 12/070 Date and time of next meeting 14th February 9.30-11.30am, Boardroom 2 Wrexham Maelor, Boardroom Ysbyty Gwynedd and Committee Room Abergele Hospital.

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Summary Action Plan Name Action Deadline EP ICG12/060 – amend the minutes of the

previous meeting. 20.12.12

MD 12/030 RTT– present at the next Board meeting.

DW 12/049 Informatics Operational Plan – to submit to the next Health Board meeting.

31.01.13

JD & DW 12/061 Matters arisi ng regarding sharepoint – to discuss the problem Mrs Dean is experiencing with accessing meeting papers.

GLP & Chair 12/061 Matters arising regarding sharepoint – to liaise with the independent members to see if they are experiencing similar problems as Mrs Dean.

JP 12/062 Issues of Significance from HRG – arrange a task and finish group

JP 12/063 Issues of Significance from IGC – arrange a task and finish group

DW 12/064 Issues of Significance from HIG – exception report and schedule

April

JP 12/065 Data Protect Subject Access Request Procedures – to amend the procedure to reflect comments received and circulate.

DW 12/067 Standards for Health (Star Chambers) – feedback from the January meeting.

14.02.13

EP 12/068 Any other Business – to confirm the times of 2013 meetings.

18.12.12

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IGC October 2012

Version 1.0 Approved

Betsi Cadwaladr University Health Board

INFORMATION GOVERNANCE COMMITTEE

Minutes of meeting held on 11th October 2012 Via videoconference between Ysbyty Gwynedd and Ysbyty Maelor Wrecsam

Present: Professor M Jones Chairman Mrs Jenie Dean Independent Member Mr K McDonogh Independent Member Mrs Marian Wyn-Jones Independent Member Mr Harri Owen-Jones Independent Member Mrs Vera Wilson Community Health Council Representative In Attendance: Mr Dylan Williams Assistant Director of Informatics Mrs Justine Parry Head of Information Governance Mrs Barbara Jackson Assistant Director of Corporate Affairs Mrs Grace Lewis-Parry Director of Governance and Communications Mr Robert Atenstaedt Public Health Wales (Joined the meeting at 10.50am) Mrs J Trevor Welsh Audit Office Mr David Davies Director of NHS Engagement, NWIS Mr Mike Lugg Programme Manager Mrs Joy Littlehales Deputy Programme Manager Mr Christopher Roseblade Consultant Obstetrician, Assistant Medical Director (Joined the meeting at 10.30am) Mr Clive Sparkes Chief of Staff, Therapies and Clinical Support Mrs Gaynor Gould Information Governance Officer Miss Emma Pritchard Minutes Secretary Apologies : Mr Mark Scriven Medical Director & Director of Clinical Services Mrs Jill Newman Assistant Director Performance Analysis Dr Martin Duerden Deputy Medical Director Mrs Lorraine Hughes Staff Representative

Agenda Item Action

IGC 12/043 Welcome, Introduction and Apologies The Chairman welcomed attendees to the meeting of the Information Governance Committee (IGC) and introductions were made. Apologies were duly noted.

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IGC 12/044 Minutes of the last meeting held on 21 st June 2012 The minutes of the previous meeting were accepted as a true and accurate record, subject to the following amendments:

• IGC/031 Page 6 paragraph 4 should read “Experience tells us that this is more likely to take longer and this will mean we have to negotiate further contract extension with Isoft”.

EP

IGC 12/045 Matters Arising IGC 12/027 and 12/029: Mrs Gould confirmed that these actions have been completed. IGC 12/030: Mr Davies reported that NWIS is currently looking at referral to treatment (RTT). NWIS are happy to support BCUHB with the approach to re-focus informatics resources on implementing a single patient administration system across North Wales as a priority. RTT recommendation 4, this action has been completed and Mr Scriven will review the orginal report and present the report to the next Board of Directors meeting in October. An SBAR has been written to request additional trainers, which requires reviewing by Finance. Mr Williams also advised that training will be taking place at the end of October for Patient Index Management System (PIMS) and for staff involved in RTT in Ysbyty Gwynedd. Resources will also be published on the intranet to provide guidance on good record keeping. Comments were made as to whether processes are in place if a member of staff inappropriately accessed patient administration systems. Mrs Lewis-Parry explained that there are processes in place for this and individual line managers should follow due process. The first session for RTT training is October. Focus is also to be placed on management and cultural issues to ensure they are addressed. The Chair proposed that in order to reassure the Committee a progress update would be presented 6 monthly.

MS DW

IGC 12/046 Issues of significance from the Health Informatics Group (HIG) Mr Williams presented. He noted that discussions took place at the IGC meeting in June regarding simplifying and reconciling the Informatics Progress Report and the Informatics Cost Improvement Programme Report

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It was recognised that the implementation of a new single patient administration system across BCUHB will help enable integrated care across Wales. The Committee was in support of this and recognised the need to reprioritise the action plan to reflect this as a priority. It was also noted that the new system will need to take into account the needs of clinicians. Data from January 2009 will be transferred from the old laboratory Information Management System (LIMS) to the Welsh Clinical Portal (WCP) and historical data prior to this will be available via the historic systems for viewing purposes only. Through tight financial management the Informatics service are currently forecasting a balanced position for this year. However, there are some concerns regarding the cost improvements for 2013/14 and beyond as some cost savings have been made in part through non-recurrent savings and income. Mr Williams asked for comments on the National Information Strategy – Enabling Integrated Care in Wales.

ALL

IGC 12/047 Issues of significance from the Health R ecords Group (HRG) Mrs Parry presented and noted that the members of the HRG were happy to approve the retention and destruction of records and that the terms of reference had been amended. Mrs Parry asked the Committee to note the concerns raised with medical case notes, in particular:

• The legibility of the case notes • The need for BCU wide training regarding good practice as

stipulated in the RTT action plan. • The look and feel of case notes and in particular the large size of

individual case notes. Due to extensive care pathways, documents are between 60 and 70 pages long. Samples of care pathways were found to have been 60% completed and CPGs have now been asked to condense these documents or ensure they are fully complete. Mrs Parry will provide feedback on this at the next meeting.

• The storage of patients records due to their size. • The transportation of case notes as they are required across all

sites across North Wales. A risk assessment has been submitted to the Quality and Safety Lead Officers Group to raise awareness of this

JP

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Mrs Parry also highlighted the following discussions from the HRG:

• Changes to test result forms generated from telepath. • Currently a charge of £25 is being made for copies of X-Rays,

however the Data Protection Act (DPA) stipulates that the maximum cost for ‘computerised electronic records’ should be no more than £10. The HRG is awaiting confirmation from Radiology CPG that this has been discussed and that a revised charge will be made.

• The implementation of alert dividers across BCU. The dividers are to be used to ensure important information is brought to the attention of clinical staff and the use of them has been agreed following consultation with CPGs.

After a brief discussion the Committee expressed some concern regarding the appropriateness of including violence and aggression alerts and the need to have an alerts removal process. Mrs Parry agreed to feedback the Committee’s concerns to HRG. Mrs Lewis-Parry expressed a concern that the arrangements appear to be less clear in secondary care than in primary care.

JP

ICG 12/048 Issues of significance from the Information Governa nce Group (IGG) Mrs Jackson confirmed that the Group now has finance representation and Mr Steve Harper attended his first meeting in September 2012. Mrs Jackson presented the report and the following issues were highlighted:

• Following the last meeting she has discussed with Mr Trystan Pritchard the issues surrounding the collection of data for the Welsh Specific Equality Duties. Work is now being progressed.

• The new procedure for the handling of confidential waste has experienced a delay in its implementation due to the tendering/procurement process of identifying a single contractor to provide an on site shredding service across all BCU sites. Mrs Jackson asked the Committee if they would agree a revised date of 1st December 2012. The Committee agreed.

• Maternity records will be kept as part of the clinical case notes. • New Sharepoint sites will be limited due to technical issues.

However, Informatics are working with Mircrosoft to rectify this in the short term. The planned completion date of this work and release of the new version of Sharepoint is end of November 2012.

DW

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The Committee asked for a progress report for the next meeting. • The Welsh Audit Office, accompanied by members of BCUHB

staff, have carried out several ‘on the spot’ Caldicott compliance audits of wards within the 3 acute hospitals and the feedback has been very positive.

The quarterly statistics for Freedom of Information (FOI) and Subject Access Requests were presented by Mrs Parry. Mrs Parry also presented feedback from the Wales Health Information Governance Network (WHIGNET) noting:

• Version 4 of the Wales Accord for Sharing Personal Information (WASPI) is to be released and rolled out shortly.

• A Task & Finish Group is to be established to further develop an All Wales Email policy.

• An All Wales Information Governance E-Learning Toolkit is to be developed via a Task & Finish Group.

• The possibility of a National Intelligent Integrated Audit solution tool to audit staff behaviour when accessing clinical systems and will help with the monitoring of inappropriate access of systems, which the Committee supported.

Mrs Parry also asked the Committee to note the concerns raised at the recent Primary Care Computing Group (PCCG) regarding the encryption of GP laptops. She reported that NWIS were requested to carry out an audit of all laptops within GP Practices which found that approximately 80% of GP laptops were not encrypted. After a brief discussion the Committee asked that an update be provided at the next meeting.

JP

IGC 12/049 Updated 2012/ 13 Informatics Operational Plan The draft Informatics Operational Plan was last discussed at the IGC meeting in April. However, the Committee were unable to approve the plan as there was uncertainty about the national programme delivery at the time. Mr Williams presented version 12 of the Plan which now shows, through various strategies, a positive balance forecast for this year. The Plan requires approval by the Board. Ms Dean commented on page 7, item 6.8 ‘Improved use of communications and collaborative technologies’ and asked how urgent a matter it was for the issues regarding shared folders and the use of Sharepoint to be addressed. Mr Williams advised that this is being addressed via the development of desktop and storage strategies and Sharepoint has been highlighted as a priority.

DW

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It was also recognised that improving technologies such as video conferencing would help reduce the numbers of staff claiming mileage costs to travel to the different Health Board sites for meetings, although it was recognised that in some cases it is necessary to attend meetings in person. Investment in IM&T is extremely low in the Health Board and reprioritising the work plan will inevitably mean that there will be future implications on other projects which would have to be brought to a standstill while priority is given to other developments. The strategy being implemented is at a cost increase of only 1% rather than 4% and lack of funding in IM&T will mean objectives are taking longer to achieve and investment is needed. The Committee approved the Plan for 2012/13.

IGC 12/050 Informatics Progress Report – September 2012 Mr Williams presented the report and noted that efforts to achieve a financial balance position continue whilst there is a need to reduce revenue spends by £1.3 million and gain an income and expenditure balance. There is a need to identify further saving schemes in order for these targets to be achieved and it is recognised that National projects also have an impact. He highlighted the following points:

• Health records are a pressure area and it has been previously reported that risks are apparent due to the resources available to store records. Various sites are being looked into for creating storage capacity for health records and trials of scanning of records are taking place with NWIS. It is thought that if scanning of records is possible in the future then this facility would also be of benefit to corporate records d.

• Support has been given to the installation of the Fuji Picture Archiving and Communications System (PACS) system which is currently in place in Ysbyty Gwynedd and Ysbyty Glan Clwyd and is soon to be installed in Wrexham Maelor Hospital.

• The upgrade to version 305 (East) of Myrddin went live on 1st October which went well and was error free. There is now a foundation for this to be rolled out across North Wales.

• A further pressure has been identified by the Health Records department regarding Continuing Health Care (CHC) records and the need to have these records stored centrally. The issue stems from previous organisations and there are currently many BCU sites storing CHC records. Mr Williams informed the Committee that there is a storage strategy for reviewing storage and he will report back regarding these issues at the next IGC.

DW

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• Increased demand for health records is placing increased pressure on health records staff. There is also increased pressure for the transportation of patient case notes across BCUHB sites. A risk assessment has taken place but as yet there have not been any solutions developed. The Committee share their concerns regarding cases note availability.

After discussion Mrs Lewis-Parry requested that for future meetings an exception report be presented to the IGC to pick up significant issues. The Committee accepted the issues raised and agreed to accept exception reports for future meetings.

DW

IGC 12/051 Reprioritisation of the Informatics Programme Plan (SBAR) Mr Williams presented the Plan and advised that due to the postponement of the Welsh Clinical Portal (WCP) and the introduction of the new Laboratory Information Management System (LIMS) there is now an opportunity to reassess the existing informatics programme plan. He proposed that prioritisation would be given to the implementation of the Myrddin system across North Wales. However, there is still a need to focus on the WCP but as yet it does not meet the minimum requirements for BCUHB in Central. The additional time needed is to develop solutions for microbiology, the blood transfusion service and radiology design and functionality. Mr Roseblade offered his assistance in approaching colleagues to try and provide some help regarding the outstanding issues and work with NWIS. Mr Roseblade stressed that there is a need to deliver some positives outcomes for clinicians to reassure them with the implementation of national systems. He also strongly supports the need for a having a system that works across North Wales that will also link in with national systems. Mr Davies reported that the provision of a standardised discharge process and summary of care to the GP/referrer has been requested by GPs for some time. This is due to be piloted on 5th December 2012. He also noted that the current timeframe for the Myrddin system to be BCU wide is 2 years which is considered an ambitious deadline but could be accelerated with the support of the CPGs. Mr Williams advised that a meeting is scheduled with NWIS on 22nd October 2012 to discuss key timescales and sequences of events, and from this more detailed planning can commence. Members of the Committee commented on previous discussions that NWIS would pick up the additional costs of having to negotiate further contract extensions due to the delays in implementation of WCP and LIMS, which are as a result of IM&T resources currently concentrating on

DD

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the National Programme. Mr Davies agreed to pick this up on behalf of Health Boards across Wales. The Committee were comfortable with the development of the planbut would like to see realistic timescales set and a further plan submitted following the meeting taking place on 22nd October 2012. IGC 12/052 Laboratory Information Management System (LIMS) and Welsh Clinical Portal (WCP) update Ms Littlehales presented the report to the Committee and highlighted that there had been some high level issues with LIMS and WCP which have led to the projects being paused. LIMS and WCP currently do not meet the minimum requirements and a joint decision to pause both projects in BCU Central was made in conjunction with NWIS. WCP has been successfully implemented in BCU West. The date for implementation of LIMS across BCUHB is July/August 2013.

IGC 12/053 BCUHB Information Governance A nnual Report 2011/12 Mrs Parry presented the first Information Governance Annual Report. The report is to provide the Committee and the Board with the assurance that systems in place are adequate and provide evidence of our compliance with current legislation. The report details the achievements made for the year and Mrs Parry felt that a lot of work had been achieved especially given the small size of the Information Governance team. Mrs Parry asked the Committee to note the Health Boards compliance with requests for information under the Freedom of Information (FOI) Act and Subject Access Requests. She commented that it is recognised nationally that there has been an increase in the number of information requests being submitted nationally and they are becoming increasingly more complex. The compilation of answers frequently requires information from multiple CPGs and there is a need for support from CPGs in improving response times.

IGC 12/054 IM&T Security Procedures and Procedure for storage & transportation of patient/person identifiable (PPI) or sensitive information Mrs Parry advised the Committee that the procedures have been developed by the Information Governance team in conjunction with the IT Department to provide a consistent approach across the Health Board, and to ensure compliance with standards and legislation. The IM&T Security Procedures were discussed at the last IGC and following comments made by the Committee the procedures were updated. After discussion the Committee requested that the following be addressed:

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• An appendix be included that listed Information Sharing Protocols

(ISPs) already in existence. Mrs Parry stated that a web page of existing protocols is being developed and that a link to this web page can be included within the document.

• Some formatting errors were found on page 5. • With regards to 6.7 - visitors to be accompanied at all times, the

Committee felt that this was something not achievable and requested this to be amended to apply to visitors accessing non-public areas.

• With regards to 7.2 - passwords, an amendment is needed to reflect the current practice of a minimum of 8 characters.

The Committee approved the IM&T Security Procedures and Procedure for storage & transportation of patient/person identifiable (PPI) or sensitive information subject to the minor amendments above.

JP

IGC 12/055 Cycle of assurance – polic ies Mrs Lewis-Parry advised that there is a protocol for the sign off of minutes of meetings and a review of policies has already been adopted at Board which Committees must comply with. The Chair also commented that exception reports will provide assurances.

IGC 12/055 Standard Items • Healthcare Standards – star chambers will be held in November

to discuss HCS 19 and 20, feedback to be provided at the next meeting

DW

IGC 12/056 Any Other Business No further items or issues for discussion.

IGC 12/057 Issues of Significance to be identified to the Boar d No items of significance for identifying to the Board.

IGC 12/058 Date and time of next meeting Thursday 13th December 2012, 9.30am.

10 Page 10 of 11

IGC October 2012


Summary Action Plan Name Action Deadline EP IGC12/044

Amend minutes of the last meeting. 18.10.12

MS IGC 12/030 – Referral to Treatment Present the report at the next Board of Directors Meeting.

25.10.12

All IGC12/046 – NWIS National Information Strategy Comments from Committee Members on national strategy.

19.10.12

JP IGC12/047 Issues of Significance from HRG Mrs Parry to provide an update regarding concerns that were raised about patient case notes.

13.12.12

JP IGC12/047 Issues of Significance from HRG Mrs Parry to provide feedback regarding violence and aggression alerts in case notes.

13.12.12

DW IGC12/048 – Issues of Significance from the IGG Update regarding the reprioritisation of sharepoint.

13.12.12

JP IGC12/048 – Issues of Significance from the IGG Update regarding encryption of GP laptops

13.12.12

DW IGC12/049 – Informatics Operational Plan Version 12 to be submitted to the Board for approval.

25.10.12

DW IGC12/050 – Informatics Progress report, September 2012 Exception reports to be presented in between the annual reports.

13.12.12

DW IGC12/051 - Reprioritisation of the Informatics Programme Plan Mr Williams to provide an update regarding the NWIS meeting on 22nd October.

13.12.12

DW IGC12/050 – Informatics Progress report, September 2012 Mr Williams to report back regarding the storage strategy.

13.12.12

11 Page 11 of 11

IGC October 2012


JP IGC12/054 – IM&T security procedures and procedures for storage and transportation of PPI or sensitive information. Amendments to be made as per minutes.

13.12.12

DW IGC 12/055 – Standard Item Mr Williams to provide update on Health Care Standards 19 and 20 following Star Chambers in November

13.12.12

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