Civil Evidence Act 1995 and changing GP systems

[Peter Sommer]

The main purpose of the Civil Evidence Act 1995 was to admit hearsay 
evidence and to provide associated conditions.  Section 7 made it 
possible to admit copies of documents and section 8 allowed for the 
admission of "records" of a business or public authority provided there 
was an affidavit / certificate that the records formed part of the 
regular business activity.

Thus,  the law is about allowing such records to be admitted (whereas 
before much more complicated forms of proof were required).   Once the 
evidence is admitted it is still open to challenge on the grounds of 
weight (eg that in some respect it is not accurate).  However normally 
there will be a rebuttable presumtion in favour of reliablity.

The Civil Evidence Act does not prescribe standards by which records in 
electronic form  should be kept.   There are some applicable 
international standards:  ISO 18492:2005 and 15801:2009.  There are also 
some BSI documents:  BS 10008:2008.

I don't know if elsewhere there are specific requirements for the 
maintenance of medical records.

Off the top of my head,  I would guess that the obligation would be to 
keep old records in their original electronic format plus the software 
necessary to read them.  And probably have more than one copy kept in 
more than one place for safety's sake.   An audit trail in the form of a 
document saying when the archive was created and by whom would also seem 
to be a good plan.

Unless some-one else here knows better?




On 09/08/2010 08:40, Mary Hawking wrote:
>
> GPs were allowed to keep their patient records electronically by 
> Statutory Instrument in 2000, and the law that allowed the electronic 
> EPR in evidence was the Civil Evidence Act of 1995.
>
> GP practices change systems over the years, sometimes several times, 
> and patients move between practices: some systems only transfer the 
> records of current patients -- i.e. if a patient leaves the list the 
> day before the data is downloaded for transfer to the new GP system, 
> the only place that the record will be preserved is on that practice's 
> old system.(apart from any print-outs or GP2GP record transfers which 
> lack audit trails).
>
> How does the CEA deal with computer evidence when the 
> organisation/individual concerned has changed systems -- and does 
> anyone have any references to cases which might be relevant to the GP 
> situation?
>
> The additional twist in GP records is that for an infant at birth, 
> problems can be raised up to 3 years after the age of maturity -- or 
> indefinitely if the infant is sufficiently damaged to never reach 
> mental competence...
>
> Genuine enquiry -- topic was raised regarding GP records and keeping a 
> copy of the database in an old system: I don't think it has been 
> decided in court -- yet -- so I wondered whether there was non-medical 
> case law which might be applicable.
>
> Mary Hawking
>
> GP
>
>
>    

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