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Skin Lesions Glos Care Pathway Overview

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Assessment

Pictures can be used in two instances:

  1. Attached to Advice and Guidance referral when GPs are unsure of management options or unsure if a patient needs a 2WW referral. Advice and Guidance will be responded to within 48 hours
  2. Attached to a routine dermatology referral to aid the consultants in secondary care to manage the referral.

A good quality picture will: aid in the specialist team's ability to reassure GPs about the dianosis of a lesion, advise a GP how to manage their patient within primary care, move a referral form from Advice and Guidance to an outpatient appointment, and potentially in the future, the ability to book patients directly onto surgical lists.

  • Dermoscopy acts as an aid in the diagnosis of skin lesions
  • It must not be used in isolation but instead combined with a good history and naked eye examination
  • In the right hands dermoscopy can reduce referrals and also unnecessary skin surgery 

The Primary Care Dermatology Society provide a wealth of information about dermoscopy, for further information please see http://www.pcds.org.uk/p/dermoscopy-purpose-of-dermoscopy-in-primary-care

Feel free to save this link somewhere useful as it is a shortcut to all 9 videos.

 

Use of images for clinical purposes

Whilst it is appreciated that there may be some risks attached to the use of images for clinical purposes there also clear demonstrable benefits to patient care. The routine use of images attached to Advice & Guidance requests and referrals would add clinical value by giving greater diagnostic certainty to the triage & vetting process and help make better use of pressured clinical resources.  

The main risks identified are primarily concerning patient confidentiality, data protection and Information governance. The following points describe a process to manage the risks associated with the use of images for patient care with guidance governing the use of camera’s/smartphones that is compliant with the newly introduced GDPR (General Data Protection Regulations) and this is described below.

Good practice tips

  • Please be aware that images of facial lesions or other distinguishing features e.g. tattoos could potentially identify the patient
  • Where the identity of the patient cannot be withheld by covering identifying features, the referral can still be made without photography and referrals without supporting images will not be unnecessarily delayed.
  • Some patients may not be comfortable with images of lesions in intimate areas so approach the conversation sensitively explaining the risks & benefits of using an image for direct clinical care
  • Cameras, tablets or smartphones may be used to take images but be aware of the risks of breaching patient confidentiality, IT governance & data protection issues
  • The CCG will have an expectation that practice will have appropriate governance arrangements in place to protect patient data

 

Practice tips:

Information Governance/Patient Confidentiality

In simple terms consideration must take into account measures to protect IG, Data protection and Patient confidentiality. In simple terms the process covers connectivity, transmission, security & storage as these are points of vulnerability open to risk.

 

Connectivity

  • Please note if the devices automatically synchronise to cloud storage, and other devices you might breach all three policies at once.
  • If using a smartphone all connectivity to Bluetooth, location information and cloud-based storage systems must be disabled and social media disconnected 

 

Transmission

  • Emailing outside of nhs.net is unsecure.
  • Emailing from one NHS.net account to another is the most secure method as the platform is encrypted.
  • Images must only be transferred through secure connections (e.g. N3) using nhs.net email addresses, secure image management systems, VPN networks or encrypted image transfer apps – no trace of the image should remain on the camera or the smartphone

 

Security

  • All devices/systems must be password protected or have a security PIN activated.
  • GPs recording photographs should upload the image to the patient record as soon as possible (to ensure the image is attached to the correct patient record).
  • Once the image has been uploaded to the patient record, all copies should be deleted from the original device and any desktop etc. used in the process of uploading to the patient record system and/or eRS - the only copy that should remain is the copy that is in the patient record unless there is an ongoing clinical need/purpose.
  • Standalone cameras are a safer option as they can be securely stored in the practice and images deleted off the flash cards once they’ve been transferred to the clinical record.
  • Cameras must be kept secure under access controlled conditions at all times
  • The use of cameras/phones must comply to local information governance & confidentiality guidance set out by the CCG and the practices own policies 

 

Storage

  • If Images need to be stored they should be downloaded to a secure, backed up server and stored within an access controlled/password protected searchable retrieval system with a file structure that identifies each individual patient and, within that, each episode
  • Images should not be duplicated, so if images are stored in the record, the original downloads should be deleted unless there is a need to store the image for clinical purposes
  • Images should not be stored in the practice on unencrypted individual PCs or memory sticks or other portable media such as CDs/DVDs
  • If images need to be stored care should be taken with the storage of PID – if an email system is used the subject line must not contain a full set of PID, if stored on portable media this should be encrypted

Primary Care Management

The majority of these will be easily recognised by GP's

Refer to appropriate benign skin lesion guidance as required (from Primary Care Dermatology Society (PCDS))

Benign symptomatic skin lesions and low risk BCCs can be removed under the Minor Surgery DES. A number of GP Practices will also accept inter-practice minor surgery referrals to remove these lesions. The list of GP Practices that can be referred to is available here and the referral form is available here.

If still unsure and there is no internal or locally accessible practice expertise seek further advice via Advice and Guidance - include clear history plus general and close up images. Wherever possible a dermoscopic image should also be included as this provides the greatest diagnostic certainty (see Assessment guidance above)

Rapid Advice and Diagnostic Support (RADS) Request

All requests must include general and close up images. Wherever possible a dermoscopic image should also be included as this provides the greatest diagnostic certainty (see Assessment guidance above) combined with clear history

Send via eRS Advice and Guidance - please mark the priority of these requests as 'urgent' to ensure a rapid response

Advise patients that request for advice may result in a referral (possible 2ww) if the specialist believe this is necessary

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