Back @ the EPR Arms: July 2016 Medical Images

'Jimmy come over here and join my selfie'.

A crowd from the hospital gathered around another smiling leaver - Jimmy Rainsford. They were dropping like flies these days. All ‘Boomers’ ready to start their new life of bliss and pensions. Lucky blighters.

'Here Mate,' he said to me, 'can you take us a selfie'
'Hardly a selfie then eh?'
'Arms ain't long enough Bud'
'OK. Right. Now then. Say ‘Cheese!'’ I frame them all in the viewfinder.

Norm, the uni lecturer who knows everything there is to know about anything, sauntered over to me.

'Do you know, saying ‘cheese’ makes your mouth smile for the camera, but in Spain they say Patatas (Potato), in Argentina it is the English word - whisky and Bulgaria its Zele (Cabbage). (For more of these see )

'Ta Bud!’ said Jimmy. ‘I'll Fb you the photo unless you wanna Bluetoof now'

Fb? Bluetoof? Another language. Another lifetime. Another beer.

'Another beer Norm?' I asked tilting my near empty glass his way.

'I'll just 'ave half thanks.' he said following me to the bar pointing at the middle tap. 'That one. Leafy Dock. New. Sounds good. Nettle after taste. 5.5% will do for me'

'It's another world Norm: Selfies. Instantly up there on Facebook or Instagram or Twitter. Another world. And it’s caused a real ‘stooshi across the road’

'At the hospital?’ he asked, ‘in what way?’ licking the nettley froth from where Bill the barman had been sloppy. 'With patients or staff?'

'Staff - of patients. It's a bit easy isn't it?’ I continued, ‘See a rash or a bed sore. Click. Done. Don't bother the Medical Illustration Department – even if you had one. No need to wait. Click. E-mailed to yourself. Sorted.’

‘And the problem is……………?’

'There isn’t A problem Norm. There’s loads of problems’ said a voice which belonged to a pretty woman entering our drinking space.

‘Lucy!’ said Norm.
‘Lucy?’ I queried
‘She’s the Medical Photographer over at my Uni hospital up in the City.’ continued Norm.

‘Yes there’s confidentiality issues- how do you control who is looking at the photo. There’s consent issues: is the patient happy to have their photo taken and how can it be used. Then there’s quality issues. I mean, you can’t just take a photo – SNAP! - and that’s it can you? Are you getting the drinks in Norm? Lime and Soda for me – I’m driving. And don’t get me started on videos.’
‘Videos ?’ I asked, thinking Blockbuster had made a comeback.

Stooshie – A Scottish word for row or commotion or fracas.

‘Surgeons videoing operations. A&E videoing Trauma events. Physios videoing before and after hip ops. The list goes on.’

‘Wow, I’d not really thought about all of this. I just assumed it would all be locked down and managed.’ I said.

Lucy continued ‘You see, many Trusts have got rid of their Medical Illustration Department and that seems to have left a real issue - a vacuum, which it appears is being filled by staff using their own cameras and phones. No-one is responsible for the management of these images and to be honest, most of them are of rubbish quality. Remember, these may have to be used as evidence in court. Out of focus is no good. And then there’s confidentiality’.

‘But hasn’t that already been sorted with your X-Rays? Can’t you simply adopt the same rules?’ I asked as Norm returned with a Lime & Soda

‘Not the same. You can’t identify someone from an X-Ray. Well not easily. There are photos in hospitals floating around the ‘ether’ or on personal cameras or worse still by mobile phones, which are not being managed. Photographs are taken in Dermatology, by staff, of patients. Taking them on the member of staff’s personal camera and saved onto their desk-top. Dental/Orthodontists take photographs of patients’ jaws/head. Podiatrists and Diabetologists take photographs of feet. Community nurses have been given smart phones to take photographs of patients in their own homes with bed sores. The list is endless. No control. No management.’

‘OK. So I see there is an issue. What would a good hospital actually do if they had a Medical Illustration Department? I mean, what does ‘good practice’ look like Lucy?

‘Well,, there is no official guidance from the NHS but there is guidance from the Institute of Medical Illustrators‘

‘The Institute of what?’
‘It’s our professional body.’

‘Go on then – run it by me’ asked Norm taking another sip of his beer.

‘Well, it is recommended that medical photography/illustration departments have a policy/protocol covering the handling of confidential material. It also goes on to say that clinical photographers should only obtain those illustrations that have been requested by the clinician and which the patient has consented to, and no others.

‘That’s seems sensible,’ as Norm drained the last of his nettles.

‘There’s more’ continued Lucy, ‘All digital images must be correctly identified and stored in an image database protected by passwords in accordance with local policy. Data should be regularly backed up to maintain its integrity and should be clearly marked with the level of consent given by the patient.’

‘Different levels of consent?’ I asked. ‘What do you mean?’

‘Well, you may be happy to share your photo for diagnostic purposes but not for teaching. Or for publication. Or anonymised for publication but not as part of your record.These images have many uses and not simply there as part of the diagnostic record. It’s complicated.’

I continued ‘,,,,,but looking at it from the other side Lucy, I can see why a doctor who is seeing a patient thinks he may as well take a photo rather than get the patient to come again to see you or your colleague with all those parking problems and getting time off work and all’.

‘Yes but even if the photo is a good, well taken one, there MUST be rules about gaining consent and they MUST be stored correctly and the quality MUST be appropriate and admissable in court. I can sew but it doesn’t make me a good surgeon does it?’

‘And those rules can be found at?’

‘The Institute of Medical Illustrators here

‘I need another drink. A full pint’ said Norm. ‘And less nettles this time. I think I’ll give the Deadly Nightshade a go. A dark mild if I’m not mistaken - four point eighter’.

‘Cheese!’ came the cry from the group at the bar as another memory was taken to be lost for all time – or worse still, not.

How does YOUR organisation look after clinical images in YOUR place of work? Isn’t this something we should be getting alarmed about? Isn’t this something which needs some top-down rules and guidance? Or do you think it is not an issue. Please email your thoughts to This email address is being protected from spambots. You need JavaScript enabled to view it.

Back @ the EPR Arms: March 2016 Paperless by 2018?

‘She’s been at it for thirty years has our Thelma. Thirty years I said. Thirty years!’

‘At it? At it? At what?’ asked Louise?

‘You know. Medical records. Pulling notes. Filing notes. Lifting notes….’

‘Finding notes’ said a grumpy voice from across the table. ’Under consultants’ desks, in secretaries’ ‘secret’ hiding places. Stacked up behind cupboards. In coders’ cupboards absolutely anywhere. Flipping anywhere!’

‘Pushing notes in a trolley from the dusty basement to the records prep room to the clinics. Thirty years I say thirty years.’ continued Lorraine picking up her glass of chilled chardonnay.

‘Ay – haven’t we all’ said Louise slurping her vodka tonic and swirling the ice cubes round and around.

‘Well – no’ corrected Lorraine, ‘I’ve only been at it twenty years. I’m a relative newbie!’

They all giggled at that. The medical records staff were sat round a big table in the pub after work on a Thursday. It was Thelma’s last day. This after-work gathering was a rare occurrence.

‘Grab us a sausage roll wilt Suze’ shouts Lorraine to the queue at the buffet in a grating Yorkshire accent.

‘She started when she was 16 – straight from school. Had a 10 year brek for babbies but all in all 30 years she’s done. And now she’s free. Free I say! Free!’ Lorraine sounded like she’d just watched her best mate tunnell out of either Tom Dick or Harry in the Great Escape. ‘And what’s she got to show for it eh? A mouldy buffet with curling sandwiches and flakey sausage rolls. Oh and a clock. A clock! I ask you who wants to watch the time when you retire.’

‘It’s been a long thirty years’ says Thelma joining the group and pulling up a chair with one hand while balancing a plate of sandwiches with her other. ‘I remember when we were told we were going paperless.’

‘Oh by Jeremy Hunt? Paperless by 2018 he said’ reported Louise.

‘No not the Hunt – way before that. In the 80’s then the 90’s. Another hint in the noughties and again in the whatever we call ‘now’’ ‘The teenies!’ shouted someone coming over with a big bendy sausage roll in her hands.

‘Thanks Suse. Teenies? Is that where we are now? I like it. We are the oval teenies’ giggled Lorraine.’That teks me back’

‘Who are you calling Oval!’ said a large woman joining them with four pork pies.

‘……and you weren’t even in the war!’ corrected Louise.

‘Feels like I have been. Anyway, where was I? Oh yes. They’ve been threatening us with going paperless for yonks. Ever since Adam were a lad’ said Thelma

‘Our Adam? He still IS a lad !’

‘No – I mean Adam and Eve’s Adam. I mean, like, yonks ago! But still we’re pulling notes’

‘And filing them’ joined in Suzie

‘if you can find them’ repeated the same grumpy voice from across the table.

‘And prepping them’ said Adam. The token male of the group.

‘….and wheeling them’ mumbled Lorraine through a sandwich.

‘…and filing them again.’

‘I need a drink!’ said Suzie. ‘Want one Thelma? Another special ‘last-day’ glass of wine?’

‘What another one? I’ve still got two waiting for me. But go on then. Why not. It IS my last day isn’t it. But I’m gonna miss you all’ said Thelma with a hint of dampness at the corner of her left eye. She was either sad or had the beginnings of conjunctivitis. ‘I hated the job but I will miss you lot. I’ve seen more of you than I’ve seen of my Jack over these last 30 years.’

May not be conjunctivitis, (conjunctivitis (unspecified) H10.9). It could be Meibomian gland dysfunction (MGD) (Not sure of that code. Not used it for a while) thought a psychic clinical coder who had just joined the group with her glass of claret and a carrot.

‘Oh hello Michelle. How’s coding? Cracked it yet?’

Michelle was expecting another Bletchley Park jibe but didn’t get one. She quietly nibbled her carrot stick instead.

‘Good buffet Thelma ! You’ve been here a long time haven’t you?’ said Michelle as she raised her claret.

‘Aye lass she has and I bet she’s got lots of stories to tell,’ said Lorraine ‘….but she wont be here to tell ‘em no more. You’ll be sun-bathing in Spain or Italy or Cornwall won’t you Thelma?’

‘Huddersfield more like! And there’s no sun there !’ said Thelma. ‘I’m going nowhere. I will miss you – my mates. I really will’ ‘Well – listen, here’s an idea. Why don’t we all meet here once a month – on a Thursday - straight after work, and put the world to rights?’ Do you mean like a Thelma’s Thirsty Thursday night. Wouldn’t that be good?

‘And what will we talk about?’

‘We’ll think of something. You lot are always going about something or other.’ said Thelma, warming to the idea. ‘We won’t have any problem finding topics to discuss. In fact, why don’t we ask the readers of the blog to suggest topics?

That’s it, dear reader. Email your suggestions for the Thelma’s Thirsty Thursday to This email address is being protected from spambots. You need JavaScript enabled to view it. and every month we will join them all at the EPR Arms. Good idea?



































Back @ the EPR Arms: April 2016 To share or not to share: That is the question

‘He went to Wales I think. Angelsey. Somewhere foreign that’s for sure’.

‘Not sure Wales is classed as foreign Bill’ I said to the landlord.

‘Well – it’s a long way away and they speak funny!’ he replied while he emptied the pot washer. Steam gushed out like a rising cumulus cloud, momentarily fogging his glasses.

‘So when did you take over as landlord Bill?’ I asked while he cleaned his glasses with his pot towel which was still securely wrapped around his waist.

‘Oh about six years ago. You know the old EPR Arms shut in, what was it, 2004 I think. Just like that. No rhyme or reason.’

‘Didn’t it open again as a fancy wine bar or something?’ I asked vaguely remembering a period when it was all shiny noisy laminate floors and high tables and even higher stools. Not for me.

‘I ripped all that up and put it back to what it was. Even got the same real ales back. Badgers Crushed Paw Bitter to name just one’.

‘Tapas!’ snapped a regular sat on a stool at the bar. ‘Tapas in Huddersfield. I mean – how was that ever going to work. Only bottled beer. Only tiny portions. Little Plates. Big Prices. Died a death. I say died a death. Know your market.’ He looked (and sounded) a bit like Fred the Butcher from Corrie and coincidentally shared his name. ‘That’s it. Know your market. We want us beer. Good beer none of that fancy bottled fizzy muck wi’ a lime shoved darn its s’neck.’

He was warming to his theme of the old days. Any minute now, Fred would say it was different in his day.

‘T’were different in my day’ said Fred, not letting me down. ‘I worked darn’t’pit and on us way back home, I’d have us pint to wash’t muck awa. It were part of us routine. ’

‘See you later Fred’ I said picking up my pint of Badgers Crushed Paw Bitter and having a quick slurp to get me across the room safely. I spotted a rowdy lot coming across the road from the hospital, so I wanted to grab a seat before they arrived.

Fred stayed where he was – on his stool at his bar drinking from his tankard. Not many folk do that anymore do they? Old Albert (God bless him) sat in that place. The only thing different between Fred and Albert was that Fred didn’t have a ferret. Or a flat cap. The world’s moved on. Old Albert used to cause quite a storm in the old days but now ferrets, along with ciggy smoking, have been banned. I must admit I don’t miss either smell.

The gaggle crashed through the door and they were all talking at once. ‘Did you hear what she said – her from Manchester way? They’ve done some brilliant work sharing records across their social care and GPs and hospitals. Why can’t we do that eh?’

‘Because our IG lead won’t let us’ said one lad pointing to Robert who had been pushed to the front to get the drinks in.

‘Why not?’


‘What scent?’

‘Consent. To share a patient’s or client’s information they have got to say they are happy to share their information. We have to tell them who we are sharing it with.’ said Robert attracting Bill’s attention with a curious wave of his wallet.

I listened to this from afar.

I noticed one of the gaggle was someone from medical records. I’d seen her last month at Thelma’s leaving do.

‘Ay up Loz’ I said. Lorraine was happy for me to save my breath on her name.

‘N’athen. Hows you doin’?’ she asked – like Geoffrey Boycott in a frock.

‘Whats this lot then Loz? What’s occurrin’ I asked.

‘Just had a DFC sesh over road’ she said..

‘Fried Chicken?’

‘No – Dame Fiona Caldicott. DFC. All about sharing records or not.’ She grabbed her (large) Chardonnay and popped across the room to join me. ‘Thanks Robert’ she shouted at the poor harassed (and now considerably poorer) man who had got the round in. ‘Have you heard of the Caldicott Review? The Caldicott Guardians? The Caldicott committees?’

I admitted I had. Actually a pet subject of mine.

‘Well you will know that (Dame) Fiona Caldicott was initially asked by the NHS Chief Medical Officer (CMO) to come up with some rules about sharing patients’ information,’ said Lorraine, ‘Mmm a hint of apricots’.

‘That was yonks ago though wasn’t it?’ I said, thinking about getting my second pint.

’Yes, you could say that. The original report was written in 1997. It was a different world then though – you could say far more ‘paternalistic’ and much less patient centred. It was officially known as guidance on "the protection and use of patient information" and identified the issues and complexities……’

‘And tensions!’ I interjected.

……………’ of sharing patients’ information. Tension? What tension?’ she retorted.

‘Well, we have on the one hand the need to protect and maintain patient confidentiality, and at the same time we need to share information about our patients. A tension.’

‘Yes you are quite right. There were some staff who adopted the ‘Computer says no’ attitude and used the Caldicott principles to smother any good meaning intentions to share data – speaking of which …….’

At that point, the bespectacled and harassed man who had just been relieved of twenty two pounds thirty pence by Bill at the bar decided he needed to sit down.

‘£22.30 that’s just cost me! Anyway, I can’t share an individual’s data unless they tell me EXPLICITLY that I can do so on their behalf.’

He sounded just like a jobsworth nasally stamp collecting trainspotter.

‘But how do you know WHO will need to see that patient’s data?’ I asked, wishing I had replenished my pint earlier as this could be a long long session.

‘Consent! Plain and simple. I need to know they are happy for me to share with anyone we intend to share it with.’ I could feel my BP rising and I don’t mean the cost of diesel across the road.

‘I think you will find that DFC’s Review of 2014 actually clarified that Robert!’ I said rather more forcibly than I had originally intended. ’She actually actually said ‘over recent years, there has been a growing perception that information governance was being cited as an impediment to sharing information, even when sharing would have been in the patient’s best interests’. And not just with named individuals but anyone with a legitimate relationship and delivering Direct Care. Anyone.’

‘If they don’t want to share their data then they are quite at liberty not to do so’ he continued in a nasally voice that instantly got up mine the minute it had left his.

‘Loz added gently ‘She also said that services cannot work effectively without trust and trust depends on confidentiality. However, people also expect professionals to share information with other members of the care team, who need to co-operate to provide a seamless, integrated service. So good sharing of information, when sharing is appropriate, is as important as maintaining confidentiality.

‘But if they don’t want their data to be shared with a member of any clinical team then I cannot allow any of that patient’s data to leave my organisation.’ A forceful end to an increasingly forceful conversation.

‘Whoa Whoa Whoa’ said Lorraine.’ I think we all agree that we must take care of all data we hold. And when we share it, I think we all agree that patients must be happy for that data to be shared. DFC said that her overarching aim has been to ensure that there is an appropriate balance between the protection of the patient or user’s information, and the use and sharing of such information to improve care. The issue is, we do not know who will need that data, so we can’t ‘up front’ ask for that specific permission for any specific individual. We must simply ask the patient to trust that we will manage their clinical information safely and securely and only people who need to see their information actually do do’

‘Doo –doo?’ I asked. ‘Doo Doo?’

And that seems a good place to pop to the bar to get my refill.

What is your experience of these tensions dear reader? How have you managed it? How do you ask and record consent? What do YOU do if a patient refuses to share their data? I would be really really interested and I can bring it up in the next episode of Back @ the EPR Arms.














































What is EPR Arms?

The EPR Arms is an imaginary pub in Yorkshire opposite a busy General Hospital. It first opened in 2002 but closed down after a couple of years. It has now re-opened and is a meeting place for hospital and other NHS staff together with the public where regulars (and others) meet and, over a pint or cup of coffee, chat about everyday NHS issues that affect you and me.

Some call it 'Quirky' but why not have a read and find your own word to describe it!

To view all issues please hover over the EPR Arms tab on the navigation bar at the top of this page and click Archive.

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