Royal College of Speech and Language Therapists Online Outcome Audit

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Integrated Services Information Governance Board

Information Sharing Business Case

Service / Team / Project Name:

Royal College of Speech and Language Therapists online Outcome Audit

Date of completion:

2/4/2019

Completed by:

Marjan Daneshpour

Head of Information and Child Health

Information Sharing - presenting a Business Case:

Introduction

This document is a tool for practitioners and sets out the principles that will be applied to sharing information (such as aggregate data) across organisations, both internal and external. It sets out the commitment to information sharing, explains what information is generally shared, grounds for sharing information and the controls and assurances which are agreed. Most importantly it provides a clear way of demonstrating compliance with the various legislation, such as the Data Protection Act.

Commitment to responsible information sharing

Information will be shared with partner organisations to provide high quality people focussed services.

Understanding the benefits to be gained through working in partnership, the commitment to building effective partnerships and sharing information is recognised - in particular to ensure early intervention to achieve positive outcomes.

The importance of sharing information is carefully balanced with the need for privacy. This is done by assessing whether the sharing is necessary and proportionate and having controls in place against loss, inaccurate recording or misuse of information and by working tightly to the Data Protection Act and other relevant legislation.

In particular, in sharing information: -

  • Anonymised information will be used where possible and appropriate.
  • Information will be shared on a "need to know" basis, the minimum information consistent with the purpose for sharing.

About the principles and proforma

When to use this document?

This document is a guide designed for use when sharing aggregate data or personal/ sensitive data between different organisations on a regular basis and/or seeking permission for staff to access specific databases outside of their own service area. You should use it as part of the early stages of considering to share information.

What it includes and how used?

The key principles of good practice in sharing information and compliance with various legislation (e.g. the Data Protection Act) are set out. This document can be used for a wide range of information sharing purposes, for example, to facilitate information sharing under the Crime and Disorder Act 1998.

This document does not intend to set out all legal issues; instead it is designed for use by practitioners focussing on the practicalities of information sharing and requires them to detail how compliance will be achieved.

Using this document does not invalidate any existing information sharing agreements.

The proforma

Attached to this principles document (Appendix 1) is the proforma to set up individual information sharing arrangements. The proforma requires practitioners to describe what, where and how information will be shared by answering a series of questions.

The proforma is designed to be completed by practitioners responsible for the day to day management of the information which is proposed to be shared. To ensure proper compliance checks, the proforma must be sent to the Caldicott Guardian /Data Controller for each participating organisation who will arrange for the information sharing arrangement to be checked and verified by the Integrated Information Governance Board.

What sort of information may be shared?

Aggregated data - is statistical information (i.e. non-personal). Sometimes, even though data is statistical and aggregated, individuals may be identifiable (e.g. data by postcode – where there is one property in a postcode an individual could be identifiable). Therefore care must be taken to check whether data is statistical or personal or where information together can reveal a person (e.g. Age, Postcode and Gender).

Personal data* - is information which identifies a living individual – Data Protection Legislation and related legislation must be complied with. For example, a name of an individual and home address.

Special category data - The conditions are listed in Article 9(2) of the GDPR:

  • a) the data subject has given explicit consent to the processing of those personal data for one or more specified purposes, except where Union or Member State law provide that the prohibition referred to in paragraph 1 may not be lifted by the data subject;
  • b) processing is necessary for the purposes of carrying out the obligations and exercising specific rights of the controller or of the data subject in the field of employment and social security and social protection law in so far as it is authorised by Union or Member State law or a collective agreement pursuant to Member State law providing for appropriate safeguards for the fundamental rights and the interests of the data subject;
  • c) processing is necessary to protect the vital interests of the data subject or of another natural person where the data subject is physically or legally incapable of giving consent;
  • d) processing is carried out in the course of its legitimate activities with appropriate safeguards by a foundation, association or any other not-for-profit body with a political, philosophical, religious or trade union aim and on condition that the processing relates solely to the members or to former members of the body or to persons who have regular contact with it in connection with its purposes and that the personal data are not disclosed outside that body without the consent of the data subjects;
  • e) processing relates to personal data which are manifestly made public by the data subject;
  • f) processing is necessary for the establishment, exercise or defence of legal claims or whenever courts are acting in their judicial capacity;
  • g) processing is necessary for reasons of substantial public interest, on the basis of Union or Member State law which shall be proportionate to the aim pursued, respect the essence of the right to data protection and provide for suitable and specific measures to safeguard the fundamental rights and the interests of the data subject;
  • h) processing is necessary for the purposes of preventive or occupational medicine, for the assessment of the working capacity of the employee, medical diagnosis, the provision of health or social care or treatment or the management of health or social care systems and services on the basis of Union or Member State law or pursuant to contract with a health professional and subject to the conditions and safeguards referred to in paragraph 3;
  • i) processing is necessary for reasons of public interest in the area of public health, such as protecting against serious cross-border threats to health or ensuring high standards of quality and safety of health care and of medicinal products or medical devices, on the basis of Union or Member State law which provides for suitable and specific measures to safeguard the rights and freedoms of the data subject, in particular professional secrecy;
  • j) processing is necessary for archiving purposes in the public interest, scientific or historical research purposes or statistical purposes in accordance with Article 89(1) based on Union or Member State law which shall be proportionate to the aim pursued, respect the essence of the right to data protection and provide for suitable and specific measures to safeguard the fundamental rights and the interests of the data subject.

Controls and assurances when sharing information

Controls, whether legislative or otherwise, need to be commensurate with the risk and proportionate to the objective which is sought to be achieved.

Legislative controls include:

  • Data Protection Act 2018 and GDPR
    • The first principle requires that you process all information lawfully, fairly and in a transparent manner. Sharing information is only lawful if you have a lawful basis under Article 6. And to comply with the accountability principle in Article 5(2), you must be able to demonstrate that a lawful basis applies.
    • The DPA and GDPR places duties on organisations on how to process personal data (‘process’ includes obtaining, holding, use of or disclosure of information). It also gives rights to individuals e.g. to access information about themselves. There are 7 GDPR key principles which form the backbone of the data protection legislation.
    • Where personal data is shared, the GDPR sets out seven key principles which lie at the heart of the general data protection regime.
      • 1. processed lawfully, fairly and in a transparent manner in relation to individuals (‘lawfulness, fairness and transparency’);
      • 2. collected for specified, explicit and legitimate purposes and not further processed in a manner that is incompatible with those purposes; further processing for archiving purposes in the public interest, scientific or historical research purposes or statistical purposes shall not be considered to be incompatible with the initial purposes (‘purpose limitation’);
      • 3. adequate, relevant and limited to what is necessary in relation to the purposes for which they are processed (‘data minimisation’);
      • 4. accurate and, where necessary, kept up to date; every reasonable step must be taken to ensure that personal data that are inaccurate, having regard to the purposes for which they are processed, are erased or rectified without delay (‘accuracy’);
      • 5. kept in a form which permits identification of data subjects for no longer than is necessary for the purposes for which the personal data are processed; personal data may be stored for longer periods insofar as the personal data will be processed solely for archiving purposes in the public interest, scientific or historical research purposes or statistical purposes subject to implementation of the appropriate technical and organisational measures required by the GDPR in order to safeguard the rights and freedoms of individuals (‘storage limitation’);
      • 6. processed in a manner that ensures appropriate security of the personal data, including protection against unauthorised or unlawful processing and against accidental loss, destruction or damage, using appropriate technical or organisational measures (‘integrity and confidentiality’).
      • 7. The controller shall be responsible for, and be able to demonstrate compliance with, paragraph 1 (‘accountability’).
  • Human Rights Act 1998: Under Article 8 of the European Convention of Human Rights (brought into force by the Human Rights Act 1998) individuals have the ‘right to respect for private and family life, home and correspondence’. As a general rule information sharing should not interfere with this right. Provided that the interference had a clear legal basis, was necessary, and was proportionate to the aim, then the interference could be justified on the following grounds: national security, protection of economy, public safety, protection of health and morals, prevention of crime and disorder, and the protection of the rights and freedoms of others.
  • Law of confidentiality: Even though there may be legal powers to share, the law of confidence still applies (even after death of the individual, who the information is about). This means that anyone proposing to disclose information not publicly available and obtained in circumstances giving rise to a duty of confidence will need to establish whether there is an overriding justification for doing so. If not, then consent would need to be obtained.

See https://ico.org.uk for further detail and information on the above legislative controls.

Assurances

Accuracy of information – the accuracy of information is likely to be relied upon by partner organisations and therefore, the accuracy of information must be communicated to all parties (subject to legal obligations).

Updating of information – the information providing and receiving organisations should put arrangements in place to inform each other (and any other parties to the arrangement) of any relevant changes or updates to the information shared (after the information has been shared). The responsibility of onward correction must be considered and assigned.

Information use – Whether aggregated or personal data, information must only be used for the purposes it has been shared. If the organisation receiving the information wishes to use it for purposes not clearly described in the proforma separate permission must be sought from the organisation that has provided the information.

Disclosure –information should only be disclosed to any other partner organisations/ third parties with the permission of the partner organisation providing the information or, where appropriate, the permission of the individual who the information is about.

Security

Security measures should be commensurate with the type of information shared and the risk (e.g. of loss, inappropriate disclosure etc).  Any special security controls that need to be taken in regard to transfer, collection, holding and use of the information should be communicated to all organisations involved in the handling of the shared information.

The partner organisation receiving the information should set out what security controls they plan to have in place; they are responsible for the security of that information.  In some cases a signed undertaking may be appropriate, but generally the information sharing arrangements (such as the proforma, Appendix 1) will be sufficient. 

Where the information is protectively marked then further advice should be sought on the specific handling and care arrangements that need to be in place when dealing with that information. 

Keeping a record of information sharing arrangements

The final record of the completed proforma should be kept on record in a central register (a copy held by all parties to the arrangement).

As a matter of good practice, in setting up arrangements for accountable and auditable information sharing, key information about arrangements in place should be recorded in a central system. Following should be recorded as a minimum: -

  • Data to be shared (e.g. data set, or data user)
  • Partners to the information sharing agreement
  • Start date of agreement (and end date where appropriate)
  • Frequency of sharing information
  • Review date for arrangement

Staff and public awareness

Partner organisations will ensure that all relevant staff are aware of and comply with their responsibilities in relation to:

  • the information sharing arrangements
  • the confidentiality of information about any service users; and
  • the commitment to share information in accordance with the agreement (principles and proforma which is agreed) and appropriate legislation.

As appropriate, the public will be informed of information sharing arrangements (in particular, where this involves sharing of personal data).

As far as possible, the individual information sharing arrangements should be published on websites/ publication schemes or in some other way to ensure openness and transparency.

Complaints procedures

Partners are committed to having procedures in place to address complaints relating to the sharing of information and or about how information about individual service users has been shared. Complaints procedures will be provided to members of the public/ service users, ideally on the website.

Appendix 1 – Data Protection Impact Assessment (DPIA)

A DPIA is a way for you to systematically and comprehensively analyse your processing and help you identify and minimise data protection risks.

DPIAs should consider compliance risks, but also broader risks to the rights and freedoms of individuals, including the potential for any significant social or economic disadvantage. The focus is on the potential for harm - to individuals or to society at large, whether it is physical, material or non-material.

To assess the level of risk, a DPIA must consider both the likelihood and the severity of any impact on individuals.

A DPIA does not have to eradicate the risks altogether, but should help to minimise risks and assess whether or not remaining risks are justified.

DPIAs are a legal requirement for processing that is likely to be high risk. But an effective DPIA can also bring broader compliance, financial and reputational benefits, helping you demonstrate accountability and building trust and engagement with individuals.

A DPIA may cover a single processing operation or a group of similar processing operations. A group of controllers can do a joint DPIA.

It’s important to embed DPIAs into your organisational processes and ensure the outcome can influence your plans. A DPIA is not a one-off exercise and you should see it as an ongoing process, and regularly review it.

Who completes what?

It is suggested the partner organisation (lead organisation if more than one partner) receiving the information completes sections 1 – 5 and the partner organisation providing the information completes section 6 and sections 7 and 8 completed at the end by all parties. Once agreed and completed, all parties should sign section 9.

Step 1: Identify the need for a DPIA

Explain broadly what project aims to achieve and what type of processing it involves. You may find it helpful to refer or link to other documents, such as a project proposal. Summarise why you identified the need for a DPIA.

The on line audit will support speech and language therapists in clinical practice as well as service users, service managers and other key stakeholders.

For practising clinicians, outcome measurement increases reflective practice leading to improvements in patient care, professional development and informing clinical decision making. At a service level, outcomes data can assist in informing service change, quality improvement, and resourcing decisions. Furthermore, a robust and validated demonstration of the impact of speech and language therapy has the potential to be useful evidence to present to commissioning bodies, to demonstrate how the profession contributes to the delivery of policies and frameworks across the UK and to influence key decision makers.

The RCSLT Online Outcome Tool (ROOT) facilitates the collection of Therapy Outcome Measures (TOMs) data to support with monitoring, evaluating and reporting on outcomes for individuals receiving speech and language therapy. The ROOT has been developed by Different Class Solutions Ltd in collaboration with SLT services involved during a pilot.

It facilitates the collection of data about individual service users’ outcomes at different points in time, using TOMs. It is a stand-alone online tool that collects, collates and reports on outcomes data.

Step 2: Describe the processing

Describe the nature of the processing: how will you collect, use, store and delete data? What is the source of the data? Will you be sharing data with anyone? You might find it useful to refer to a flow diagram or other way of describing data flows. What types of processing identified as likely high risk are involved?

Data is entered in RCSLT Online Outcome Tool (ROOT) by Your Healthcare Speech and Language Therapy team for children. SLT team will add service users’ Therapy Outcome Measures (TOMs) data in ROOT directly or upload in bulk to the ROOT. The RCSLT has adopted a privacy-friendly approach in the development of the ROOT, with respect to the information collected about the individuals receiving speech and language therapy and the SLTs using the tool. The ROOT is a securely hosted web system utilising SQL Server 2016 and ASP.net 4.6.1. The servers have SSL certification to ensure that all data flowing to and from the server is encrypted and could not be deciphered if intercepted in transit. The servers are protected by firewalls to protect the data and prevent unauthorised access by anyone else. The data is stored using an encryption algorithm so that if anyone physically removed a disk or the server itself, they would not be able to access the data. The servers are located in a UK data centre, hosted by a third party supplier.

Describe the scope of the processing: what is the nature of the data, and does it include special category or criminal offence data? How much data will you be collecting and using? How often? How long will you keep it? How many individuals are affected? What geographical area does it cover?

The data is pseudonumised and doesn’t include special category or criminal offence data. The data has been provided by Your Healthcare’s SALT team.

The data items included are:

  • A pseudonymised local patient identifier
  • Gender
  • Year of birth
  • Medical diagnoses
  • Communication and swallowing disorder descriptor(s)
  • Therapy Outcome Measure (TOMs) scale
  • Therapy Outcome Measure (TOMs) scores
  • Date of TOMs rating
  • Type of TOMs rating (start-of-episode/interim/end-of-episode/discharge)
  • Any other patient or rating data item that may from time to time be added to the ROOT, provided that data item does not contain any personally identifiable information.

Additional fields may be added, if required, but additional data shared with the ROOT by users of the system must comply with local information governance policies and frameworks and is not the responsibility of the data processor or the RCSLT.

This information is collected when the individual registers to use the ROOT and will be updated annually. Personal data about the individuals using the ROOT is retained for as long as any outcomes data related to them is retained. This is analogous to keeping patient forms in their file with the staff member’s name on. The geographic area that it covers is Kingston.

Data about speech and language therapists and other individuals using the ROOT Personal data collected about the individuals using the ROOT includes:

  • Name
  • Employing organisation
  • Email address
  • RCSLT membership number (where applicable)
  • The IP address that the user connects from

This information is collected when the individual registers to use the ROOT and will be updated annually. Personal data about the individuals using the ROOT is retained for as long as any outcomes data related to them is retained. This is analogous to keeping patient forms in their file with the staff member’s name on.

Describe the context of the processing: what is the nature of your relationship with the individuals? How much control will they have? Would they expect you to use their data in this way? Do they include children or other vulnerable groups? Are there prior concerns over this type of processing or security flaws? Is it novel in any way? What is the current state of technology in this area? Are there any current issues of public concern that you should factor in? Are you signed up to any approved code of conduct or certification scheme (once any have been approved)?

Pseudonumised data on individuals who are receiving speech and language therapy is collected to support better care, professional development and informing clinical decision making . Individuals won’t access the tool.

Speech and language therapy data are related to children. There is no concern over the processing and security flaws. A privacy policy is also provided on the ROOT. Different Class Solutions Ltd has prior experience of this type of processing for other similar products and it is not expected, therefore, that the processing of personal data in relation to the ROOT will be considered unreasonable or cause concern. Your Health care and Different Class Solutions Ltd is certified for ISO27001 Data Security.

Describe the purposes of the processing: what do you want to achieve? What is the intended effect on individuals? What are the benefits of the processing – for you, and more broadly?

The intended outcome of the ROOT is that it will have benefits for patient care by supporting quality improvement in speech and language therapy services. The minimum amount of data about individuals receiving speech and language therapy is collected in order to achieve this.

The processing of personal data about speech and language therapists and other individuals using the ROOT is required to ensure that the individuals accessing the ROOT have a legitimate reason for doing so. This is required to ensure the fidelity of the outcome data collected and to enable use of the system to be audited. It is also required to support users of the system, including in instances whereby help is requested.

Step 3: Consultation process

Consider how to consult with relevant stakeholders: describe when and how you will seek individuals’ views – or justify why it’s not appropriate to do so. Who else do you need to involve within your organisation? Do you need to ask your processors to assist? Do you plan to consult information security experts, or any other experts?

The data entered in ROOT system is pseudonymised and individuals will not be identifiable from the data.

Step 4: Assess necessity and proportionality

Describe compliance and proportionality measures, in particular: what is your lawful basis for processing? Does the processing actually achieve your purpose? Is there another way to achieve the same outcome? How will you prevent function creep? How will you ensure data quality and data minimisation? What information will you give individuals? How will you help to support their rights? What measures do you take to ensure processors comply? How do you safeguard any international transfers?

The data collected about individuals receiving speech and language therapy are pseudonymised and in the majority of cases, individuals will not be identifiable from the data. Nevertheless, the data should be treated as personal data.

Step 5: Identify and assess risks

Describe source of risk and nature of potential impact on individuals. Include associated compliance and corporate risks as necessary.Likelihood of harmSeverity of harmOverall risk
1. Security breach of servers. The impact would be that personal data is at risk. Possible Significant Medium
2. Inappropriate use of the system by users authorised to access the ROOT. This might include attempting to access unauthorised areas, disclosing account details to others, and attempting to use someone else’s login details to access the ROOT. The impact would be access to other users’ personal data. Possible Significant Medium
3. Inappropriate users given access to the system. The impact of this would be that those without a legitimate reason would have access to pseudonymised data about speech and language therapy outcomes for the service. Possible Minimum Low

Step 6: Identify measures to reduce risk

Identify additional measures you could take to reduce or eliminate risks identified as medium or high risk in step 5
RiskOptions to reduce or eliminate riskEffect on riskResidual riskMeasure approved
1. Security breach of servers The physical security arrangements for the servers have been reviewed and approved. The demographic data is held in encrypted tables. In the unlikely event of a breach the servers will be taken off line to minimise any use of the data. Accepted Medium Yes
2. Inappropriate use of the system by users authorised to access the ROOT. Limited number of users have access to the system. Access is managed and controlled by the service leads. Reduced Medium Yes
3. Inappropriate users given access to the system. Entry and control of users will be validated by the service leads. Limited number of users have access to the system. Tight control is in place. Reduced Low Yes

Step 7: Sign off and record outcomes

ItemName/dateNotes
Measures approved by: Marjan Daneshpour Integrate actions back into project plan, with date and responsibility for completion
Residual risks approved by: Marjan Daneshpour If accepting any residual high risk, consult the ICO before going ahead
DPO advice provided: DPO should advise on compliance, step 6 measures and whether processing can proceed
Summary of DPO advice:
DPO advice accepted or overruled by: If overruled, you must explain your reasons
Comments:
Consultation responses reviewed by: If your decision departs from individuals’ views, you must explain your reasons
Comments:
This DPIA will kept under review by: The DPO should also review ongoing compliance with DPIA