What should be part of the health record?

Start of content

Table of Contents Show

How can My Health Record transform healthcare?
Improving medication safety
Access to information for people and their healthcare providers
Reducing unnecessary services
How are benefits measured?
How are benefits realised?
Access to key health information
Sharing information
Greater efficiency
1. Conformant software
2. National Provider Portal
Establish roles, responsibilities and policies
Consumer portal guides
Changes to your organisation
User account management
Data quality
Ongoing participation obligations

The My Health Record system can transform quality, experience and value in Australia's healthcare system through a range of important benefits.

How can My Health Record transform healthcare?

My Health Record aims to transform Australia’s healthcare system through benefits realisation. The Australian Digital Health Agency is working closely with stakeholders to implement a range of projects and programs to support changes and measure expected benefits associated with My Health Record.

Some identified ways My Health Record can provide benefits to Australia’s healthcare system are through:

Avoided adverse drug events
Enhanced patient self-management
Improvements in patient outcomes
Reduced time gathering clinical information
Avoided duplication of services

Improving medication safety

Medication errors that lead to harmful medication safety incidents and adverse drug events may be preventable through increased accessibility to patient information.

Access to information for people and their healthcare providers

Access to information via My Health Record may enable self-management and reduce clinicians’ time necessary to perform several information-led tasks, freeing up productivity for more critical activities.

My Health Record offers an electronic summary of a person’s key health information that can be shared securely between them and registered healthcare providers involved in their care to support improved decision making and continuity of care.

Reducing unnecessary services

Access to information via My Health Record may help patients by avoiding duplication of diagnostic tests and services.

How are benefits measured?

The Australian Digital Health Agency has developed a 10-year My Health Record Benefits Evaluation Plan that includes continuous research and monitoring of My Health Record adoption, use, impact and benefits realisation. The insights gained from this research are continuously used to guide Agency programs and product initiatives aligned to realising My Health Record benefits.

How are benefits realised?

Benefits realisation for My Health Record is driven by activities that create health system efficiencies and support greater effectiveness in healthcare management.

These include:

Healthcare providers being connected to My Health Record to allow viewing and use of the information in the system, which can lead to improved care pathways and outcomes.
Uploading of information to My Health Record from clinical information systems for a larger proportion of Australians with a My Health Record, which can lead to greater adoption and use.
Helping healthcare providers (and patients) understand how to view information in My Health Record, which could lead to greater patient engagement in care.

References

Hospitals are an important part of Australia’s health landscape, providing services to many Australians each year.

My Health Record provides a vital source of information for healthcare professionals and their patients enabling continuity of care between the hospital health system and community care.

Achieving a critical mass of awareness of staff within all healthcare settings will be key to the success of increased use of the My Health Record system across Australia.

For hospital staff, the key behavioural change requirement is increased awareness of the My Health Record matched with a consequent increase in the viewing of such things as patient shared health summaries, medications view documents, pathology and diagnostic reports within the My Health Record. This will be dependent on the connectivity of hospital services’ clinical information systems and the readiness of eHealth solutions within each state and territory and private hospital readiness.

This section contains information for hospital staff who wish to increase their awareness and understanding of My Health Record.

My Health Record benefits patients, healthcare providers and hospitals by sharing key health information at the point of care, anywhere, anytime. The two videos below, taken from a case study in our online learning module, illustrate how a patient’s hospital journey can change depending on whether or not they have a My Health Record.

To find out more about the benefits of My Health Record in hospital environments and how you can start to use it in your work, access our new interactive online learning module.

Access to key health information

By accessing the My Health Record system through your hospital’s clinical information system you can access information about your patients such as:

shared health summaries (which include medications, medical history, allergies and immunisations)
event summaries (including information about a significant healthcare event)
MBS and PBS history
medication prescription and dispense records
previous hospital discharge summaries, and
advance care planning documents and custodian information.

If your hospital has compliant software, you will also be able to upload important health information about your patients, such as a discharge summary, which can then be viewed by other hospitals and other healthcare providers involved in their care. You will be able to view the patient shared health summary when they are in your hospital.

Greater efficiency

Having access to a patient’s key health information can help you operate more effectively by allowing you to:

Quickly gain a picture of the health history of your patient.
Reduce the time you spend looking for and receiving information about your patients from other healthcare providers (e.g. patients with chronic diseases).

Hospitals that want to register for the My Health Record system should contact their local health department eHealth team or the Australian Digital Health Agency Provider Readiness team for further information and assistance.

There are two ways through which authorised healthcare providers can access an individual’s record in the My Health Record system.

1. Conformant software

Accessing the My Health Record system through conformant clinical software enables healthcare providers to upload, view and download information from an individual's My Health Record.

Click here for more information on access via conformant software

2. National Provider Portal

If a healthcare provider does not have access to conformant software, they can view an individual’s My Health Record through the National Provider Portal at: https://portal.ehealth.gov.au. The healthcare provider will be able to view and download information from the individual’s My Health Record, but will not be able to upload any clinical information.

Click here for more information on access via the National Provider Portal

Establish roles, responsibilities and policies

Prior to registering your organisation, you will first need to establish your team members’ roles and responsibilities as they relate to interacting with the Healthcare Identifiers Service and the My Health Record system.

While your registration is being processed, this is an opportune time to:

Contact your local PHN for assistance with the above if required.

Please note that the majority of documents, available for upload within hospital and health services, are uploaded in the background (automatically) by each State/ Territory eHealth department through normal delivery portals, unless the consumer has requested otherwise. Further guidance and training should be sort from your organisations eHealth/Digital Health team.

Please refer to your organisations policies and procedures for viewing and uploading of clinical information through jurisdictional health and private hospital clinical information systems in the first instance.

Learn how to:

Please refer to local organisational policies and procedures.

Learn more about/how to:

A range of training and resource materials are available to support hospital staff with My Health Record, including webcasts and online learning modules.

Access training and resources for hospitals

Brochures

A range of brochures are available to support you in introducing My Health Record to your patients. Further brochures will be uploaded as they are developed and published.

Consumer portal guides

A range of step-by-step guides are available to support patients in interacting with their My Health Record, including uploading a personal health summary, setting privacy controls and a range of other functions.

Contact us

See the Contact us page for guidance on who to call for help and support.

Start of content

A healthcare organisation that is participating in the My Health Record system is required to comply with a range of obligations.

Healthcare organisations must comply with the following legislation:

Changes to your organisation

It is important to understand what changes your organisation may need to make before registering to participate in the My Health Record system, and to ensure ongoing compliance with the above legislation. Potential changes include:

Security

You will need to review, update, maintain, enforce and promote to staff policies that ensure the My Health Record system is used safely and responsibly. These policies need to address matters such as how authorised persons access the system, the training delivered to staff before accessing the My Health Record system, and the physical and information security measures used by the organisation.

See Privacy and Security.

User account management

You will need to confirm the IT system(s) staff use to access the My Health Record system employ reasonable user account management practices, including: restricting use, uniquely identifying users and secure access mechanisms (such as passwords).

Data quality

Your existing obligations to maintain your own detailed and accurate clinical records remains, and you are also responsible for ensuring that information uploaded to the My Health Record system complies with your participation obligations. This includes ensuring your employees are registered healthcare providers (i.e. they have a healthcare provider identifier; HPI-I) before they author any record that will be uploaded to the My Health Record system.

Ongoing participation obligations

Set out below are a number of ongoing obligations on a participating healthcare organisation. Please note, this is not an exhaustive list of obligations. If in doubt of your organisation’s obligations, you should contact the System Operator.

To participate in the My Health Record system, your healthcare organisation must:

Not discriminate against an individual because they do not have a digital health record or because of their My Health Record's access control settings;
Take reasonable steps to ensure that their employees exercise due care and skill so that any record uploaded to the My Health Record system is at the time it is uploaded, accurate, up-to-date, not misleading and not defamatory;
Not upload a clinical document to the My Health Record system where an individual has withdrawn consent to the uploading of that clinical document;
Only upload a clinical document to the My Health Record system that has been prepared by a person who is a registered healthcare provider (i.e. has an HPI-I) and whose registration is not conditional, suspended, cancelled or lapsed;
Tell the System Operator as soon as practicable after becoming aware of a potential or actual data breach, that is:
- There has been an unauthorised collection, use or disclosure of health information included in an individual's My Health Record; or
- An event has, or may have, occurred that compromises, or may compromise, the security or integrity of the My Health Record system;
Tell the System Operator, within two business days of becoming aware, of a non-clinical My Health Record system-related error in a record, or your organisation undergoes a material change;
Tell the System Operator within 14 days if your organisation has ceased to be eligible to be registered (for example, the organisation has cancelled its HPI-O);
Give the System Operator necessary assistance in relation to any inquiry, audit, review, assessment, investigation or complaint regarding the My Health Record system;
Develop, maintain, enforce and communicate to staff written policies relevant to the My Health Record system to ensure that interaction with the My Health Record system is secure, responsible and accountable, and to provide a copy of your policy to the System Operator on request.

There is an overview of policies required to participate in My Health Record and templates for writing your My Health Record Security and Access Policy and Use of a NASH PKI certificate policy.

General practices participating in the Practice Incentives Program (PIP) eHealth Incentive are required to establish and put into writing a Secure Message Delivery policy and a Clinical Coding and Terminology policy. There are a Secure Messaging Delivery policy template and Clinical Coding and Terminology policy template to help you.

In addition, a number of organisations have developed sample policies to assist you: