What You Need to Know About My Health Record
29 May 2018
All doctors and frontline staff need to know:
- the basic concepts of My Health Record2
- the personal choice elements,3 including that an individual may choose to not have a My Health Record created
- how My Health Record is used within the context of their organisation.
This article addresses some frequently asked questions to help you understand MHR.
Must I open a patient’s MHR if I notice they have one?
No, you are not compelled to do so as a matter of routine, and you can decide whether you clinically need to access it.
Do I need to get consent to access an MHR?
No, as long as you are accessing the record to provide health care to the individual. Patients consent to this when they register for MHR. However, if you access it in their presence, it would be courteous to inform the patient. Patients can place controls on who can access their whole record or documents within their record. They can also view which organisations have accessed their record, and can get SMS or email notifications when an organisation first accesses their MHR.
Can my staff access an MHR for me if I am at the hospital?
Yes, if they have been authorised. Once a healthcare organisation is registered to participate in the MHR system, individual healthcare providers and other relevant employees can be authorised to access the system.
Do I need consent when I upload documents?
When a patient registers for MHR, the patient provides a standing consent for documents to be uploaded to their MHR. So it is not necessary to obtain consent each time you upload a document, except for Shared Health Summaries (see below). However, the AMA recommends4 informing patients when you upload all documents, particularly if the information is sensitive. If a patient requests that a document or a certain piece of health information not be uploaded, you are obliged to comply. Patients are able to remove documents you have uploaded, but not edit them.
What is a Shared Health Summary?
A Shared Health Summary (SHS) provides a patient’s status at a point in time. These are especially beneficial for patients with chronic conditions or multiple co-morbidities.
To create an SHS a healthcare provider must obtain the patient’s agreement that they are to be a nominated healthcare provider (NHP) for the patient. If you are not the NHP (but you are authorised) you can still access the patient’s MHR, and you can upload clinically relevant information using an Event Summary which details significant healthcare events relevant to ongoing care, e.g. a new diagnosis or a clinical intervention. Any healthcare provider at an organisation participating in the MHR system can upload an Event Summary.
Can I bill Medicare for uploading to an MHR?
There are no MBS item numbers for uploading to an MHR. However, the time taken to prepare documents for uploading counts toward consultation time for billing the MBS, as long as the document preparation was part of providing a clinical service, and the patient was present.
What happens to the MHR on the death of a patient?
The record is retained in the system for 30 years (or if date of death is not known, for 130 years after their birth date). It will not be accessible to healthcare providers, but only where allowed by law for purposes such as audit or maintenance.
Does the MHR form part of the record for the purposes of a subpoena?
No, as a doctor does not have possession and control of the MHR. However if a doctor downloads documents from the MHR (e.g. a discharge summary or test results) into their own record, those documents will be part of the doctor’s record for the patient and will need to be produced in response to a subpoena.
Where can I find more information?
Australian Digital Health Agency:
- Shared Health Summary (example clinical document)
- Using the My Health Record System
Royal Australian College of General Practitioners:
Claims & Advisory Services
MDA National
References
- The Department of Health. My Health Record: National Opt-out. Available at: health.gov.au/internet/main/publishing.nsf/Content/my-health-record-national-opt-out
- Australian Digital Health Agency. What is My Health Record? Available at: myhealthrecord.gov.au/internet/mhr/publishing.nsf/content/find-out
- Australian Digital Health Agency. Managing Access, Privacy and Security. Available at: myhealthrecord.gov.au/internet/mhr/publishing.nsf/Content/privacy
- Australian Medical Association. AMA Guide to Using the PCEHR. Available at: ama.com.au/article/ama-guide-using-pcehr
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