The shared health summary is a crucial part of the My Health Record system. This page presents an overview of who can create shared health summaries, when they should be created, and how to create them.
What is a shared health summary?
The shared health summary represents the patient's health status at a point in time. The Royal Australian College of General Practitioners' (RACGP's) Digital Business Kit and My Health Record position statement provides additional guidance on digital health records including shared health summaries. Shared health summaries can be created at any consultation, and may include information about a patient's medical history, including:
- Medical conditions
- Allergies and adverse reactions
The most recently uploaded shared health summary in a patient's My Health Record is likely to be the first document accessed by any other healthcare professional viewing a patient's My Health Record.
Who can create a shared health summary?
A shared health summary can only be authored/created by a patient’s nominated healthcare provider (as defined in the My Health Records Act 2012). A nominated healthcare provider can be:
- a registered medical practitioner; or
- a registered nurse; or
- an Aboriginal and Torres Strait Islander health practitioner with a Cert IV in Aboriginal and/or Torres Strait Islander Primary Health Care.
An agreement must be in place between the healthcare provider and the patient that the healthcare provider is the patient’s nominated healthcare provider for the purpose of authoring/creating the document. There are no constraints in regard to the form of the agreement and it can be verbal or written.
The provisions around who can be a nominated healthcare provider only relate to authoring/creating a shared health summary. Another employee in the organisation can upload the document on behalf of the author/creator.
Note: an enrolled nurse is not permitted by the Act to author/create a shared health summary. An enrolled nurse can create an event summary to share information about a significant clinical event, provided the enrolled nurse is providing healthcare to the patient.
A patient can have only one nominated healthcare provider at a time, who should be delivering coordinated and comprehensive care to the patient. A provider who is not the patient's usual provider could use an event summary instead to upload clinically relevant information to the patient's My Health Record.
When to create or update a shared health summary?
A shared health summary can be created at any consultation; however uploading a shared health summary will be particularly beneficial for patients with chronic conditions and co-morbidities. As part of putting the My Health Record system into practice, the RACGP recommends that a healthcare provider creates and uploads a shared health summary when completing a patient health assessment, because this is a time when the health summary within the local GP clinical system is being updated. For example:
A GP management plan
Patients who have one or more chronic medical conditions and need a GP management plan may also benefit from having a shared health summary uploaded to their My Health Record at the same point in time.
75+ health assessment
This structured assessment of a patient over 75 years may be a good opportunity to upload a shared health summary to their My Health Record given the in-depth review that is undertaken. It also supports ongoing management for the patient, their family and other healthcare providers.
Child health check
As with all patient health assessments, inclusion of a shared health summary after conducting a child health check would likely be a timely capture of an individual's health status. This may also increase a parent's understanding of their child's needs.
Another opportune time to upload a shared health summary is when offering the flu vaccination. Many of the high-risk patients to whom your practice offers the flu vaccination may also benefit from the creation of a shared health summary to manage their health.
Do I need my patient's consent to upload a shared health summary?
Under the My Health Records Act, healthcare providers are authorised to upload information to the My Health Record system. Generally, this means that they do not need to obtain consent prior to uploading information to the system when providing services to a patient. However, patients can request that particular information is not uploaded to their record, and healthcare providers must comply with such requests. There are some other situations where documents should not be uploaded.
It may be good practice to advise a patient that you will be uploading information to their My Health Record, particularly if this information might be considered sensitive.
However, there is no requirement for the patient to review the shared health summary before it is uploaded to their My Health Record.
Can I charge for uploading a shared health summary?
In billing the Medicare Benefits Schedule (MBS), healthcare providers are able to take into account the time taken to register patients for a My Health Record, and prepare shared health summaries and event summaries if these activities are undertaken as part of providing a clinical service and the patient is present at the time. These activities are considered to be part of the documentation of treatment of the patient. See MBS Online for information on item numbers relevant to actions related to a patients' My Health Record, which can be found by searching for "PCEHR" on the MBS website.
Can I edit or delete a shared health summary once it is uploaded?
The author of a clinical document can delete a clinical document from the My Health Record system if, for instance, it has been uploaded in error or contains a mistake.
If a nominated healthcare provider wishes to change the information in their patient's shared health summary, e.g. the medicines listed, they will need to upload a new shared health summary with the updated information.
Note that there is no additional responsibility for a nominated healthcare provider to prepare a shared health summary outside of a consultation with the patient.
Sections 4.5.3 and 5.4 of the AMA's Guide to using the My Health Record system provide recommendations to medical practices in these and related areas.
How do I create and upload a shared health summary?
Clinical software simulators
There are a range of clinical software simulators or ‘sandboxes’ with which you can simulate creating and uploading a shared health summary to a fictional patient’s My Health Record. The software simulators include: Bp Premier, MedicalDirector, Zedmed, Genie, and Communicare.
Clinical software summary sheets
There is a range of summary sheets with step by step instructions for uploading a shared health summary.
Clinical software demonstrations
There is a range of demonstrations showing how to upload a shared health summary.