Medical practitioners who decide to use the My Health Record system are free to apply their clinical judgement to determine when and how they will use the system.
Who can view an individual's My Health Record?
Any person involved in an individual's healthcare who is authorised by the healthcare organisation can access a My Health Record. Access is not limited to clinicians with a Healthcare Provider Identifier - Individual (HPI-I).
What is in a My Health Record?
A My Health Record may contain:
- Consumer-entered information, such as a personal health summary (containing any allergies and adverse reactions the individual may have or medications they might be taking), an advance care planning document, and emergency contact information
- MBS and PBS (and RPBS) transaction information, the individual's organ donor status (sourced from the Australian Organ Donor Register), and their Australian Immunisation Register records.
- Clinical documents uploaded by healthcare providers involved in the individual's care, including:
A full list can be found in the What's in a My Health Record? page.
Do I need the individual's consent to view their My Health Record?
No. You do not need the consent of an individual to view their record, and you can access an individual's record outside of a consultation, provided that access is for the purpose of providing healthcare to the individual.
Individuals may, however, choose to enable My Health Record privacy settings to control which healthcare organisations can access their My Health Record. They can limit access to their entire record (using a Record Access Code) or to particular documents (using a Limited Documents Access Code). The patient will need to provide their access code to a provider for them to access their My Health Record when prompted by their clinical software to do so (unless it is an emergency situation in which case a provider can use the emergency access functionality). For more information see Patient access controls and Emergency access.
Currently, the number of individuals opting to use these privacy settings is fewer than 2 out of every 1000 individuals registered, and where an individual has opted to use privacy settings, healthcare organisations do not have to be granted access to a My Health Record in order to upload to it.
When should I view the individual's My Health Record?
Healthcare providers are under no legal obligation to use the My Health Record system. It is up to the healthcare provider and his or her clinical judgement as to when and how they use the system. However, examples of when it might be relevant to see if a patient has a My Health Record are outlined below.
If the patient is visiting you for the first time
If a new patient presents to you, there could be information from multiple sources in their My Health Record to support your understanding of their needs. For example:
- A shared health summary from their prior nominated healthcare provider giving information of their medicines, allergies, immunisations and medical history.
- A record of the patient's prescribed and dispensed medicines.
After hospital discharge
The hospital may have uploaded a discharge summary providing details of the patient's stay. This could include a clinical synopsis, interventions, diagnosis, medicines and diagnostic imaging results.
After an after-hours GP visit
If your patient visited an after-hours GP service, the GP may have thought the visit warranted uploading an event summary to the patient's My Health Record.
The GP may also have prescribed new medicines which could be listed in the patient's record.
After an incident on holiday
If the patient had an incident on holiday in Australia and saw a different clinician, that clinician may have uploaded an event summary outlining the incident and treatment provided.
The patient's prescribed and dispensed medicines may also have changed due to the incident, which could be visible in their My Health Record.
After the patient has seen a specialist
The specialist may have uploaded an event summary or a specialist letter providing details of the diagnosis. This could include the specialist's recommendations, medicine review and diagnostic investigation results.
After the patient has had a community nursing visit
The nurse may have uploaded an event summary to the patient's My Health Record if the nurse thought it useful.
In an emergency situation
In an emergency situation, the patient's My Health Record could give you information about the patient's known allergies, medicines, immunisations and medical history in a shared health summary.
Patient has entered information into their My Health Record
A patient may tell you they have a My Health Record, in which they have entered information about the current medicines they're taking or their known allergies and adverse reactions. In this instance, the patient's My Health Record may support your medication assessment.
How does a healthcare provider know if the patient has a My Health Record?
Clinical software products, which include My Health Record system functionality, will all look slightly different. However, the Agency recommends that a My Health Record Status Indicator be displayed obviously and prominently for clinicians in their clinical software. For individuals who have not applied additional privacy settings to their My Health Record, this mechanism will enable healthcare providers to know whether the patient has a record.
It may also be useful to have a conversation with your patient about what is involved in having a My Health Record and the benefits it could provide.
How are clinical documents presented?
While clinical software products will all look slightly different, in the majority of cases clinical documents are presented in a document list.
How do I view a My Health Record?
The ability for a healthcare practitioner to view important clinical information from other healthcare providers is the primary purpose of the My Health Record system . Each software vendor has their own 'look and feel' for how they display information in the My Health Record.
Clinical software simulators
There are a range of clinical software simulators or ‘sandboxes’ with which you can simulate viewing a fictional patient’s My Health Record. The software simulators include: Bp Premier, MedicalDirector, Zedmed, Genie, and Communicare.
Clinical software demonstrations
There are demonstrations for a range of clinical software products showing how to view a My Health Record.
Clinical software summary sheets
There are summary sheets for a range of clinical software products with step-by-step instructions and screenshots for viewing a My Health Record.
If your software is not here, please contact your software vendor for guidance material.
Provider Portal demonstration
There is a demonstration showing how, once registered, you can log into the Provider Portal and view the range of information that might be available in an individual's My Health Record.