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Understanding the PCEHR

The AMA recently released the Draft Guide to using the PCEHR, which will assist medical  practitioners to make choices about how (and whether) to participate in the PCEHR system.

The Australian Government has  invested $467 million over two  years to develop the critical national  infrastructure for e-health records as  a key element of the national health reform agenda. Since 1 July 2012 all  Australians have had the option of  signing up for a personally controlled  e-health record. This enables better  access to important health information  currently held in dispersed records around the country.

The Personally Controlled Electronic  Health Record (PCEHR) system is  not intended to replace practitioners’  patient medical records, which still  need to be maintained as they are now.  It is a patient’s decision to opt in to the  PCEHR system – done by registering  with the system operator – establishing  a relationship between the patient and  the system operator. The Government  is responsible for educating the community about the PCEHR.

The system design, which will be  introduced incrementally, provides  patients with complete control over  both the health information that is held  in the PCEHR and who can access that  information. Use of the system does  however carry new responsibilities for  medical practitioners as decisions need  to be made about how to use it and  what information should be shared with other medical practitioners/healthcare providers.

Voluntary - ‘opt in’
Patients in their personal capacity can  choose to use the PCEHR (opt in) by  registering personally with the system  operator directly. A patient is not  required to have, or use, any form of shared electronic health record system and those who opt to participate in the  PCEHR system can opt out at any time.

Medical practitioners may decide to  assist some or all of their patients to  register for a PCEHR by a facilitated registration process in their practice.

There is no duty or obligation to use the  PCEHR system. Medical practitioners  who decide to use it are free to apply  their clinical judgement to determine  when and how, including using the  PCEHR for some patients but not  others, and can stop using it at any  time.

Personally controlled
A PCEHR is ‘owned’ by the patient  who has the right to determine what  information is included and who is able  to access all or part of that information.  By registering for a PCEHR patients  give ‘standing consent’ to all healthcare  providers uploading the patient’s health  information to their PCEHR.

Patients, by legislative right, may  control the information that is included  or accessed in their PCEHR by  accepting the basic access controls,  which allow all healthcare providers  involved in the care of a patient  access to the patient’s PCEHR, or  by applying more advanced access  controls. They can expressly advise  medical practitioners not to upload  certain healthcare information, remove  a document in its entirety or request  that the Nominated Healthcare  Provider modify the Shared Health  Summary. A medical practitioner is  not under an obligation and cannot be  forced to include or exclude particular information in a patient’s PCEHR.

Information includes:
• A single Shared Health Summary  with up-to-date, curated information  about a patient’s healthcare status,  clinical documents created and  uploaded by participating healthcare  providers about healthcare events,  information from the following data  repositories: Medicare Benefits  Schedule, Pharmaceutical Benefits  Scheme, Australian Childhood  Immunisation Register and  Australian Organ Donor Register.

• Information and diary notes added  by the patient themselves. Only  contact details, medications,  allergies and location of advanced  care directives will be visible to  medical practitioners.

Information access
Authorised access to a PCEHR can  only occur in accordance with the  access controls set by the patient.  The system operator may recognise  ‘authorised representatives’ to  operate the PCEHR on behalf of the  patient e.g. a person with parental  responsibility for patients aged under  18. Medical practitioners, medical students, employees, contractors,  volunteers and designated others  can access a patient’s PCEHR under  the authorisation of the healthcare organisations with which they are associated.

Information disclosure
Providing disclosure accords with the  access controls set by the patient.  Circumstances where information in a  patient’s PCEHR may be disclosed but  are not covered by patient-set PCEHR access controls are:

• Where the information is disclosed  to the patient, by the patient, or  for any purpose with the patient’s consent.

• For provision of emergency care if  they are unable to consent.

• As authorised by law, to courts and  tribunals, or for law enforcement  purposes.

• In the course of providing indemnity  cover to a healthcare provider. 

Emergency access
For any patient – including one who has  applied advanced access controls that  prevent access to some information  in their PCEHR and is incapable of  providing consent to PCEHR access  – treating medical practitioners may  gain emergency access if they make  a clinical judgement that would  lessen or prevent a serious threat to  an individual’s life, health or safety.  Such emergency access is subject  to retrospective audit. There is no  obligation on any medical practitioner  to access a patient’s PCEHR in an  emergency situation.

Good patient care
Even if a patient has a PCEHR  it remains the treating medical  practitioner’s responsibility to take  a detailed clinical history from their  patient, perform a relevant clinical  examination of the patient and derive  a list of all medications that a patient  is currently taking, as well as any allergies.

Working with patients
Patients may seek advice about the  PCEHR system, particularly when a long-term doctor-patient relationship  exists. Engage in the conversation  in good faith based on the unique relationship with each patient. 

If a patient asks for advice about  the PCEHR system, provide her or  him with information supported by  appropriate Government-supplied  educational materials and discuss how  you and your practice use the system,  supported by practice protocols or  patient information material. The  potential benefits and possible  inconvenience of not having a PCEHR should be discussed.

Where clinically appropriate, counsel  patients about the importance of full  disclosure of all clinically relevant  information on the accessible areas of  their PCEHR to all medical practitioners  who may need to access their record.

Patient-entered information
When considering a PCEHR’s patiententered  information for inclusion in  deriving a clinical decision, the treating  medical practitioner should take  into account the content, accuracy, accessibility and relevance of this  information.

Informed consent related to use of  the PCEHR
When patients first use the PCEHR they should be informed that its use will form  part of the therapeutic relationship. The  patient should be given the opportunity  to request more information regarding  its use within your practice. Medical  practitioners should note on their  patient’s file that their patient has  consented to interacting with the  patient’s PCEHR every time that  consent is obtained.

Authorised and Nominated Representatives
The PCEHR legislation permits patients  up to 18 years of age, or those who  otherwise do not have sufficient  capacity to make decisions about  their own healthcare, to nominate
authorised representatives who hold responsibility for managing the patient’s  PCEHR. Patients may also nominate  representatives (e.g. family members or carers) who will be able to view and/or control information.

Working with the PCEHR system
The PCEHR system is not intended  to, and should not, replace a medical  practitioner’s own patient files and  medical records system. Ensure  information from the PCEHR used in the course of decision making or caring  for a patient is included in medical  practitioner records and the origin of  this information is documented.

Medical practitioners should only  access a patient’s PCEHR in the  course of making a clinical decision  relating to the patient’s care. This  includes decisions made outside of
direct patient consultations such as  when preparing for a consultation. It  is safest to assume the information in  a patient’s PCEHR is not a completely  accurate record of the patient’s clinical  history or current health status, so it  should be verified from other sources  of patient information and ideally with the patient.

Nominated Healthcare Provider and  the Shared Health Summary
Nominated Healthcare Providers can  prepare, create, upload and curate a Shared Health Summary on the  patient’s PCEHR. They may be medical  practitioners, registered nurses or  Aboriginal and Torres Strait Islander health practitioners.

Personally controlled
Each patient ‘owns’ their PCEHR  record, determines what information  is included and who has access to it.  When information has been effectively  removed from a patient’s PCEHR or  if advanced access controls have  been set limiting access to information  there will be no indication to medical  practitioners who view the record that  this has occurred.

Shared Health Summary
If a patient advises a Nominated  Healthcare Provider not to include  some clinical information on their  Shared Health Summary a clinical  judgment should be made about:  whether the omission of those  clinical facts creates an inaccurate or  misleading summary of the patient’s current health status and whether not  including that information would be  a breach of your professional duties/standards/ethics.

If a patient advises a Nominated  Healthcare Provider not to include  some information in a Shared Health  Summary and a practitioner believes  omission of that clinical information  would present a risk, counsel the  patient about the risks of not including  that clinical information; record that  this conversation occurred in the  patient’s file and consider refusing to  be the patient’s Nominated Healthcare Provider.

Non-engagement with the PCEHR
If you choose not to engage with the PCEHR system there is no obligation for you to change your current practice in any way or take action in relation to the PCEHR system other than being familiar with its existence and aims.

Within one medical practice some medical practitioners may participate in the PCEHR system while others may not. Details of how you manage this in your practice should be recorded and described in practice protocols.

If, having participated in the PCEHR system, a practitioner discontinues participation, they should advise patients, practices and colleagues according to the impact that discontinuation might have on patient care and clinical workflows.

It is your responsibility to ensure your information technology system meets your needs. It is prudent to assume that no data is secure, so take appropriate steps and seek appropriate advice to minimise inadvertent disclosure of PCEHR information.

Doctor as a patient
Medical practitioners in the patient role should accord the treating medical practitioner the professional courtesies of permitting the treating medical practitioners to share their patient information electronically. Medical
practitioners should NOT be their own Nominated Healthcare Provider for their PCEHR if they have elected to use the system as a patient.

The AMA supports patients taking responsibility for their own health and recognises that ‘personal control’ of health information could empower and encourage them in this role. The PCEHR does however have practical clinical limitations for medical practitioners in the treatment of patients in respect of the content, accuracy and accessibility of the information. The AMA would prefer the PCEHR to be an opt-out system rather
than opt-in to ensure the success of the system in healthcare delivery, nevertheless it considers it will become a valuable addition to the quality of health in Australia over time.

We thank AMA NSW for allowing us to adapt this content. For more information on the PCEHR, see: www.ama.com.au/media/draft-guide-usingpcehr

If you have any feedback or would like to relate your experience with the PCEHR, email Elizabethm@amavic.com.au

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