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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.
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.
• 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.
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.
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.
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.
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.
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