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My Health Record

My Health Record (MHR) is an online clinical document store of patients’ interaction with Australian healthcare providers.

In WA, more than 90 per cent of people eligible for Medicare have a MHR.

Clinical summaries, medications information, results and reports will accumulate in the MHR as patients interact with GPs, hospitals, pharmacies, pathology and imaging facilities.

Clinicians caring for a patient are pre-authorised by national legislation to access this information to assist patient care.

Access to information is the bedrock of high quality health care. The MHR will, over time, become an invaluable repository of a patient’s health information.

How do I view MHR?

General access

Access to MHR is by clicking on the coloured MHR logo in Notifications and Clinical Summaries (NaCS). A greyed-out logo means the patient does not have a MHR or has placed a Record Access Code on their MHR. Health Support Services is working on adding viewing to the following clinical applications by the end of 2018: ADA, eReferrals, webPAS, BOSSNet and iCM (iSoft).

MHR can also be viewed through the online portal (external site) however, individual setup is required.

Record Access Code

If the MHR logo is grey and the patient tells you they have a MHR with a Record Access Code, you will need to select ‘access with code’ and enter the PIN or passcode the patient provides. You may not write down the code for future use.

Limited Document Access Code

If a patient has restricted access to specific documents, you will be requested to provide a PIN or passcode to access the document. The patient can provide you with this code.

Emergency Breakglass function

If the patient has set a Record Access Code or Limited Document Access Code to their MHR and is unable to provide consent to you to view information contained within the MHR, you may utilise the ‘Emergency Breakglass’ function.

Criteria for activating the ‘breakglass’ function

1. When it is necessary to either:

a. ‘lessen or prevent a serious threat to an individual’s life, health or safety’ OR
b. ‘lessen or prevent a serious threat to public health or public safety’.

and

2. "It is unreasonable or impracticable to obtain the recipient’s consent to the collection’ (otherwise, MHR may be accessed via general access).

The ‘breakglass’ function cannot be tested between consenting staff members. It can only be ‘tested’ in a true emergency.Think you need to breakglass? Do the following:

Check if you have general access.
If not, discuss and seek approval to breakglass with the most senior doctor on duty in your area.
Document their decision in the clinical record.
Breakglass and document the date and time you accessed the MHR.

Breakglass access will be audited.

What is WA uploading and not uploading?

NaCS summaries are uploaded automatically

Currently all WA public hospitals are connected to MHR for upload via NaCS; however, the following requirements need to be met for the automatic upload to occur:

A NaCS discharge summary has been created. The patient has an active MHR.
The patient has not withdrawn consent by informing clerical staff.
You agree to uploading the NACS summary.

If you have concerns about uploading the particular summary, tick the ‘My Health Record Exclusion’ box in NaCS before finalising the summary to prevent upload to MHR.

Acting on Patient Consent Withdrawal

A patient can withdraw consent for upload by advising the clinic/ward clerks. Clerks will then ‘uncheck’ the ‘inform GP’ box in the patient administration system.

The check box is an ‘all or none’ flag. No clinical summary, no pathology and no imaging reports will be uploaded for that episode of care if the ‘inform GP’ box is unchecked.

Future upload capability

Most public pathology and diagnostic imaging reports will be uploaded, except for select ‘sensitive tests’ such as STI, HIV, pregnancy under 16 and andrology tests.

Legal requirement to ensure information uploaded is accurate and verification with patients

You have a legal obligation to ensure that the information in your uploaded summaries is accurate. Remember: other clinicians will be relying on the accuracy of your information to make safe clinical decisions for your patient further down the track.

Are there any concerns I need to know about?

Completeness

The MHR is a personally controlled health record, therefore, patients may be able to hide or remove documents that have been uploaded. You cannot assume the record is complete. Please apply your clinical judgement when reviewing information contained within.

Additional information (clinician-centric FAQs)

Futher information about the many questions you and your patients may have about MHR can be found on HealthPoint (intranet), the WA health system intranet.

Several ‘Take 5’ (5 slides only) slide packs have been prepared that should answer the most common questions you may have. The site also contains links to other, more detailed, information resources.

Please provide feedback or questions to: MyHealthRecord.Queries@health.wa.gov.au

Fact sheet authorised by: Dr Peter Sprivulis, Chief Clinical Information Officer Department of Health (July 2018).

Last reviewed: 18-06-2019