Access to core information critical to e-health record success

Doctors and other health workers need to have access to core clinical information in electronic medical records if the Federal Government’s My Health Record system is to deliver an improvement in patient care, the AMA has said.

Releasing the AMA’s updated Position Statement, Shared Electronic Medical Records 2016, today, AMA President Dr Michael Gannon said that giving patients the ability to block or modify access to critical information such as medications, allergies, discharge summaries, diagnostic test results, blood pressure and advance care plans compromised the clinical usefulness of shared electronic medical records loaded on the My Health Record system.

“Doctors treating a patient need to be confident that they have access to all relevant information,” Dr Gannon said. “Shared electronic medical records have the potential to deliver huge benefits by giving health workers ready access to critical patient information when it is needed, reducing the chances of adverse or unwarranted treatments and improving the coordination of care.

“But, if patients are able to control access to core clinical information in their electronic medical record, doctors cannot rely on it.

“Giving patients such control, as the My Health Record system does, is a big handicap to the clinical usefulness of shared electronic medical records.”

The Federal Government launched My Health Record earlier this year to replace Labor’s troubled Personally Controlled Electronic Health Record (PCEHR) system, and trials of its opt-out arrangements are due to commence in mid-July.

But the system, like the PCEHR, gives patients the power to control what goes on the health record, and who can view it.

The AMA said giving patients such control meant the My Health Record would never realise the full benefits of a national electronic health record system.

“All shared electronic health records must include core clinical information that is not subject to patient controls,” the AMA Position Statement said. “Certainty that shared electronic health records contain predictable core clinical information which is not affected, conditioned or qualified by the application of access controls, is critical to the achievement of the legislated objectives of the My Health Record.”
Like its predecessor, the My Health Record system has generated little interest among patients or doctors – in April just 798 health providers had uploaded a shared health summary to the system.

An AMA survey of 658 medical practices, undertaken last month, found GPs were reluctant to take part because of lack of confidence in the reliability of information it contained, combined with little patient demand and an absence of support for practices undertaking the task of creating shared health summaries.

Dr Gannon said the AMA encouraged individuals to take responsibility for their health and strongly supported the idea of a national shared health summary system, but it had to be the right one – one that supports clinical care.

“All health care workers involved in providing clinical care to a patient should have access to core clinical information,” he said. “Where specific information, other than core clinical information, is not made generally available, this should be made clear to treating doctors with a flag on the medical record.”

The AMA added that in ‘break glass’ emergency situations, implied consent must sometimes be assumed to allow access to the full medical record.

The Association said the system should also provide protections for doctors who acted in good faith but missed or were unable to locate critical data “because it is buried in a sea of electronic documents”.

Dr Gannon said shared electronic medical records should not be treated as a replacement for a patient’s medical record, and should not be treated as the single and definitive source of ‘truth’ regarding clinical information about a patient.
But he said it was an extra source of information, accessible at the point of care, which may otherwise have not been available.

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