Use of digital health records by healthcare providers
Digital Health Evidence Review: This section provides information on how healthcare providers access and use shared digital health systems.
How can healthcare providers access the My Health Record system?
Healthcare providers have two options available to access a patient’s My Health Record: the national provider portal (which allows them to view information only) or from their clinical information system (CIS) (which allows them to upload and/or view information). There are 50 CISs that are linked to the My Health Record system (please see register of conformity for more information). These different CISs are developed by a wide range of software organisations and each offer healthcare providers a unique interaction with the My Health Record system.
National Provider Portal
Clinical Information System (CIS)
(uploading or viewing)
To access the My Health Record via a CIS, the clinician must be a registered health care provider – for example, registered with our regulatory body, the Australian Health Practitioner Regulation Agency. They must have conformant software that has a secure and encrypted connection to the My Health Record system. In addition, the patient must have a record on the provider’s CIS, as a patient of the practice, with a number of identifiers in the system. Only then can the clinician see whether their patient has a My Health Record, and even then, the provider’s access will depend on their patient’s individual privacy settings.
What information is available to healthcare providers in the My Health Record system?
Similar to individuals, healthcare providers can view either single documents or summary views that combine information from a range of sources in the My Health Record system. The information below summarises the types of documents that are within the My Health Record system and their author.
- Consumer health summary
- Consumer-entered notes
- Consumer-entered child notes
- Advance Care Plan or custodian
- Emergency Contacts
- Shared health summary
- Event summary
- Discharge summary
- Specialist letters
- Prescription & dispense record
- Pathology & diagnostic imaging reports
- Medicare history
- Pharmaceutical Benefits Scheme (PBS) history
- Australian Organ Donor Register
- Australian Immunisation Register
How are healthcare providers actively using EHRs and shared digital health records internationally?
This section provides some case studies describing international EHR use and clinician experience in Canada, the US, the UK and Finland to demonstrate the variation in active use and experience with shared digital health information systems.
At a national level, Canada estimates that there will be 500,000 users when the EHR system has reached maturity. This number of users represents 80% of all physicians, nurses and pharmacists as well as 50% of other clinicians and administrators. Active use is closely related to system maturity with the highest level of access by users seen in systems that have been in operation the longest.  Figure 1 below shows how national levels of active use have increased over time.
Figure 1. Percentage of estimated monthly active users in Canada, 2015 - 2016
At a local level, active use can vary considerably. For example, a summary of active users in the Greater Toronto Area between Jan 2015 and May 2016 showed that the level of active use ranged from 18% to 100% within healthcare organisations. The highest proportion of active users (>50%) was seen in community-based hospitals and community care access centres. 
Data from the 2014 Healthcare Information and Management Systems Society (HIMSS) Analytics survey were analysed to assess the intensity with which different EHR functionalities were used in ambulatory practices (i.e. outpatient care). The 7 domains of health IT functionality were:
- Data repository (e.g. medication lists, current encounter vital signs, nursing and physician documentation)
- Clinical decision support (e.g. clinical guidelines, suggested patient follow-up, remote device monitoring process alerts)
- Order entry management (e.g. e-prescribing for new medications, e-prescribing for refill medications)
- Electronic messaging (e.g. patient communications, referral communications)
- Results management (e.g. output from diagnostic and intelligent medical devices incorporated directly into patient’s record)
- Health information exchange (e.g. capable of data exchange across multiple platforms, including governmental agencies, other clinics, pharmacies)
- Patient use (e.g. email communication with physicians or nurses, patient portal, medical education content)
Practices reported their use of the above domains and it was classified as either low, moderate or high use. The domains categorised as high use were order entry management (39.4% reported high use) and results management (37.5% reported high use).  The domains categorised as low use were results management (56.1% reported low use) and patient use of EHR tools (48.6% reported low use). Overall, 26.6% of practices were considered super-users and 38.9% were considered under-users.  The authors suggest that this highlights the importance of investing in health IT capacity.
In Finland, usability surveys were completed throughout 2010 and 2014 to assess the user experience of healthcare providers with EHRs. Clinicians were asked about the degree to which EHRs supported collaboration and information exchange between clinicians working in different organisations. Key findings were: 
- In public hospitals, there was no change between 2010 and 2014 with 17% agreeing EHRs supported information exchange
- In public healthcare centres, there was a 4% increase from 15% in 2010 to 19% in 2014
- In private health, there was a 4% increase from 5% in 2010 to 9% 2014
- Overall, this was a significant 2% increase from 14% in 2010 to 16% in 2014
Figure 2. Percentage of clinicians in Finland who agreed that EHRs supported collaboration and information exchange, 2010 - 2014
System-wide information sharing requires access to EHRs across the full spectrum of care. One example of significant differences between clinical types and access to shared information is from a 2009 study within cancer services in Canada. Key findings were :
- Overall, 22% of clinicians reported access to other organisation’s EHRs.
- Medical oncologists and ‘other’ physicians were more likely than surgeons to report access to other organisation’s EHRs.
- Those working in community-based care were six times less likely than those in teaching hospitals to report access to other organisation’s EHRs.
Moreover, evidence from Canada demonstrates different experiences for clinicians based on the accessibility of connected care information or access to patient health information from outside their practice through health information exchanges. Key findings were:
- Across five types of health information, connected physicians were more likely than unconnected physicians to report having the information they needed during clinical encounters. 
- Lab results were the most common piece of missing information and were missing for 11% of encounters for connected physicians and 25% of the time for unconnected physicians. 
- For the majority of cases where information was missing there was no action required. This was 87% for connected physicians and 77% for unconnected. 
- Unconnected physicians were forced to proceed with incomplete information 13% of the time and wasted time seeking information 13% of the time. 
In the UK, the National Health Service (NHS) asks secondary care providers (e.g. hospitals, mental health, and acute care) to complete a Digital Maturity Self-Assessment survey. This survey measures the current level of digital services the healthcare organisations are using and provides an overview of how the country is doing as a whole.
In regards to information sharing between healthcare provider organisations the 2016 UK Digital Maturity Survey showed :
43% somewhat disagreed with the statement ‘other local healthcare providers have digital access to the information they need from your organisation’.
33% mostly disagreed that healthcare providers have digital access to all relevant diagnostic test results and images for patient under their care, including those undertaken by other local providers.
36% mostly agreed that healthcare providers have digital access to all relevant diagnostic test results and images for patient under their care, including those undertaken by other local providers.
In the US, efforts have been made to survey different types of information sharing so that these can be consistently measured and tracked over time. The core components of interoperability or information sharing in this survey were:
Ability to query for patient data from outside institutions. Particularly important for unplanned, emergency care.
Providing patient information to outside organisations during planned care transitions (e.g. referrals, following hospital discharge).
Information is shared electronically with no special effort on the part of the user needed to merge informaton into a provider's EHR.
Getting patient information from outside organisations during planned care transitions (e.g. referrals, following hospital discharge)
In a 2014 survey of 3307 US hospitals, participants were asked, ‘Do providers at your hospital routinely have necessary health information available electronically from outside providers or sources when treating a patient who was seen by another healthcare provider/setting?‘. Key findings of the survey data showed :
- 21% of hospitals could perform all four functions related to sharing information (find, send, receive and integrate). 17% could do three functions, 20% could do two and 17% could do one function. A further 25% could do none of these functions.
- For those with only one function, the most common was to send (47.7%) then find (23%) information.
- The hospitals who could complete all four functions were more likely to be medium-sized, part of a system, and participating in medical home model participation.
- 36% of hospitals reported having health information available from outside providers when needed. These hospitals were more likely to be government owned rather than private and have answered yes to all four of the functions above.
The US has shown growth in sharing information between organisations. National rates of hospitals’ electronically sending, receiving and finding information to and from providers or sources outside their hospital system significantly increased between 2014 and 2015. A substantial majority of hospitals were electronically sending and receiving summary of care records, and a little over half of hospitals were electronically finding information from outside sources.  In 2015, 18.7% of hospitals reported that they ‘often’ use patient data from outside providers.
US policy on interoperable health information focuses on both inter-system (i.e. between organisations) and intra-system exchange (i.e. within organisation). Recent data shows that hospitals are prioritising within-organisation information exchange over exchange between different organisations with almost 5 types of information shared intra-system and almost 3 types of information shared inter-system.
The information in the My Health Record system flows from connected and conformant clinical information systems in hospitals, general practices, pharmacies, specialist rooms, pathology and radiology providers. It also provides healthcare provider access to patients’ MBS and PBS data, the Australian Immunisation register and the Australian Organ Donor Registry. The implementation of EHRs, PHRs and portals represents a significant benefit for consumers and clinicians, as well as a change in healthcare delivery processes for a range of healthcare providers.
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