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My Health Record participation obligations

Establish a My Health Record security and access policy

Healthcare organisations must operate in accordance with relevant policies and legislation when participating in the system. They must establish, review, update, maintain, enforce and promote policies that ensure the system is used safely and responsibly by staff.

Prior to registering to participate in the system, your organisation will need to have a Security and Access policy in place. See the ongoing participation obligations below for information about keeping your policy up to date.

You will also need to assign a responsible officer and an organisation maintenance officer to act as the system administrators and key contacts for your organisation in relation to participation in the system.

    Policy requirements checklist

    To learn more about this requirement, the Agency has developed a security and access policy checklist.

    The checklist is a guide only, and should be assessed against the needs and risks that may apply to your organisation.

    Healthcare provider organisations need to ensure the policy includes and addresses the topics outlined in Rule 42 of the My Health Records Rule as outlined below. 

    1. Healthcare provider organisation policies
    • A written My Health Record Security and Access policy is in place prior to the healthcare provider organisation registering to participate in the system, and the policy is maintained on an ongoing basis. 
    • The policy is communicated and remains accessible to all employees.
    • The policy is communicated with any healthcare providers to whom the organisation supplies services under contract, and remains accessible to these providers. For example, a healthcare provider organisation that supplies information technology services to individual healthcare providers to enable them to access the system, must communicate the policy to these providers. 
    • The policy is enforced in relation to all employees and any healthcare providers to whom the organisation supplies services under contract. 
    2. Manner of authorising and process for suspending and deactivating user accounts
    • The policy details the manner of authorising persons accessing the system via or on behalf of the healthcare provider organisation.
    • The policy outlines the ways a user account is suspended and/or deactivated in the following circumstances:
      • A user leaves the organisation
      • A user’s security is compromised
      • A user has changed duties and no longer requires access to the system
    3. Training for authorised users, before they access the system
    • The policy includes a requirement that, before a user is authorised to access the system, they receive training covering:
      • How to use the system accurately and responsibly 
      • Legal obligations of the healthcare provider organisation and people who access the system on behalf of the organisation 
      • Consequences of breaching those obligations 
    • The Agency is planning to publish a recommended training checklist and declaration form that may support your organisation in meeting this legislative requirement.
    • It is recommended that organisations maintain a register of staff training.
    4. Process for identifying the individual who accesses a person’s record (on each occasion)
    • The policy outlines the process for identifying a person who requests access to a healthcare recipient’s record and communicating the person’s identity to the My Health Record System Operator (Australian Digital Health Agency).
    • Generally, this would occur via the My Health Record National Provider Portal, or clinical information systems, where:
      • the clinical software is used to assign and record unique internal staff member identification codes, including a Healthcare Provider Identifier-Individual (HPI-I); and
      • the unique identification code, or the provider’s HPI-I, is recorded by the clinical software and automatically provided to the System Operator for each instance of system access.

    Note: See the legislative obligations for communicating to the System Operator under Section 74 of the My Health Records Act.

    5. Physical and Information Security Measures, including user account management processes
    • The policy details the physical and information security measures that are in place to mitigate information security risks and prevent unauthorised access.
    • People accessing the system via or on behalf of the healthcare provider organisation understand and adhere to the physical and information security measures.
    • The healthcare provider organisation employs reasonable user account management practices, including:
      • Restricting access to those persons who require access as part of their duties
      • Uniquely identifying individuals using the healthcare provider organisation’s information technology systems
      • Having that unique identity protected by a password or equivalent protection mechanism
      • Ensuring password and/or other access mechanisms are sufficiently secure and robust to mitigate the security and privacy risks associated with unauthorised access to the system
      • Disabling the user accounts of persons no longer authorised to access the system
      • Suspending a user account as soon as practicable after becoming aware that the account or its password or access mechanism has been compromised.

    Note: See the Agency’s cyber security resources for more information. Additional guidance is provided in the Guide to Securing Personal Information and the Guide to Health Privacy on the Office of the Australian Information Commissioner website.

    6. Strategies for identifying, responding to, and reporting system-related security risks
    • The policy describes the mitigation strategies used by the healthcare provider organisation to ensure the system-related security risks can be:
      • promptly identified
      • acted upon
      • reported to the healthcare provider organisation’s management.
    • This should include processes for identifying and reporting:
      • unauthorised access to the  system
      • any matters that may compromise the security or integrity of the system, for example, a security incident, such as ransomware, that has affected a healthcare provider organisation.
    • Organisations should ensure processes are in place to comply with data breach notification obligations outlined in section 75 of the My Health Records Act. Learn more about how to manage a data breach further down the page.
    • To assist with monitoring use of the system, audit logs should record the user identity, date and time of access, whose record was accessed and the type of information that was accessed.
    7. Assisted Registration (if offered)
    • Where the healthcare provider offers assisted registration, this topic is required within the policy. If the organisation does not offer assisted registration, it is recommended that this is noted in the policy.
    • Assisted registration is where a healthcare provider assists healthcare recipients to register for a record.
    • The policy needs to outline the methods for:
      • Authorising employees of the organisation to provide assisted registration
      • Providing training before a person is authorised to provide assisted registration
      • Confirming a healthcare recipient’s consent to be registered
      • Identifying a healthcare recipient for the purposes of assisted registration, including the process and criteria that must apply

    Note: See the legislative requirements for confirming a healthcare recipient’s consent under Rule 9 of the My Health Records (Assisted Registration) Rule.

    8. Policy implementation and maintenance
    • The My Health Record Security and Access policy must be reviewed annually (at a minimum) and when any material new or changed risks are identified (such as a change within the system, organisation, or regulation; or factors that might result in unauthorised access, use or disclosure of information in a record).
    • The policy must include a unique version number and date of effect.
    • A copy of each version of the policy must be retained by the organisation.

    Note: The Agency or the Office of the Australian Information Commissioner may request a current or previous version of your organisation’s Security and Access policy at any time. The legislation specifies that a healthcare provider organisation must comply with a request to provide a copy of the policy within 7 days of receiving the request.

    More information

    The Office of the Australian Information Commissioner (OAIC) provides Rule 42 guidance outlining points for healthcare provider organisations to consider when developing their My Health Record Security and Access policy. A My Health Record security and access policy template has also been developed by the OAIC, in collaboration with the Agency, to assist you in developing a policy for your organisation.

    Guidance and policy template

    You may also wish to complete the Agency's "Developing a security and access policy for your organisation" e-Learning module for an overview of the practical steps that should be followed when developing a security and access policy.

    General guidance is also available to help you protect health information.

    Ongoing participation obligations

    Once you have established a security and access policy for your organisation and registered with the My Health Record system, you are required to comply with a range of ongoing participation obligations.

    At a high level, you are required to:

    • Provide healthcare services, regardless of whether an individual has a My Health Record or has limited access to information contained in their My Health Record by using access controls. See the section on access controls to understand how they may be applied and the rare circumstance they may be overridden using Emergency Access - see the "Emergency access" section in the "Privacy and access" section.
    • Take reasonable steps to ensure any information uploaded to the My Health Record system is easily understood, accurate and up-to-date, at the time it is uploaded. It is also important to ensure information is not defamatory or subject to copyright. See the OAIC guidance for additional information on the relevance of the Australian Privacy Principles when using the My Health Record system.
    • Ensure that the details for the organisation’s Responsible Officer and Organisation Maintenance Officer(s) are kept up to date in Provider Digital Access (PRODA).
    • Have a process in place to prevent a clinical document being uploaded to the My Health Record system where an individual has asked that the information is not uploaded.
    • Ensure information being uploaded to the My Health Record system is prepared by individuals that are registered healthcare providers who have a healthcare provider identifier–individual (HPI-I). It is important to conduct regular checks to ensure individual’s using the system on behalf of the organisation have a registration that is not conditional, suspended, cancelled, or lapsed.
    • Train users of the system regarding appropriate collection, use and disclosure My Health Record information. This includes awareness of organisational and individual legislative obligations specific to the My Health Record system, along with the Privacy Act 1988 and any relevant state or territory laws.
    • Ensure that data quality is maintained when information is uploaded to the My Health Record system, and that it complies with the relevant legislative obligations. This includes establishing and maintaining a list of individuals authorised to access the My Health Record system on behalf of your organisation and ensuring they are registered healthcare providers. 
    • Notify the Agency as the System Operator and, where relevant, the Office of the Australian Information Commissioner (OAIC) as soon as practicable after becoming aware of a potential or actual data breach relating to the My Health Record system. See guidance on managing a data breach which describes the steps for notifying the relevant parties of a data breach.
    • Ensure that the Agency, as System Operator, is notified within two business days of becoming aware of a non-clinical My Health Record system-related error in a record, or of a material change to your organisation
    • Assist  with any inquiry, audit, review, assessment, investigation, or complaint regarding the My Health Record system.
    • Ensure that a My Health Record Security and Access policy is in place and that the policy is reviewed, at least annually, and copies of each version are retained. See the Security and Access policy checklist.
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