Uploading a Shared Health Summary
A shared health summary is a crucial part of the My Health Record system. Healthcare providers will learn how to create, upload, and edit shared health summaries as part of using the system.
The Shared Health Summary (SHS) represents the patient's status at a point in time. The Royal Australian College of General Practitioner’s (RACGP's) Digital Business Kit and My Health Record position statement provides additional guidance on Electronic Health Records including Shared Health Summaries. The SHS can be created or updated at any consultation, and may include information about a patient's medical history, including:
- Adverse reactions
The most recently uploaded SHS in an individual's My Health Record is likely to be the first document accessed by any other healthcare professional viewing a patient's My Health Record.
A SHS can be created and uploaded to the My Health Record system by:
- a Registered Medical Practitioner
- a Registered Nurse
- an Aboriginal and Torres Strait Islander Health Practitioner
By uploading a SHS, the healthcare provider automatically becomes the patient's 'nominated healthcare provider.' A patient can have only one nominated healthcare provider at a time, who should be delivering continuing, coordinated and comprehensive are to the individual. (Note: a provider who is not the patient's usual provider could use an Event Summary instead to upload clinically relevant information to the patient's My Health Record).
A SHS can be created or updated at any consultation; however uploading a SHS will be particularly beneficial for patients with chronic conditions and co-morbidities. As part of putting the My Health Record system into practice, the RACGP recommends that a healthcare provider creates and uploads a SHS when completing a patient health assessment, because this is a time when the health summary within the local GP clinical system is being updated. For example:
A GP management plan
Patients who have one or more chronic medical conditions and need a GP management plan may also benefit from having a SHS uploaded to their My Health Record at the same point in time.
75+ health assessment
This structured assessment of a patient over 75 years may be a good opportunity to upload a SHS to their My Health Record given the in-depth review that is undertaken. It also supports ongoing management for the patient, their family and other healthcare providers.
4 year-old health check
As with all patient health assessments, inclusion of a SHS after conducting the "4 Year-Old Check" would likely be a timely capture of an individual's health status. This may also increase a parent's understanding of their child's needs.
Another opportune time to upload a SHS is when offering the flu vaccination. Many of the high-risk patients to whom your practice offers the flu vaccination may also benefit from the creation of a SHS to manage their health.
Click here for software demonstrations showing how easy it is to create a SHS using your clinical software. If there isn't a demonstration for your clinical software, check your software vendor's website. Your Primary Health Network (PHN) can also provide training for your practice team in how to use the digital health features in your clinical software.
To create a SHS, the healthcare provider will need to obtain the patient's agreement that:
- the healthcare provider is to be the individual's Nominated Healthcare Provider;
- the healthcare provider is to create a SHS for the patient.
The Australian Medical Association (AMA) states that it is good medical practice to advise a patient that you will be uploading information to their My Health Record, particularly if this information might be considered sensitive. See section 4.5 of the AMA's Guide to using the PCEHR.
However, there is no requirement for the patient to review the SHS before it is uploaded to their My Health Record.
In billing the Medicare Benefits Schedule (MBS), GPs will be able to take in to account the time taken to register patients for a My Health Record, prepare Shared Health Summaries and Event Summaries if these activities are undertaken as part of providing a clinical service and the patient is present at the time. These activities are considered to be part of the documentation of treatment of the patient. See MBS Online for information on item numbers relevant to actions related to a patients' My Health Record, which can be found by searching for "PCEHR" on the MBS website.
The author of a clinical document can delete a clinical document from the My Health Record system if, for instance, it has been uploaded in error or contains a mistake.
If a nominated healthcare provider wishes to change the information in their patient's SHS, e.g. the medicines listed, they will need to upload a new Shared Health Summary with the updated information.
Note that there is no additional responsibility for a nominated healthcare provider to update a Shared Health Summary outside of a consultation with the patient.
Sections 4.5.3 and 5.4 of the AMA's Guide to using the My Health Record system provide recommendations to medical practices in these and related areas.