Advisory AS18/11: Implementing systems that can provide clinical information into the My Health Record system

Advisory details

Purpose

To describe the minimum requirements for health service organisation compliance with Actions 1.17 and 1.18 working towards implementing the My Health Record system.

Issue

Actions 1.17 and 1.18 are requirements in the second edition of the National Safety and Quality Health Service (NSQHS) Standards. They relate to health service organisations implementing systems for the use of the My Health Record system.

The subjects of this advisory are Action 1.17 and Action 1.18.

Action 1.17 states:

The health service organisation works towards implementing systems that can provide clinical information into the My Health Record system that:

1. Are designed to optimise the safety and quality of health care for patients
2. Use national patient and provider identifiers
3. Use standard national terminologies

Action 1.18 states:

The health service organisation providing clinical information into the My Health Record system has processes that:

1. Describe access to the system by the workforce, to comply with legislative requirements
2. Maintain the accuracy and completeness of the clinical information the organisation uploads into the system

This advisory describes the minimum actions all health service organisations must demonstrate to be compliant with the requirements of Action 1.17 and the processes for Action 1.18.

The NSQHS Standards complement the participation requirements set out in Part 5 of the My Health Records Rule 2016 (the Rule). The Rule outlines the participation requirements for providers contributing to the secure operation of the My Health Record system, to ensure the safety and quality of health care provided to patients. These participation requirements should be described in organisational policies and procedures.

In relation to the use of national patient and provider identifiers, health service organisations are expected to have identity management systems that align with the national Healthcare Identifiers (HI) service. This includes collecting sufficient patient demographics to obtain or revalidate a patient’s Individual Healthcare Identifier (IHI). In addition, health service organisations are required to maintain and monitor local systems that allow timely and accurate identification of Healthcare Provider Identifiers for both organisations (HPI-Os) and individual providers (HPI-Is).

Health service organisations that provide (or are working towards providing) clinical information into the My Health Record system using standard national terminologies should consider supporting material from the National Clinical Terminology Service (NCTS). It is expected that health service organisations will work towards integrating standard national terminologies (for example, SNOMED CT-AU and Australian Medicines Terminology) into their clinical information systems.

It is also expected that all health service organisations will comply with Actions 1.17 and 1.18, recognising the Intergovernmental Agreement on National Digital Health and supporting the seven strategic priorities outlined in the National Digital Health Strategy.

Previous Advisories have required health service organisations to:

• Complete a gap analysis
• Have developed a detailed plan.

Requirements

To comply with Actions 1.17 and 1.18, health service organisations must:

• By December 2023, have implemented a detailed plan that complies with:
  • all requirements of Part 5 of the Rule;
  • use of national patient and provider identifiers (IHIs, HPI-Os, HPI-Is); and,
  • use of standard national terminologies.
• By December 2024, have established ongoing monitoring and evaluation of the requirements of Action 1.17 and 1.18.

Accrediting agencies are required to:

• Review evidence that:
  • From January 2024, the organisation has completed a gap analysis, has a detailed plan and the plan is implemented
  • From January 2025, the organisation has in place an ongoing monitoring and evaluation system of the requirements of Action 1.17 and 1.18.
• Rate Action 1.17 as met, only if the organisation demonstrates progress against the specific requirements of the action in the relevant year.
• Prior to an organisation providing clinical information into the My Health Record system, rate Action 1.18 as met when Action 1.17 is met or met with recommendations.
• Once an organisation is providing clinical information into the My Health Record system, assess evidence of compliance with the requirements of Action 1.18.

Resources are available from the Australian Digital Health Agency’s website and My Health Record website, which may provide further understanding of the My Health Record system (see Attachment 1).

Australian Digital Health Agency resources

• Understanding national identifiers
• Introduction to clinical terminology
• My Health Record stakeholder materials (for healthcare professionals)
• Roles and responsibilities – when registering to use My Health Record system
• Webinars for healthcare providersExternal link
• Sample digital health policies (downloadable templates)
• Data quality checklist of ‘active’ patients
• Software simulations
• National Clinical Terminology Service
• Security and Access policy template