This action 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

Intent

Health service organisations securely share a patient’s clinical information with authorised clinicians in other settings, including the My Health Record system.

Reflective questions

What processes are used to ensure that the health service organisation’s IT systems comply with the requirements of the My Health Record system?

How does the health service organisation ensure that the workforce is appropriately trained in the use of the My Health Record system, including the use of identifiers and terminology?

Key tasks

  • Use unique national identifiers for patients, clinicians and health service organisations in local information systems and in clinical documents loaded into the My Health Record system
  • Implement standard national terms such as the Australian Medicines Terminology (AMT) in healthcare records and clinical documents loaded into the My Health Record system.

Strategies for improvement

Hospitals

The My Health Record system allows secure collection, storage and exchange of health information between consumers and providers. It uses information from general practitioners, pharmacies, pathology laboratories, imaging services and hospitals to improve the safety and quality of care by supporting clinical handover and making clinical information accessible in different settings.

Health service organisations will have different levels of preparedness to provide clinical information to the My Health Record system. Implementation of this action may depend on the resources available and the organisation’s current healthcare records system.

For more information on My Health Record visit the Commission’s e-Health Safety web page.

Use unique national healthcare identifiers

Unique healthcare identifiers help ensure that individuals and clinicians are confident that the correct information is associated with the correct individual at the point of care.

The My Health Record system uses unique national identifiers for patients, clinicians and health service organisations to ensure secure access to healthcare records. Using national patient identifiers in local information systems can prevent duplication of records and minimise the chance of information being assigned to the wrong patient. It also allows correct identification of treating clinicians and health service organisations, enabling follow-up by other clinicians involved in the patient’s care.

Every Australian resident is allocated a unique 16-digit identifier called the Individual Healthcare Identifier (IHI).

The Australian Health Practitioner Regulation Agency issues unique national identifiers to the clinicians it registers.

Health service organisations that employ one or more clinicians can apply for an organisational identifier from the Healthcare Identifiers Service.

For more information, see Healthcare Identifiers Service – frequently asked questions.

Use standard national terminologies

Adopting standard terms such as AMT and SNOMED CT-AU ensures that clinical information captured in local information systems can be readily understood and used by other clinicians accessing this information. See the Australian Digital Health Agency website for more details.

Examples of evidence

Select only examples currently in use:

  • Healthcare records management system that uses Individual Healthcare Identifiers and standard national terminologies
  • Policy documents about the healthcare records management system
  • Audit results of compliance with policies, protocols or procedures for accessing healthcare records and sharing information
  • Audit results of the use of unique identifiers to link the paper healthcare record to the electronic healthcare record
  • Committee and meeting records in which the governance of the health service organisation’s data and IT systems is monitored or discussed, including validation and protection of data
  • Training documents on the use of the My Health Record system
  • Observation that data and records are kept secure and safe in both soft and hard copies
  • Observation that systems are in place to provide IT infrastructure and support to the workforce using national standard secure messaging to generate national standard e-referral discharge summaries or event summaries
  • Examples of electronic correspondence or referrals that use secure messaging.

Day Procedure Services

The My Health Record system allows secure collection, storage and exchange of health information between consumers and providers. It uses information from general practitioners, pharmacies, pathology laboratories, imaging services and hospitals to improve the safety and quality of care by supporting clinical handover and making clinical information accessible in different settings.

Health service organisations will have different levels of preparedness to provide clinical information to the My Health Record system. Implementation of this action may depend on the resources available and the organisation’s current healthcare records system.

For more information on My Health Record visit the Commission’s e-Health Safety web page.

Use unique national healthcare identifiers

Unique healthcare identifiers help ensure that individuals and providers are confident that the correct information is associated with the correct individual at the point of care.

The My Health Record system uses unique national identifiers for patients, clinicians and health service organisations to ensure secure access to healthcare records. Use of national patient identifiers in local systems can prevent duplication of records and minimise the chance of information being assigned to the wrong patient. It also allows correct identification of treating clinicians and health service organisations, enabling follow-up by other healthcare providers involved in the patient’s care.

Every Australian resident is allocated a unique 16-digit identifier called the Individual Healthcare Identifier (IHI).

The Australian Health Practitioner Regulation Agency issues unique national identifiers to the clinicians it registers.

Health service organisations that employ one or more clinicians can apply for an organisational identifier from the Healthcare Identifiers Service.

For more information, see Healthcare Identifiers Service – frequently asked questions.

Use standard national terminologies

Adopting standard terms such as AMT and SNOMED CT-AU ensures that clinical information captured in local systems can be readily understood and used by other clinicians accessing this information. See the Australian Digital Health Agency website for more details.

Examples of evidence

Select only examples currently in use:

  • Healthcare records management system that uses IHIs and standard national terminologies
  • Policy documents about the healthcare records management system
  • Audit results of compliance with policies, protocols or procedures for accessing healthcare records and sharing information
  • Audit results of the use of unique identifiers to link the paper healthcare record to the electronic healthcare record
  • Committee and meeting records in which the governance of the health service organisation’s data and IT systems is monitored or discussed, including validation and protection of data
  • Training documents on the use of the My Health Record system
  • Observation that data and records are kept secure and safe in both soft and hard copies
  • Observation that systems are in place to provide IT infrastructure and support to the workforce using national standard secure messaging to generate national standard e-referral discharge summaries or event summaries
  • Examples of electronic correspondence or referrals that use secure messaging.

MPS & Small Hospitals

The My Health Record system allows the secure collection, storage and exchange of health information between consumers and providers. It uses information from general practitioners, pharmacies, pathology laboratories, imaging services and hospitals to improve the safety and quality of care by supporting clinical handover and making clinical information accessible in different settings.

The My Health Record system uses unique national identifiers for patients, clinicians and health service organisations to ensure secure access to healthcare records. Use of national patient identifiers in local systems can prevent duplication of records and minimise the chance of information being assigned to the wrong patient. It also allows correct identification of treating clinicians and health service organisations, enabling follow-up by other clinicians involved in the patient’s care. For more information, see Healthcare Identifiers Service – frequently asked questions.

Adopting standard terms such as Australian Medicines Terminology (AMT) and SNOMED CT-AU ensures that clinical information captured in local systems can be readily understood and used by other clinicians accessing this information. See the Australian Digital Health Agency website for more details.

MPSs or small hospitals that are part of a local health network or private hospital group should implement and use the established processes for My Health Record locally.

Small hospitals that are not part of a local health network or private hospital group, and that are implementing the My Health Record system, should ensure that policies and processes:

  • Use unique national identifiers for patients, clinicians and health service organisations in local systems, and in clinical documents loaded into the My Health Record system
  • Use standard national terms such as the AMT in healthcare records and clinical documents loaded into the My Health Record system.

Health service organisations will have different levels of preparedness to provide clinical information into the My Health Record system. Implementation of this action may depend on the resources available and the organisation’s current healthcare records system.

For more information on My Health Record visit the Commission’s e-Health Safety web page.

Examples of evidence

Select only examples currently in use:

  • Healthcare records management system that uses Individual Healthcare Identifiers and standard national terminologies
  • Policy documents about the healthcare records management system
  • Audit results of compliance with policies, protocols or procedures for accessing healthcare records and sharing information
  • Audit results of the use of unique identifiers to link the paper healthcare record to the electronic healthcare record
  • Committee and meeting records in which the governance of the health service organisation’s data and IT systems is monitored or discussed, including validation and protection of data
  • Training documents on the use of the My Health Record system
  • Observation that data and records are kept secure and safe in both soft and hard copies
  • Observation that systems are in place to provide IT infrastructure and support to the workforce using national standard secure messaging to generate national standard e-referral discharge summaries or event summaries
  • Examples of electronic correspondence or referrals that use secure messaging.

Hospitals

The My Health Record system allows secure collection, storage and exchange of health information between consumers and providers. It uses information from general practitioners, pharmacies, pathology laboratories, imaging services and hospitals to improve the safety and quality of care by supporting clinical handover and making clinical information accessible in different settings.

Health service organisations will have different levels of preparedness to provide clinical information to the My Health Record system. Implementation of this action may depend on the resources available and the organisation’s current healthcare records system.

For more information on My Health Record visit the Commission’s e-Health Safety web page.

Use unique national healthcare identifiers

Unique healthcare identifiers help ensure that individuals and clinicians are confident that the correct information is associated with the correct individual at the point of care.

The My Health Record system uses unique national identifiers for patients, clinicians and health service organisations to ensure secure access to healthcare records. Using national patient identifiers in local information systems can prevent duplication of records and minimise the chance of information being assigned to the wrong patient. It also allows correct identification of treating clinicians and health service organisations, enabling follow-up by other clinicians involved in the patient’s care.

Every Australian resident is allocated a unique 16-digit identifier called the Individual Healthcare Identifier (IHI).

The Australian Health Practitioner Regulation Agency issues unique national identifiers to the clinicians it registers.

Health service organisations that employ one or more clinicians can apply for an organisational identifier from the Healthcare Identifiers Service.

For more information, see Healthcare Identifiers Service – frequently asked questions.

Use standard national terminologies

Adopting standard terms such as AMT and SNOMED CT-AU ensures that clinical information captured in local information systems can be readily understood and used by other clinicians accessing this information. See the Australian Digital Health Agency website for more details.

Examples of evidence

Select only examples currently in use:

  • Healthcare records management system that uses Individual Healthcare Identifiers and standard national terminologies
  • Policy documents about the healthcare records management system
  • Audit results of compliance with policies, protocols or procedures for accessing healthcare records and sharing information
  • Audit results of the use of unique identifiers to link the paper healthcare record to the electronic healthcare record
  • Committee and meeting records in which the governance of the health service organisation’s data and IT systems is monitored or discussed, including validation and protection of data
  • Training documents on the use of the My Health Record system
  • Observation that data and records are kept secure and safe in both soft and hard copies
  • Observation that systems are in place to provide IT infrastructure and support to the workforce using national standard secure messaging to generate national standard e-referral discharge summaries or event summaries
  • Examples of electronic correspondence or referrals that use secure messaging.

Day Procedure Services

The My Health Record system allows secure collection, storage and exchange of health information between consumers and providers. It uses information from general practitioners, pharmacies, pathology laboratories, imaging services and hospitals to improve the safety and quality of care by supporting clinical handover and making clinical information accessible in different settings.

Health service organisations will have different levels of preparedness to provide clinical information to the My Health Record system. Implementation of this action may depend on the resources available and the organisation’s current healthcare records system.

For more information on My Health Record visit the Commission’s e-Health Safety web page.

Use unique national healthcare identifiers

Unique healthcare identifiers help ensure that individuals and providers are confident that the correct information is associated with the correct individual at the point of care.

The My Health Record system uses unique national identifiers for patients, clinicians and health service organisations to ensure secure access to healthcare records. Use of national patient identifiers in local systems can prevent duplication of records and minimise the chance of information being assigned to the wrong patient. It also allows correct identification of treating clinicians and health service organisations, enabling follow-up by other healthcare providers involved in the patient’s care.

Every Australian resident is allocated a unique 16-digit identifier called the Individual Healthcare Identifier (IHI).

The Australian Health Practitioner Regulation Agency issues unique national identifiers to the clinicians it registers.

Health service organisations that employ one or more clinicians can apply for an organisational identifier from the Healthcare Identifiers Service.

For more information, see Healthcare Identifiers Service – frequently asked questions.

Use standard national terminologies

Adopting standard terms such as AMT and SNOMED CT-AU ensures that clinical information captured in local systems can be readily understood and used by other clinicians accessing this information. See the Australian Digital Health Agency website for more details.

Examples of evidence

Select only examples currently in use:

  • Healthcare records management system that uses IHIs and standard national terminologies
  • Policy documents about the healthcare records management system
  • Audit results of compliance with policies, protocols or procedures for accessing healthcare records and sharing information
  • Audit results of the use of unique identifiers to link the paper healthcare record to the electronic healthcare record
  • Committee and meeting records in which the governance of the health service organisation’s data and IT systems is monitored or discussed, including validation and protection of data
  • Training documents on the use of the My Health Record system
  • Observation that data and records are kept secure and safe in both soft and hard copies
  • Observation that systems are in place to provide IT infrastructure and support to the workforce using national standard secure messaging to generate national standard e-referral discharge summaries or event summaries
  • Examples of electronic correspondence or referrals that use secure messaging.

MPS & Small Hospitals

The My Health Record system allows the secure collection, storage and exchange of health information between consumers and providers. It uses information from general practitioners, pharmacies, pathology laboratories, imaging services and hospitals to improve the safety and quality of care by supporting clinical handover and making clinical information accessible in different settings.

The My Health Record system uses unique national identifiers for patients, clinicians and health service organisations to ensure secure access to healthcare records. Use of national patient identifiers in local systems can prevent duplication of records and minimise the chance of information being assigned to the wrong patient. It also allows correct identification of treating clinicians and health service organisations, enabling follow-up by other clinicians involved in the patient’s care. For more information, see Healthcare Identifiers Service – frequently asked questions.

Adopting standard terms such as Australian Medicines Terminology (AMT) and SNOMED CT-AU ensures that clinical information captured in local systems can be readily understood and used by other clinicians accessing this information. See the Australian Digital Health Agency website for more details.

MPSs or small hospitals that are part of a local health network or private hospital group should implement and use the established processes for My Health Record locally.

Small hospitals that are not part of a local health network or private hospital group, and that are implementing the My Health Record system, should ensure that policies and processes:

  • Use unique national identifiers for patients, clinicians and health service organisations in local systems, and in clinical documents loaded into the My Health Record system
  • Use standard national terms such as the AMT in healthcare records and clinical documents loaded into the My Health Record system.

Health service organisations will have different levels of preparedness to provide clinical information into the My Health Record system. Implementation of this action may depend on the resources available and the organisation’s current healthcare records system.

For more information on My Health Record visit the Commission’s e-Health Safety web page.

Examples of evidence

Select only examples currently in use:

  • Healthcare records management system that uses Individual Healthcare Identifiers and standard national terminologies
  • Policy documents about the healthcare records management system
  • Audit results of compliance with policies, protocols or procedures for accessing healthcare records and sharing information
  • Audit results of the use of unique identifiers to link the paper healthcare record to the electronic healthcare record
  • Committee and meeting records in which the governance of the health service organisation’s data and IT systems is monitored or discussed, including validation and protection of data
  • Training documents on the use of the My Health Record system
  • Observation that data and records are kept secure and safe in both soft and hard copies
  • Observation that systems are in place to provide IT infrastructure and support to the workforce using national standard secure messaging to generate national standard e-referral discharge summaries or event summaries
  • Examples of electronic correspondence or referrals that use secure messaging.