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Last updated 08 December 2016

Patient control and My Health Record

Published 28 November 2016

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As My Health Record is personally controlled, the individual has the ability to say what information is uploaded, what information stays in their My Health Record and who can see their record. The patient can request that their healthcare provider not upload certain information to their My Health Record; set access controls restricting access by healthcare providers to their My Health Record entirely or to certain information; and choose whether or not certain information stays in their My Health Record. This article addresses some of the common questions from healthcare providers on patient control.

Can patients edit or delete information? How do I know if important information is missing from a My Health Record?

  • No document is ever actually deleted from the My Health Record system. However, an individual has the ability to remove from view any document in its entirety from their My Health Record. Individuals can subsequently restore documents they have removed from view.
  • An individual cannot edit any document that has been uploaded by their healthcare providers to their My Health Record. This means they cannot change or remove parts of any document uploaded by healthcare providers.
  • If an individual removes a document from view from their My Health Record, the authoring healthcare provider organisation will see a flag indicating that the document they uploaded has been removed by the patient. The healthcare provider will no longer be able to view the document in the patient’s My Health Record, but can still access the information from within their local clinical information system. This flag can act as a useful prompt for the healthcare provider to discuss with the patient the clinical impact of removing the document from their My Health Record.
  • Healthcare providers who were not the authors of the document that was removed, will not see a flag. This ensures a patient is not subject to pressure from other healthcare providers.

If patients are able to control the information in their My Health Record, how can I rely on it and why should I use it?

  • My Health Record is an electronic summary of health information that is provided by healthcare providers and individuals. It is not a comprehensive medical record and does not replace the medical records held by healthcare providers, nor does it change the current obligations of healthcare providers to maintain their own detailed and accurate clinical records for their patients. It should not be assumed that a patient’s My Health Record is a complete history of their health information but rather an additional source of information to complement the information that the treating healthcare organisation may or may not already hold about the individual in their local clinical information systems. It is not intended to be the source of all truth about an individual’s health.
  • One of the many benefits of My Health Record is that a provider can have access to information about their patient that they may not otherwise have had, such as results of a test ordered by another healthcare provider or a discharge summary from an interstate hospital.
  • Currently, in any one week, one in three Australian GPs will see a patient for whom they have little or no health information at all. More than one in five GPs face this situation every day. With My Health Record, treating healthcare providers will over time have at least some information about their patient’s medical history. This is particularly important when the patient cannot remember the details of past treatments or medications they may be taking.
  • Whilst the My Health Record system enables individuals to set access controls to limit who can access their record and the information within it, less than 1% of individuals with a My Health Record have set any access controls.

What if a patient asks me to omit information that I think is important?

  • If the patient requests that you do not upload a particular document or information to their My Health Record, you must not upload it. This is a condition of your organisation’s registration with the My Health Record system.
  • However, the patient should be advised about potential risks of excluding information from their My Health Record and the benefit of ensuring all the relevant information is included. Ultimately it is their decision as the information in their My Health Record is controlled by them.

Last updated 08 December 2016