My Health Record implementation in private specialist practice

Specialist practices may benefit from the implementation framework and resources developed at Melbourne Hand Surgery

My Health Record is a secure online health record containing summary health information from a range of clinical settings and consumer‐entered health notes. The system initially commenced in 2012 as the Personally Controlled Electronic Health Record, created as part of Australian Government e‐health initiatives. The establishment of a secure, nationwide system that interacts with clinical software and requires individual registration has been supported by national investment of more than $1 billion. While many clinical information systems can connect with My Health Record, there are ongoing implementation and use challenges.

My Health Record aims to provide health care professionals with access to key health information, and to enable consumers to share information with any of their health care providers who are registered and connected to My Health Record. Key documents which can be shared include:

• hospital discharge summaries;
• general practice‐created shared health summaries, listing medicines, allergies and key diagnoses;
• event summaries with clinician‐created details of consultations and other events;
• radiology and pathology test results;
• specialist letters;
• medicines information from Pharmaceutical Benefits Scheme claims, pharmacy dispensing records, and prescriptions;
• Medicare Benefits Schedule data; and
• consumer‐entered information.

It is hoped that My Health Record will address safety risks associated with difficulties in obtaining patient history and investigation results, and reduce administrative burden for doctors, practice staff and patients.

The Australian Government has provided general practice incentive payments to encourage My Health Record uptake and use,1 but not specialist practice incentive payments. In addition, there are no specialist‐specific templates from medical colleges or other medical organisations to help specialists introduce and use My Health Record in their practices. Furthermore, specialist practices generally have lower digital health penetration than general practices and are not subject to accreditation requirements of the Royal Australian College of General Practitioners.

My private surgical practice introduced My Health Record use in January 2017. We aimed to introduce it in a manner that identified and proactively addressed the relevant legislative, privacy and medicolegal considerations, and could be replicated by other practices. A tested and successful implementation framework is expected to reduce provider scepticism regarding the system and facilitate the complex changes associated with its uptake.2

Before commencing clinical use of the system, we installed software, trained staff and followed the formal processes required to obtain authority to access My Health Record. We created and implemented new policies and altered administrative workflow patterns. This included obtaining an Individual Healthcare Identifier for each new patient when they registered with our practice. The Individual Healthcare Identifier is a unique 16‐digit number which is required for a health care practitioner to connect to a patient's My Health Record.

The changes were surgeon led. We added information about our use of My Health Record to our practice website, appointment confirmation email templates, privacy consent form and social media channels. We created instruction inserts for patients’ post‐operative envelopes, advising whether the patient was or was not registered with My Health Record, and the options and implications of their registration status. We also obtained Australian Digital Health Agency brochures that were placed in the post‐operative envelopes and in our reception area. This work was done in‐house and the financial cost was that of the time spent — largely the practice principal's time — in researching, developing, documenting and implementing the changes, and subsequently uploading event summaries. Uploads cannot be delegated to administrative staff as only registered health care professionals are able to access the My Health Record system through our clinical information system.

Practice staff completed two online Australian Digital Health Agency training modules and further in‐house training covering administrative requirements, and privacy, legislative and security obligations. Nursing staff signed the “Agreement to access the My Health Record through or at Melbourne Hand Surgery” policy before gaining access.

The implementation phase was conducted in two 13‐week stages. The first stage included patients who underwent inpatient surgery. The second stage included patients who underwent inpatient or outpatient surgery. We aimed to upload an event summary containing pertinent histology, microbiology, radiology and/or prothesis details for every surgical patient who had a My Health Record at the time of their first post‐operative appointment and provided consent.

Over the two stages, there were 174 eligible patient encounters (Box 1). Eligible patients included all Medicare‐eligible patients who underwent inpatient surgery (in stage 1) or who underwent either inpatient or outpatient surgery (in stage 2). Of these, 24 (14%) were for patients who had registered for a My Health Record, which was similar to the proportion of the Victorian population who had registered at the time (13%).3 I ultimately uploaded an event summary for 37 patients, or 21% of eligible patients. The increased number was due to patients registering between the date of their surgery and their first post‐operative appointment — that is, after being advised of the option to register and being provided with written information on how to register by their surgeon. One patient had a My Health Record but elected not to have an event summary uploaded.

I encountered technical problems relating to the local clinical information system when uploading event summaries throughout the implementation phase, affecting 12 of 37 uploads (32%). These elicited user frustration and increased the time needed to upload the event summaries. Problems included:

• error messages relating to the necessary or correct demographic information not being found in the patient's clinical software file;
• the clinical information system crashing (closing without warning) when an event summary upload was attempted; and
• the summary failing to upload after it was typed and submitted.

It was not readily evident which demographic details were incorrect or omitted but necessary, and “necessary” information did not necessarily need to be correct to permit an upload. The error messages displayed did not describe in plain English what the error related to or what the user could do to remedy the problem. No error messages were received before seemingly random software crashes, or in instances where the summary simply failed to upload for reasons that could not be determined.

Some problems were managed with simple workarounds, but should ideally be rectified through software improvements. For example, multiple administrative staff independently determined that it was not possible to enter a Medicare card expiry date in the local clinical software, as the card date is in the format MM/YYYY, but the software field has the format DD/MM/YYYY. Users noted that if the digits “0” or “00” were entered in the DD section, the software would not retain the MM/YYYY portion of the entry, and the entry would revert to 00/00/0000. Troubleshooting demonstrated that entering the digits “01”, or any combination of two digits that can be recognised as a day of the month, allowed a date to be accepted by the software. Failing to enter a Medicare expiry date in patient demographic details had no workflow implications before My Health Record use, but to upload an event summary to a My Health Record, the Medicare expiry date had to be entered in the demographic field. Surprisingly, we discovered that entering an incorrect Medicare card expiry date or the date 01/01/2001 permitted the event summary upload. It appears that entry of a date is mandated by the practice clinical information system (Genie Solutions version 8.9.2) not the My Health Record system. A wish list of changes that would improve usability of My Health Record via our practice clinical information system software is shown in Box 2.

A barrier to seeking assistance from our software vendor helpdesk is the invariable request to upload log files or email screenshots (and not merely transcriptions of error messages) for assessment. Our patient privacy policy does not seek permission from patients to send their data to a software vendor. While the vendor has configured its software with the option to upload data logs, and helpdesk staff routinely ask for screenshots that include patient demographic data, this has privacy implications. Our practice staff are prohibited from transmitting log files to the vendor or providing screenshots to helpdesk staff unless they have sought and documented patient consent. This adds to the work of troubleshooting and is a disincentive to reporting problems. Frequent upload errors are also a powerful disincentive to using My Health Record, as are the limited upload functionality and content options.

My Health Record use will change and evolve. One significant change is the move to opt out rather than opt in, with all Australians having a My Health Record created unless they opted out prior to 31 January 2019. This will significantly increase the proportion of Australians with a My Health Record, and will benefit practitioners who wish to upload and access shared health information for their patients. However, it will add to the administrative work involved for a surgeon who elects to upload an event summary for every patient that she operates on, unless this task is delegated to a nurse or other health care provider. Early clinician adopters will encounter software imperfections when using the system. Moreover, there may be little impetus for improvements in the system without financial incentives, market forces, or stricter conformance or legislative requirements to push software vendors.

Specialist use of My Health Record is likely to continue to lag behind general practice use as long as lower digital health penetration and the absence of financial incentives persist in this setting. There are parallels here for other e‐health initiatives, including real‐time prescription monitoring. Widespread My Health Record use is unlikely to be achieved unless clinical sites including hospitals are incentivised, particularly given the evident limitations of existing software integration.

Overall, our implementation framework for introducing My Health Record to our practice was successful. We successfully uploaded event summaries for all eligible consenting patients with a My Health Record, and we did not encounter issues that adversely affected patients such as privacy or data breaches. Our patients and practice staff gained a greater understanding of My Health Record, and our patients had the option of an event summary upload.

We have developed a replicable implementation framework and resources, and we hope that these resources will facilitate the complex changes associated with My Health Record uptake for other practices. These resources include policies and procedures, a risk assessment analysis, and flow charts. They are available online at http://melbournehandsurgery.com/35-mhs/268-my-health-record-introduction-to-specialist-practice-resources-for-specialist-practices.