Using My Health Record in a private obstetrics and gynaecology clinic

My Health Record is an easy‐to‐use and effective clinical tool for specialists

My Health Record is a critical development in empowering patients, allowing them to access their medical history themselves and to share this information with all health care providers involved in their care.

In 2016, after discovering my region in Cairns was a My Health Record participation trials1 opt‐out area, I registered my practice for My Health Record. I also had to apply to Medicare and the Australian Digital Health Agency, in a lengthy process that, at the time, took 9 months and required much patience. In 2019, this process is now much quicker and can be completed by visiting the registration website (https://www.myhealthrecord.gov.au/for-healthcare-professionals/howtos/register-your-organisation) and completing the steps outlined. Once the My Health Record software was registered and my practice software connected, I obtained instant access to the patient's My Health Record via a mouse click. Now, in my clinic, with the patient in front of me, I first ask her verbal consent for access, then click on a tab in my usual program to view her record. To add a new record, I click “Add event summary”. I can also now add pathology or imaging results that I have received electronically. To remove an event summary, I simply click “remove”.

My Health Record is free and I have found it easy to use. In a busy clinical setting, it takes me less than a minute to access and add to the record, with patient permission sought each time. My Health Record does not upload all of a patient's medical file, and I check with the patient as to which items of information they would like shared.

Within my field of obstetrics and gynaecology, I have found several extremely useful applications for My Health Record:

• Recording the insertion and removal of an intrauterine device (IUD) or implant, or the administration of a contraceptive injection. I usually type a very simple sentence such as: “Mirena IUD inserted 01/04/2018 with nil difficulty. To be removed no later than 01/04/2023”. At the same time, I also inform the patient that they can access their record online if they ever need to check the date.
• Recording the diagnosis, staging and treatment of a malignancy after a tertiary hospital admission. At a post‐operative appointment, I might add this entry:
  • Diagnosis: grade 1, stage 1A1 endometrial cancer
  • Treatment: laparoscopic modified radical hysterectomy with bilateral salpingo‐oopherectomy with washings and staging
  • Date of treatment: 01/04/2018
  • Treating gynaeoncologist: Dr Doctor
  • Follow‐up: 6‐monthly specialist review for 3 years
• Consulting discharge summaries for a record of previous surgery. I was recently able to confirm that a patient had had a tubal ligation at the time of her caesarean section by accessing a previous discharge summary in her My Health Record. This saved my staff time applying to the hospital's medical records department for her records.
• Providing a digital pregnancy handheld record. This is my main use of My Health Record. I have created a template in my practice software that extracts data from different sections of my practice record and feeds this into a form summarising the investigations and management plan for the pregnancy.

My practice software currently requires clumsy cutting‐and‐pasting of this summary into My Health Record, but the software company has agreed to look into importing data directly. Once the data are entered, the patient pregnancy summary is uploaded with one click. I update this summary at each antenatal visit, removing any older summaries to prevent confusion.

A separate third party mobile phone app (https://yourhealthi.com.au/) has been approved for use by the Australian Digital Health Agency, allowing mobile access to My Health Record, and I ask my patients to download this app onto their smartphones. For security, they need to enter their MyGov user name and password the first time, and then they create a PIN code for subsequent entry. With this, the patient always has their record with them, even if travelling. At public hospitals, with software that can access My Health Record, midwives can now immediately access the patient's latest pregnancy summary, rather than relying on handheld records that may have been forgotten or misplaced. Throughout a patient's pregnancy, I no longer need to update the hospital from my rooms by continually faxing summaries that are then manually filed.

Patients who either opt out, or who are Medicare‐ineligible, have a paper‐based record instead. Apart from this small group of patients, My Health Record effectively enables two‐way communication between me and the planned delivery hospital, any other hospital where the patient may present as an emergency, or her general practitioner.

If the community of hospitals, obstetricians and GPs sought to use My Health Record as the primary mode of communication in pregnancy, over 300 000 women per year in Australia2 would have a very effective tool, superior to the old paper‐based pregnancy record. It is the responsibility of medical practitioners to increasingly be aware of, and to become familiar with, operating such technologies.

In the future, I would also like to see the National Cervical Screening Register (https://www.ncsr.gov.au/) data included in My Health Record, so that when assessing cervical dysplasia, I can access the patient's past screening record.