- What is a Shared Health Summary?
- Who can create and upload?
- When do you upload?
- Do you need patient consent?
- How do you upload a Shared Health Summary?
- Can you edit a Shared Health Summary?
- Is there an MBS item for preparing a Shared Health Summary?
- How do you keep track of the uploads?
What is a Shared Health Summary?
The Shared Health Summary (SHS) is a clinical document uploaded to the My Health Record. Based on the RACGP's template for a GP health summary, the SHS represents the patient's status at a point in time. The document has 4 clinical data elements:
- Medicines
- Diagnoses
- Allergies and adverse reactions
- Immunisations
The most recently uploaded SHS is likely to be the first document accessed by any other healthcare professional viewing the patient's My Health Record.
Here is an example of what an SHS looks like (all software displays it the same):
You'll probably find that the medicine section is the most complex part of the SHS. There may need to be agreement amongst the clinicians in your practice on how to decide which medicines should be included.
For more information, see the Australian Digital Health Agency's web page on Uploading a Shared Health Summary.
Who can create and upload?
An SHS is created and uploaded by the patient's nominated healthcare provider, which could be either:
- A Registered Medical Practitioner;
- A Registered Nurse (Div 1); or
- An Aboriginal and/or Torres Strait Islander Health Practitioner.
The provider uploading the SHS is the nominated healthcare provider at that point in time. A patient can have only one nominated healthcare provider at a time. (Note that this is not static and may change at the discretion of the healthcare recipient).
Important note:
- The upload of information is prescribed by regulations. For example, parts of the Public Health Acts of New South Wales, Queensland and the Australian Capital Territory prohibit the disclosure of certain sensitive information (such as in connection with AIDS or HIV) without the express consent of the individual.
Note:
- A provider who is not the patient's usual provider could instead use an Event Summary (if their software has this function) to upload clinically relevant information. Bear in mind that an Event Summary does not count for ePIP.
- A registered (Div 1) nurse can create and upload, but an enrolled nurse cannot create an SHS. An enrolled nurse is only permitted to upload an SHS that has already been created (by one of the provider types listed above).
When do you upload?
First, consider the priority patient groups who could benefit most from the My Health Record. An SHS can be uploaded during a consultation or afterwards if more convenient. The patient does not have to be present in the room when the SHS is uploaded, but they should know who is uploading and why.
It could be done in conjunction with another activity, e.g.:
- Completing a health assessment (e.g. GP management plan, 75+ health assessment)
- Flu vaccination.
- Any time there is a clinically relevant event that is useful for others involved in the patient's care to know (e.g. new prescribed medications or dosages, new medical conditions).
The Australian Digital Health Agency has more information on Shared Health Summaries and opportunities for uploading.
Note:
- You can upload a Shared Health Summary more than once for the same patient. In fact, if their health record changes and it is clinically relevant, then uploading a new Summary is encouraged.
- It shouldn't be your aim to upload a Shared Health Summary for every consult. It wouldn't be possible, and it's not appropriate.
- When viewing a patient's My Health Record, the uploaded Shared Health Summaries are listed with the most recent first.
Do you need patient consent?
No, patient consent is not required. However you and your patient must agree that you are the patient’s nominated healthcare provider (see above for who can upload) for the purpose of uploading a Shared Health Summary. This should minimise the upload of inappropriate uploads by providers who are not the regular healthcare provider.
The Australian Medical Association (AMA) suggests that it is good practice to advise a patient when uploading an SHS to their My Health Record, particularly if the document contains information that might be considered sensitive by the patient.
How do you upload a Shared Health Summary?
Below are cheat sheets for different software you can cut out and attach to screens to help clinicians get used to the steps:
Also see the Training section in the Using My Health Record article.
Tip: Ensure there is a person (clinician, admin, or management) in the practice who is very familiar with the process (it might be you!). This person can be the 'champion' who can answer questions quickly.
Can you edit a Shared Health Summary?
Once uploaded, a SHS cannot be edited. In the case of an error in the SHS, it should be deleted by the author and a new one created if appropriate. If an SHS needs to be updated due to changes to any of the 4 clinical elements contained within it, a new and complete Shared Health Summary needs to be created and uploaded. A new document supersedes the previous one.
Is there an MBS item for preparing a Shared Health Summary?
No. However, you can take into account the time taken to prepare the summary, if it is undertaken as part of providing a clinical service and the patient is present at the time. For example, you can claim a level C item if it takes longer than a normal level B consultation.
Consider when you upload (see above). For example, you might do it as part of a health assessment or care plan.
Also see question 7 in Katrina Otto's Top 30 questions.
How do you keep track of the uploads?
For all of the below, make sure you have the correct date range for the ePIP quarter.
- Genie: not available within software (Pen CAT is compatible with Genie).
- Medical Director: Use their tracking tool.
- POLAR GP: the My Health Record sheet.
- Pen CAT: Use their SHS upload recipe.
- Zedmed: The new version of Zedmed will have a function to count SHS uploads.
- Best Practice:
- From Management, select the ‘Reports’ tab, then select the ‘Shared Health Summaries – Uploaded’ report.
- Another option is to go to Utilities > Search, and enter the below in the SQL Query box and click Run Query:
SELECT * FROM BPS_Patients bp INNER JOIN PCEHRACCESS p ON bp.InternalID = p.InternalID WHERE StatusText = 'Active' AND p.SERVICE = 7 AND p.RESULT = 1 AND CAST(p.ACCESSDATE as date) BETWEEN '20160101' AND '20160201' ORDER BY surname, firstname Note: edit dates in YYYYMMDD format