the following is derived from the AMA draft guideline April 2012
the PCEHR system is not intended to, and should not, replace a medical practitioner’s own patient files and medical records system.
patients voluntarily opt-in to use the system personally via the system operator directly, although doctors may assist in this process via a facilitated registration process in their practice
patients can opt-out at any time
the PCEHR is “owned” by the patient
the PCEHR is fundamentally a tool for the patient to use to record and remember their health information.
the patient has the right to determine what information is included in their PCEHR, and who is able to access how much of that information.
on registration, the patient by default gives consent to all health providers to upload health information to their record.
parents or guardians will remain the authorised representatives for young people aged from 14 to 18, unless the young person chooses to manage their own PCEHR by personally registering with the system operator.
circumstances where details held in the PCEHR may be disclosed without the patient's explicit consent appear to be:
emergency access when they are unable to consent:
for any patient, including one who has applied advanced access controls that prevent access to some information in their PCEHR, and who is incapable of providing consent to PCEHR access, treating medical practitioners may gain emergency access if they make a clinical judgement that this would lessen or prevent a serious threat to an individual’s life, health or safety. Such emergency access is subject to retrospective audit. The medical practitioner is not obliged to access the PCEHR even in this circumstance.
as authorised by law, to courts and tribunals, or for law enforcement purposes
in the course of providing indemnity cover to a healthcare provider
a medical practitioner is not under any duty or obligation to use the PCEHR system.
a medical practitioner can cease using the PCEHR for some of their patients but not for others.
a medical practitioner will not be able to see what aspects of the information the patient has chosen to hide
a medical practitioner’s duty of care to exercise reasonable care and skill in the provision of professional advice and treatment to their patient extends to the medical practitioner’s use (accessing, disclosing, uploading) of the PCEHR.
the PCEHR does NOT replace the taking of an adequate history directly from the patient
medical practitioners should only access a patient’s PCEHR in the course of making a clinical decision relating to the patient’s care.
if a medical practitioner discusses the PCEHR with their patient, it is recommended that they record that the discussion occurred in their own patient’s notes.
medical practitioners should note on their patient’s file that their patient has consented to the medical practitioner interacting with the patient’s PCEHR every time that consent is obtained.
good medical practice involves advising the patient you will upload information to their PCEHR
clinical documents uploaded to the PCEHR system must be authored by a healthcare provider who has an individual healthcare provider identifier.
those who upload patient information or Event Summaries to the PCEHR should consider how the information they choose to add will benefit subsequent users.
if you identify erroneous or poor quality information in the PCEHR, you should inform the patient and document you have done this in your own record
medical practitioners should not be their own Nominated Healthcare Provider for their PCEHR if they have elected to use the PCEHR system as a patient.
the PCEHR will automatically be populated with data from:
Medicare Benefits Schedule
Pharmaceutical Benefits Scheme
Australian Childhood Immunisation Register
Australian Organ Donor Register