Appendix 4: National EHR system features by jurisdiction Process Feature Country Australia Austria Denmark England Northern Ireland Scotland Wales General EHR name; date introduced; main website 2012 (Elektronische Gesundheitsakte) 2015 (National Health Record) 2014 2008 Emergency Care Summary (ECS) – 2008 This is the GP summary. (NIECR) – 2013 This is the broader record / system providing access to data from a range of sources – see below. Emergency Care Summary (ECS) -2006 (no public access to main site) Key Information Summary (KIS) -2013 Palliative Care Summary (PCS) - 2009 (2016) (formerly the Individual Health Record – 2005) Coverage (population with record) Approximately 21% of total population is registered (as of 14/9/17) Data not available 67% of individual healthcare providers use sundhed.dk portal through which the National Health Record is accessed 96% of people registered with a GP have a Summary Care Record (55 million records) (2016) 99% of 1.8 million population ECS - 99.9% of people registered with a GP have an ESC (5.1 million). KIS – 2-3% have a KIS (generally for complex, chronically ill) 65% of 3 million Accessible in ED / urgent care settings Pilot only Public hospital roll out in 2015 (roll out in ED not specified) Public hospital roll out (from 2013) (roll out in ED not specified) Progressively from 2008 2008 2006 National agreement for introduction to ED from 2009 (Individual Health Record) Governance Overseeing agencies ELGA GmbH National eHealth Authority (NSI) Regional eHealth Organisation (RSI) Managed by Implemented by NHS Digital (previously the Health and Social Care Information Centre) eHealth and Social Care Board Information Sharing Board NHS Wales Informatics Service
uploaded into the National Repositories Service (NRS) or obtained from participating repositories (such as DHS operated repositories, diagnostic service providers, public health systems). Access is via the Provider Portal for healthcare professionals and via the MyGov website for patients. Some individual states have local portals through which the My Health Record is accessed. to data stored in decentralised repositories Medication data are stored in encrypted form in a central repository. Access to health data and medication is via the . and accessed via the portal The information is collected from hospitals in all five Danish regions, as well as from GPs and other private practice healthcare provider. stored on the and accessible via the which also hosts other shared services. is available as part of the NIECR accessible via the HSC secure network. NIECR also collects and links to information from other sources including hospital records, imaging, and pathology. ECS and KIS are available on the central repository (ECS Store). accessible via local clinical portals in NHS regions through which clinicians access a range of other local and linked data. Records Service. Data source and updating Data is sourced from authorised healthcare provider systems (mainly primary care) which are uploaded to the NRS and participating repositories. Most data (except for medication data) are sourced from hospitals, GP/ specialist repositories and displayed as links on the ELGA portal. Medication data is sourced from a Data is sourced from local hospital and GP/specialist EHR systems and transferred to the central repository. Only authorised healthcare professionals can create, host and access data. GP records are the source of data for the SCR. Data is automatically ‘pulled’ from the record when it is updated. Data can only be updated at the GP practice. GP records are the source of data for the Emergency Care Summary. The timing of information extraction form GP records was not available. Other data is drawn from GP records are the source of data for the ECS and KIS. Data is ‘pulled’ from the record twice daily. Data can only be updated at the GP practice. GP records are the source of data.
Data is also sourced from patients’ own documents and notes uploaded to My Health Record. Authorised healthcare providers can enter data using Conformant Clinical Software. central repository. Only ELGA healthcare providers can create, host, access and update data. Existing data can only be updated or edited by the healthcare provider who registered the data. Patients and other health providers cannot add to or change the SCR. hospital records, imaging, and pathology, as described above. Information can also be recorded directly on the system (limited details available about how this occurs) Only authorised healthcare professionals can create, host and access data. Patients cannot directly access or change the data. There are local exceptions where, for example other health professionals can create or update the KIS without having access to the GP system. Content Scope Health Health Social care Health Health Social care (in expanded record) Health ECS – Health KIS – Health and social care Health Specific content My Health Record contains – added by healthcare providers: Shared Health Summary (created by the patient’s ‘nominated healthcare provider’) – medical history, current medications, allergies, ELGA currently contains: Laboratory data Radiology data Medications Medical and nursing discharge letters from public hospitals Planned content includes: Patient summary – overview of National Health Record contains: Laboratory data Imaging Medications Allergies Vaccination records Hospital and treatments – care summaries from hospitals GP and healthcare Summary Care Record core information: Demographics Medications Adverse reaction Allergies Expanded information (with patient consent): Past and present medical history Emergency Care Summary Record contains Demographics (name, DOB, gender, contact details) Medication prescribed by GP Allergies NIECR contains ECS contains: Demographics (name, DOB, CHI number, GP surgery Medication prescribed by GP Adverse reactions and allergies to medicines KIS contains: Past medical history Welsh GP Record contains: Demographic Current medication and medication prescribed in the last two years Allergies or any adverse reactions
adverse reactions, immunisations) Event Summaries – created by other providers (e.g. pharmacists, emergency department) Hospital discharge summaries Pathology and diagnostic imaging reports Prescribed and dispensed medication Specialist and referral documents Medicare, PBS and PRBS information Organ donor decisions Immunisations Personal health notes written by individual or an authorised representative: Contact numbers and emergency contact details key health data (from primary care) Vaccination and immunisation status Outpatient reports Pathology report Imaging Mother-child pass Wills Precautionary powers medical register specialists – an overview of services received over time Referrals – from healthcare professionals Contact details of primary physician and other health professionals Reason for medication Anticipatory care information e.g. care of long term conditions Communication preferences End of life care Immunisations Exclusions: Sensitive information like fertility treatments, sexually transmitted infections, pregnancy terminations and gender reassignment are not automatically included. Emergency Care Summary Laboratory results Imaging results Investigation requests Appointments Encounter and discharge letters read codes are automatically included) Baseline functional and clinical status, including capacity Triggers for deterioration Current care needs and arrangements Emergency contacts and next of kin details How far to escalate care Preferred of care, and final care, other specific patient/carer wishes Palliative care information Legal issues such as power of attorney DNACPR status Special alerts – for example around staff safety Current problems or diagnosis Results of in the previous year, for example, blood tests and x-rays
Current medications Allergy information and previous adverse reactions Indigenous status Veteran or ADF status Advance care planning documents Client / patient participation & permissions Participation model Record creation Presently voluntary system for creating the record. The automatic creation of My Health Record (opt out for every Australian will begin from Ongoing access Patients can: Hide any clinical data or Medicare documents and restore hidden documents. Once hidden, this Record creation Patients may opt out of ELGA totally. Patients can choose to opt-in at any time. Patients can also opt out for certain components of the system (e.g. e-medication, (situational Patients who have fully opted out and opted in again will start with a blank ELGA record; data previously saved in the system is deleted. Record creation Authorised healthcare professional are under legal obligation to keep and update health records. Patient consent is not required to create the record; not allowed to refuse creation of health data. Ongoing access Generally, patients’ consent to treatment also implies consent for healthcare providers to access data necessary for treatment. Patients have limited abilities to Record creation Patient may opt out of having a record created by GP. Patient can choose to opt out at any time (by advising their GP). Patient can also provide consent to enable more extensive information to be included in the record (as above). Ongoing access Each clinician must obtain consent from the patient to access the Record creation Patient may opt out of having a record created by their GP. Patient advises GP if they do not wish for ECR to be made available through Ongoing access Each clinician must obtain consent from the patient to access the record for each episode of care. Consent in an emergency situation is not clear. ECS Record creation Patient may opt out of having a record created by their GP. Patient can choose to opt out at any time. When this happens, all data including historic data is removed from ECS Store. Ongoing access Each clinician must obtain consent from the patient to access the ECS record for Record creation Patient may opt out of having a record created by their GP. Patient can choose to opt out at any time. Ongoing access Patient consent required every time the records are accessed
information is not accessible, even in an emergency. Control who accesses information Prevent other healthcare providers from accessing record unless in an emergency Flag specific documents as ‘limited access’, and control who can view these documents Ongoing access Patients can: Choose to of specific encounters or during a specified timeframe (exception is when the patient unable to consent in an emergency situation). Delete links to health data Prevent access by a particular healthcare provider or institute to a particular piece or all of their data Control duration of access. For encounters such as HIV infections, psychiatric treatment, genetic examinations, and abortions, the healthcare provider is obliged to inform the patient refuse access to health data in certain circumstances (details unclear) Emergency access is however always granted if deemed necessary for treatment. record for each episode of care. Exception is when the patient unable to consent in an emergency situation. each episode of care. Exception is when the patient unable to consent in an emergency situation. KIS Record creation Patients opt in to the creation of a KIS record Ongoing access Consent for viewing in secondary care is not required.
actively about their rights to request a situational Patient access and contribution to data . They can control health provider access to the record as described above. They can contribute content as described above. Patients can access, view and download records once they have electronically identified themselves by a mobile phone signature or the citizen Patients can delete links to health data and can prevent access by a particular healthcare provider or institute as described above. Patients cannot change or contribute to the data. Patients can access and view records via sundhed.dk portal using their NEM-ID login. Patient access to data is delayed (up to two weeks for hospital records; up to 45 days for GP/specialist consultations) to prevent coincidental access before communication of health status by the health professional. Patients cannot contribute directly to the data. Patient cannot directly access the record but can request a copy from the GP. They can request a change to the information if they think it is incorrect. Patient cannot directly access the ECR but can request a copy from the GP. Request to the GP or Health Trust can be made to see the NIECR. The hospital or surgery has 40 days to respond to a request in writing. Patient cannot directly access the record but can request a copy from the GP. They can request a change to the information if they it is incorrect. Patient access to WGPR is intended to be available in 2017. Access by health providers & data protection Health professional authorisation Access only by healthcare providers registered with the HI Service (Healthcare Provider Identifier). AHPRA registered health professionals Access only by authorised healthcare providers involved directly in patient care and treatment. Authorised providers are registered with ELGA, called ELGA healthcare Access only by authorised healthcare providers involved directly in patient care and treatment. Level of access restricted depending on role (Role Based Access Control). Access only by authorised health service staff. Access restricted depending on role e.g. clinical versus (Role Based Access Control). Access only by authorised HSC staff involved in provision of care. Detail of authorisation process not available. Available only to those involved directly in care. ECS was initially restricted to authorised health service providers in out of hours medical Hospital doctors and nurses directly involved in care. Doctors and nurses working in the GP out of hours service and directly
within that patient’s record in their own clinical system or portal. Boards will register all users and have processes in place to control role based access, ensure that clinicians access ECS/KIS appropriately and audit users. Access process A National Authentication Service for Health (NASH) Public Key Infrastructure (PKI) Certificate is a digital certificate that authenticates an individual provider or organisation whenever they access the My Health Record system Healthcare providers have two methods to access My Health Record: via conformant clinical software Access by healthcare providers is through the ELGA portal. Validation and proof of treatment relationship is required (e.g. by scanning the patient’s citizen card/e-card). Default duration of access = 28 days proof of treatment (e.g. inserting of ecard and healthcare provider card in the office); pharmacies can only access ELGA for 2 hours. Access by healthcare providers is through the Sundhed.dk portal. Patients’ consent to treatment also implies consent for healthcare providers to access data necessary for treatment. There are different rules for identification and authentication which are dependent on regional EHR systems (controlled via local data controller in accordance Access is via the Spine portal using a NHS smartcard and passcode Access via secure HSC network portal. Patient consent required every time the records are accessed Regular audits are made of who has accessed the record (no technical data about how this is conducted). Access via local clinical portals in NHS regions. Can usually be accessed via interface with user’s main system so that multiple passwords not required. Access requires user name and password
which connects to and interacts with the My Health Record system; and through the National Provider Portal (read-only via the internet browser). Data protection strategies System records and reports all instances of data access. This is in the healthcare identifier history. Education and awareness programs which highlight the need for individuals to protect themselves against security threats, hoaxes and scamming activities. Monitoring access to My Health Records and the My Health Record system to quickly detect suspicious or inappropriate behaviour. Rigorous, security System records and reports all instances of data access which is available to patients. System records and reports all instances of data access which is available to patients. Bi-annual is conducted where a random sample of log files are checked for irregularities. System records and reports all instances of data access. Each time an SCR is viewed, an alert will be generated on a system database called the alert viewer. Future plans include enabling direct access to such alerts / records by patients. Presently a report can be requested by the patient. is auditing of these records to identify breaches. There is mandatory training for authorised health professionals regarding data Data access is audited (no specific details provided). The ECS Store keeps an audit trail of all successful and attempted accesses to ECS records. GPs can access ECS Store and review the audit trail for the records of patients registered with their practice. Auditing is also conducted by health boards as above. A record is kept of all access. GP surgery can check who accesses record Health Boards also audit. NIIAS keeps a log of every access to a patient’s medical record and who looked at the record. The system integrates with a wide range of existing electronic health record systems to produce a range of automatically generated reports, instantly highlighting any potential issues if access has not been for the legitimate care of the patient.