Shared Health Summaries

Communicare creates Shared Health Summaries in the CDA format compliant with eHealth standards in Australia. Shared Health Summaries can then be uploaded to My Health Record or an internal CDA repository.

A Shared Health Summary is a clinical document written by the nominated provider, that contains key pieces of information about an individual's health status and is useful to a wide range of providers in assessing individuals and delivering care. Shared Health Summaries contain medical history and adverse reactions, immunisations and medications from the current service.

The Personally Controlled Electronic Health Records Act states that the author of a Shared Health Summary should be one of the following:
  • Medical Practitioners
  • Registered Nurses
  • Aboriginal or Torres Strait Islander health practitioners, with a Certificate IV in Aboriginal or Torres Strait Islander Primary Health Care (Practice)

Prerequisites

The following configuration is required before Shared Health Summaries can be generated:
  • Encounter places must have a valid HPI-O configured.
  • The current Provider must have a valid HPI-I.
  • The patient must have a valid IHI.
  • Either My Health Record or an internal CDA repository must be configured. See My Health Record.

Creating and Uploading Shared Health Summaries

When you exit a service, you can send a Shared Health Summary for the patient to My Health Record if they have a valid IHI, or to an internal CDA repository.

To upload an Event Summary to My Health Record:
  1. After you have completed a service, close the Clinical Record.
  2. In the Service exit window, set Send Shared Health Summary to My Health Record.
    • This option is automatically selected if the patient consents to My Health Record uploads, or if the patient has not been asked whether they consent to My Health Record uploads. See My Health Record Upload Consent.
    • If there are no MHR options available in the Service exit window, the patient may not have a valid IHI. Click My Health Record to display information about why an Event Summary cannot be generated.
    • If you are exiting a service that is not for today's date, this window is not displayed and you cannot generate an Event Summary.
  3. Click Yes - This service is now complete.
  4. In the Service Record window, complete the Medicare details and click Claim now or the Private billing details and click Save. The Shared Health Summary is generated and displayed in the New Shared Health Summary window. Only information from the current service is included.
  5. In the Shared Health Summary tree view in the right panel, select the information to include in the Shared Health Summary and exclude any information that is not relevant. The information included by default depends on what you included in the Event Summary for the same service. If an Event Summary was not created for the service, no items are selected. Include any or all of the following information:
    • Adverse Reactions - lists any adverse reactions for the patient that were recorded in the current service. See Clinical Record - Summary Tab.
    • Immunisations - lists any immunisation class clinical items that were recorded during the current service. See Clinical Records.
    • Medical History - lists any procedures and conditions from previous service encounters. These are not included by default.
    • Medications - lists any new medications, and any existing medications that are still current. See Medication Summary.
  6. If you want to edit progress notes in the Event Summary:
    1. Select one of the Clinical Synopsis options.
    2. Click Edit Clinical Synopsis.
    3. In the Edit Clinical Synopsis window, add notes anywhere.
    4. Click Save. These changes do not alter the data recorded in the database, only the event summary.
  7. To display the history for any data section for which additional data is recorded in the current service, except for the progress notes and clinical synopsis, click Show History.
  8. When you are happy with the document, click Save and Upload to My Health Record.

Results

The document is queued and is uploaded to My Health Record at the next upload.