Pathology and diagnostic imaging reports can now be added to a My Health Record (MHR). However, we understand that not all providers have yet begun adding reports to MHR. There is a list of participating providers on the MHR website.
If you are the requesting doctor, the reports will continue to be sent directly to you, and they will also be uploaded to MHR unless:
- the patient requests they are not uploaded
- you request they not be uploaded, if you believe uploading is not in the patient’s best interests; or
- it is not legal to disclose the results.
A MHR is intended to be a summary of a patient’s health information. Your patient can allow you to access their test results, whether or not you initiated the request. They can also share test results with other health professionals involved in their care. This is intended to help reduce duplication of testing.
If you download pathology reports into your clinical information system, they will be in a document format only, so will not have the same flags and labelling as many reports currently do.
Does the patient need to consent to every test result being uploaded?
It is not necessary for you, or the pathology laboratory or imaging centre, to obtain a patient’s express consent to upload each individual document to MHR, since patients provide a standing consent for doctors to upload documents to their MHR. The authority to upload information is provided for in the legislation.
However, the patient can choose to withdraw consent or ask that a report not be uploaded at any time before it is uploaded to their MHR.
A healthcare provider must not upload information or ask for pathology results to be uploaded to a MHR if a patient has advised the provider not to upload that information.
Concerns about uploading certain documents?
A MHR is controlled by the patient and they can decide what is or isn’t uploaded to their MHR. They can also restrict those who can see their test results or hide them from view.
If a patient raises a concern about uploading a pathology report or diagnostic imaging report, and you believe it is in their best interests that the information is uploaded, you need to discuss this with the patient.
However, documents should not be uploaded when:
- a healthcare provider believes uploading the information would not be in the patient’s best interests, for example because it is particularly sensitive
- state or territory legislation restricts the circumstances in which certain information may be disclosed (for example, AIDS or HIV status).
If you have reasonable concerns about the risk to the patient’s health or safety of having access to the results in the MHR after the seven- day period you should also discuss this with the patient.
Patient access to results
The patient will be able to access the results seven days after they are uploaded. Uploading pathology results was the subject of detailed discussion between various organisations including health consumer groups, the Department of Health, the Colleges of Pathology and General Practitioners and the AMA.
Consumer groups initially wanted the results to be uploaded instantly, but a compromise was reached to upload them after seven days, on the understanding that this would allow referring doctors time to receive, consider and recall the patients to discuss the results before they were available on the MHR.
How to request documents are not uploaded
If a patient does not wish a result to be uploaded, you can let the relevant pathology or imaging provider know by:
- checking the "Do not send reports to My Health Record" check box in the practice management software, or
- checking the "Do not send reports to My Health Record" check box on the paper request form, or
- writing "Do not send reports to My Health Record" on the request form.
You would also check one of these boxes if you have reasonable concerns about the result being uploaded, as discussed above.
The withdrawal of consent to upload will then apply to all tests on the request form.
If the patient withholds consent, particularly in circumstances where you believe it is critical information for other doctors, document the discussion about uploading the documents in the patient’s medical records.
As a doctor, you will be able to download reports from MHR into your clinical information system, for example if they were ordered by another practitioner. Your responsibility to manage your own patient records is unchanged. If you have copies of pathology or radiology reports in your clinical information system you need to continue to secure, store and manage these as part of the patient record, even if they are also uploaded to a MHR
Your responsibility to follow up results and recall patients will also be unchanged.
A MHR is the patient’s record, and the inclusion of pathology and radiology reports in the MHR does not replace existing communication of such reports between laboratories or clinics and doctors or consumers. You are not expected to know about results purely because they have been uploaded into a MHR, equally, uploading files to a MHR will not be sufficient to communicate information to other healthcare providers.
For advice on your MHR obligations when uploading pathology and diagnostic images, visit our website or call our Medico-legal Advisory Service (MLAS) on 1800 128 268 for expert advice, 24/7 in emergencies.