Glossary

A

access code

See personal access code (PAC)

access history

A record of all activity related to an individual’s My Health Record. Every time My Health Record is accessed, changed or a user removes information from the record, an automatic audit trail is created and can be viewed.

access list

A list associated with an individual’s My Health Record that specifies the registered healthcare provider organisations permitted to, or blocked from, accessing an individual’s My Health Record. The access list will show the healthcare provider organisations who have previously accessed the record.

accessing organisation

The healthcare organisation that accesses the My Health Record system.

achievement diary

Developmental milestones throughout childhood, such as first words spoken or the first day of primary school, can be recorded in the achievement diary by an individual or their authorised representatives, such as a parent. Healthcare provider organistations cannot view these.

administration portal

An online tool used by the System Operator for administrative actions on individual My Health Records, for example when assisting an individual with an enquiry.

advance care document custodian

An advance care document custodian is someone who holds a copy of an individual’s advance care planning document. An individual can add their advance care document custodian’s name and contact details in their My Health Record so that doctors will be able to contact the custodian should the need arise. 

advance care planning documents

A document that is a type of written statement regarding a person’s wishes for their future medical or healthcare treatment and may formally appoint a substitute decision-maker. Advance care planning documents detail your future medical care preferences. It provides guidance to your family, close friends and medical professionals if you are unable to communicate due to illness or injury. Advance care planning documents (and goals of care documents) can be uploaded to and stored on your My Health Record by a healthcare provider with your consent. Also refer to goals of care document.

advanced access controls

The access controls that enable a registered individual to set controls on the registered healthcare provider organisations and nominated representatives who may access the individual’s My Health Record or documents within it.

assisted registration

The process that enables healthcare providers to assist their patients to register for a My Health Record.

Assisted Registration Tool (ART)

Purpose-built software to enable an HPI-O to assert a patient’s identity and then submit their details to the My Health Record system for registration.

Australian Health Practitioner Regulation Agency (Ahpra)

The organisation responsible for the implementation of the National Registration and Accreditation Scheme across Australia. The Ahpra currently regulates 15 health professions.

authoring organisation

The healthcare provider organisation that created the content of a document.

authorisation link

A link that connects a healthcare provider to a healthcare provider organisation so the healthcare provider can access the My Health Record system via the National Provider Portal on behalf of their organisation.

authorised employee

An employee of a registered healthcare provider organisation who has been authorised by the organisation to use the My Health Record system and access an individual's My Health Record on behalf of the organisation.

authorised representative

Someone who can apply for and manage a My Health Record on behalf of another person. For the purposes of the My Health Record system someone can be an authorised representative if they:

• have parental responsibility for a person under 14; or
• have legal authority to act on behalf of a person who is at least 14 and who is not capable of making his or her own decisions.

If there is no one with parental responsibility or legal authority, a person who is otherwise appropriate to act on behalf of the individual can be an authorised representative. An individual can have more than one authorised representative.

B

Business to Business Gateway (B2B Gateway)

An access channel by which external systems, such as clinical information systems and registered repositories, interact with the My Health Record system.

C

care and support plans

A comprehensive plan describing agreed goals of support, and outlining planned medical, nursing and allied health activities.

channel

A means of entry into the My Health Record system to enable reading and updating My Health Records. For example, individuals can use the National Consumer Portal or providers may use the system via B2B.

child development

The section of the My Health Record that contains information about childhood growth and development.

Clinical Document Architecture (CDA)

An HL7™ standard intended to specify the encoding, structure and semantics of clinical documents for exchange.

clinical information system (CIS)

A system that is used by a healthcare provider to manage patient and practice records. It may include a software component connected to the My Health Record system.

clinical synopsis

A short summary of a healthcare event (e.g. reason for visit, diagnosis etc) included in an event summary.

conformant digital certificate (for the My Health Record system)

An electronic credential used to secure access in the My Health Record system.

Consumer Portal

The portal that is used by an individual who has set up access to their My Health Record online.

consumer-shared documents

Documents that have been authored by an individual, authorised representative or full access nominated representative. These documents, such as personal health summary, are available to provider organisations and other representatives.

contracted service provider (CSP)

See registered contracted service provider

contracted service provider (CSP) officer

The officer who acts as the liaison between a registered contracted service provider and the System Operator. There must be at least one CSP officer and there can be up to three at one time.

D

default access controls

The access controls that apply where a registered individual has not set controls on the registered healthcare provider organisations or nominated representatives who may access the individual’s My Health Record. This means that any registered healthcare provider organisation involved in your healthcare can access your record.

diagnostic imaging report

A diagnostic imaging (or radiology) report is primarily a written communication between the radiologist interpreting the imaging study (eg X-ray, MRI) and the clinician who requested the examination.

E

emergency access

Access by a registered healthcare provider organisation to an individual’s My Health Record to lessen or prevent a serious threat to a person’s life, health or safety and where it is unreasonable or impracticable to obtain the individual’s consent. If a participant asserts that these circumstances exist, the access controls of the individual’s My Health Record are overridden. Emergency access can also occur where it is necessary to lessen or prevent a serious threat to public health or public safety. Emergency access expires five days after the assertion of the emergency is made.

eReferral

eReferral specification supports the seamless exchange of significant patient information from one treating healthcare provider to another via a national system of creating, storing and sharing referral reports.

event summary

A clinical document that may be uploaded to an individual’s My Health Record summarising one or more episodes of care.

F

full access nominated representative (FANR)

A representative can perform all the functions of an authorised representative in respect of an individual’s My Health Record. They cannot give another person access to your record, make changes to your other representatives, make changes to your Medicare information or cancel your record. A full access nominated representative must verify their identity to the System Operator.

G

general access (applied to a clinical document)

Document access setting which can be set from the Manage Document Access screen of the National Consumer Portal. A general access document is available to be viewed by all healthcare organisations that have access to the My Health Record. By default, all documents are set to general in My Health Record. 

general access (applied to a healthcare provider organisation)

An access level that can be given to an organisation accessing an individual’s My Health Record. General access for a healthcare provider organisation allows any  authorised employee within that organisation to access the My Health Record and read (view) those documents marked as general access. It also classifies all documents this organisation writes (adds) to the record as general access. An alternative access level that can be applied to healthcare provider organisations is restricted access.

general access (applied to a nominated representative)

The setting for a nominated representative that can be set in the Manage Access to this Record screen of the National Consumer Portal. The general access setting allows a nominated representative to access the individual’s My Health Record and view those documents classified as general access.

goals of care document

Outlines the aims of a patient’s medical treatment, as agreed in consultation between the patient, family, carers and healthcare team, including substitute decision makers. Making this information available in My Health Record will support end-of-life care that is consistent with a person’s goals, values, beliefs and preferences. Goals of care documents can be uploaded into your My Health Record by your healthcare provider with your consent, and will appear in the Advance Care Planning section. 

growth charts

Charts in the child development section that can be used to graph the measurement information recorded for a child over a certain time period, including height, weight, and head circumference.

H

health check assessment schedule

The schedule in the child development section which displays a list of questions for parents within a child’s current selected state or territory that can be completed by the individual, or representatives, for different childhood age brackets.

Health Check Assessment Schedule

The schedule in the child development section which displays a list of questions for parents within a child’s current selected state or territory that can be completed by the individual, or representatives, for different childhood age brackets.

health check questionnaires

A list of available questions about a child’s health and development is available from the Health Check Assessment Schedule in a My Health Record and can be completed by parents or the alternate authorised representatives involved in a child’s healthcare.

health information

The information that relates to the individual’s physical or psychological health, and includes the dispensing of medicines and the provision of aged care, palliative care, and care for a person with a disability.

Health Professional Online Services (HPOS)

The service that provides Services Australia services to health professionals through a secure online channel. Services accessed through HPOS include application for My Health Record registration and the ability for a HPI-O to link to a CSP.

health service

The Privacy Act 1988, defines healthcare as an activity performed in relation to an individual which is intended or claimed (expressly or otherwise) by the individual or the person performing it:

(a) to assess, maintain or improve the individual's health; or
(b) where the individual's health cannot be maintained or improved--to manage the individual's health; or
(c) to diagnose the individual's illness, disability or injury; or
(d) to treat the individual's illness, disability or injury or suspected illness, disability or injury; or
(e) to record the individual's health for the purposes of assessing, maintaining, improving or managing the individual's health.

Healthcare Identifiers Act (HI Act)

The Healthcare Identifiers Act 2010, which establishes the Healthcare Identifiers Service and regulates related matters.

Healthcare Identifiers Service (HI Service)

A national system for uniquely identifying healthcare providers and individuals, which makes sure the right health information is associated with the right individual – see IHI, HPI-I and HPI-O.

healthcare professional

See healthcare provider.

healthcare provider

A person who is involved in or associated with healthcare delivery. For the purposes of the My Health Record system, a healthcare provider is a person who has an HPI-I and is authorised by a registered healthcare provider organisation to access the My Health Record system on their behalf.

Note: this was previously referred to as ‘individual healthcare provider’

Healthcare Provider Directory (HPD)

A voluntary provider directory service established and maintained by the Healthcare Identifiers Service Operator.

Healthcare Provider Identifier – Individual (HPI-I)

A unique 16-digit number used to identify individual healthcare providers who deliver healthcare in the Australian healthcare setting.

Healthcare Provider Identifier – Organisation (HPI-O)

A unique 16-digit number used to identify organisations that deliver healthcare in the Australian healthcare setting.

healthcare provider organisation

An organisation, or a part of an organisation, that has conducted, conducts, or will conduct, healthcare.

healthcare provider organisation access 

The level of access that a healthcare provider organisation has to an individual’s My Health Record. See also general access (healthcare provider organisation) and restricted access (healthcare provider organisation).

I

identity verification code (IVC)

A code that is generated during the registration process for individuals on the Assisted Registration Tool, or via phone or face to face channels. The IVC proves that their identity has been verified by the My Health Record system. The IVC is used to access the individual’s My Health Record online for the first time.

indigenous status

A status indicator that is stored within the My Health Record for individuals who wish to indicate whether they are of Aboriginal or Torres Strait Islander origin. This indicator is voluntary.

Individual Healthcare Identifier (IHI)

A 16-digit unique number used to identify individuals who receive or may receive healthcare in the Australian health system.

individual or patient

A person who has received, receives or may receive healthcare in Australia.

individual reference number (IRN)

A number that represents the position of a person's name on a Medicare card. For example, a person who is listed second on a Medicare card has an IRN of 2. The IRN appears to the left of the patient’s name on their Medicare card. This is not a unique identifier.

inheriting organisation

A healthcare provider organisation that inherits access levels in relation to My Health Records from an accessing organisation.

L

lack capacity

Mental capacity means being able to make your own decisions. Someone lacking capacity - because of an illness or disability such as a mental health problem, dementia or a learning disability - cannot do one or more of the following four things:

1. Understand information given to them about a particular decision,
2. Retain that information long enough to be able to make the decision,
3. Weigh up the information available to make the decision,
4. Communicate their decision.

limited document access code (LDAC)

A code (4-8 alphanumeric characters) that an individual can provide to healthcare providers so that they can access documents marked as Restricted in the individual’s My Health Record.

local system identifier (LSI)

An identifier that is used by healthcare provider organisations to identify authorised employees who have read and upload (but not write) access to the My Health Record system on their behalf.

M

Medical conditions view 

A view which provides a consolidated list of medical conditions, procedures and treatments sourced from documents within a consumer's record. 

Medicare information preferences

Preferences that allow an individual to decide whether certain information (Medicare Benefits Schedule, Pharmaceutical Benefits Scheme, Australian Organ Donor Register, Australian Immunisation Register, Repatriation Pharmaceutical Benefits Scheme and Department of Veterans’ Affairs data) is included in their My Health Record.

Medicare overview

The screen that provides a consolidation, or overview, of the Medicare information in the My Health Record. This can include Medicare Benefits Schedule, Pharmaceutical Benefits Scheme, and Australian Organ Donor Register. The Medicare overview is accessed via the Documents menu.

medicine record

A summary of prescription and dispense information for the My Health Record. It delivers a list of medications that have been prescribed and dispensed to the individual.

Note: this was previously referred to as medications view.

medicines information

The view that quickly sorts and displays the most recent and available medicines information and documents in the individual’s My Health Record. It can include the individual’s latest shared health summary or discharge summary, up to two years of prescription and dispense records, and any allergy or adverse reactions. The medicines information view can be found under the Documents tab in an individual’s My Health Record.

mobile gateway

A mechanism for mobile applications to securely integrate and interact with the My Health Record system and allow individuals and authorised representatives access to My Health Records. The mobile gateway does not authenticate healthcare providers.

My Health Record

The record of information created and maintained by the System Operator in relation to the individual, and information that can be obtained by means of that record, including the following:

• information that relates to the individual in the record relating to the individual’s registration;
• health information connected in the My Health Record system to the individual, including information included in a record accessible through the index service;
• other information connected in the My Health Record system to the individual, such as information relating to auditing access to the record; and
• back-up records of such information.

My Health Record system

The system that is used for the operation of functions under the My Health Records Act by the System Operator.   The My Health Record system was launched on 1 July 2012 and provides a system of managing health information online that will make it more accessible to Australians who choose to sign up with the system, and healthcare providers.   The My Health Record system is supported by a legislative framework consisting of the My Health Records Act 2012, Healthcare Identifiers Act 2010, My Health Records Regulation 2012, Healthcare Identifiers Regulations 2010 and My Health Records Rule 2016.   Note: this was previously referred to as the personally controlled electronic health record or PCEHR.

My Health Records Act 2012

The My Health Records Act 2012 commenced on 29 June 2012 and provides the critical components of the My Health Record system, while the operational detail is contained in the My Health Records Rule 2016. The My Health Records Act establishes the role of the My Health Record System Operator, a registration framework for consumers and participants, a privacy and security framework, penalty provisions and common mechanisms associated with the transparency and scrutiny of the Act.

My Health Records Regulation 2012

The regulation that supports the effective operation of the My Health Record system by identifying the System Operator and providing additional detail in respect of various definitions, the collection of important information  and the interaction of state and territory laws. 

My Health Records Rules 2012

The My Health Records Rules (currently consisting of the My Health Records Rule 2016, My Health Records (National Application) Rules 2017 and the My Health Records (Assisted Registration) Rule 2015) contain requirements regarding the day to day operation of the My Health Record system. 

myGov

A secure myGov account gives individuals access to a range of Australian Government services.

N

NASH organisation PKI certificate

A digital certificate that authenticates a healthcare provider organisation to access the My Health Record system, using conformant clinical software.

National Authentication Service for Health (NASH)

A system for verifying the authenticity of patients and professionals for the purpose of ensuring the privacy of a person’s electronic health data, while enabling secure access to the data by the person’s authorised health providers.

National E-Health Transition Authority (NEHTA)

The organisation established by the Australian, state and territory governments to develop better ways of electronically collecting and securely exchanging health information. NEHTA ceased to operate on 30 June 2016.

National Infrastructure Operator (NIO)

The business area responsible for providing and managing the My Health Record system on behalf of the System Operator.

National Repositories Service (NRS)

The service that ensures that there is capacity to store a minimum critical set of health information about registered individuals, including shared health summaries, event summaries, discharge summaries, specialist letters, prescribed and dispensed medications and healthcare recipient-only notes. The System Operator operates the NRS.

network hierarchy

A hierarchy that is made up of a seed organisation (the lead healthcare provider organisation of the network hierarchy) and may include one or more network organisations.

network organisation

A healthcare provider organisation with an HPI-O that is part of a network hierarchy and is subordinate to a seed organisation. Network organisations can be used to represent different departments, sections or divisions within an organisation (e.g. departments within a hospital) or can be separate legal entities from the seed organisation.

nominated healthcare provider

The author of a shared health summary. Under the My Health Records Act 2012, a nominated healthcare provider must be a medical practitioner, a registered nurse or an Aboriginal and/or Torres Strait Islander health practitioner (with Certificate IV in Primary Health Care). The healthcare provider and the individual must agree that, for the purposes of the My Health Record system, the healthcare provider is the individual’s nominated healthcare provider. 

nominated representative

A representative who is provided access to a My Health Record by the individual or the individual’s authorised representative. A nominated representative can view your health information. A nominated representative with read-only access is not required to provide any evidence of identity to the System Operator.

notification settings

This is an area in the My Health Record where an individual can set preferences for when and how to receive notification when someone accesses their My Health Record, or when a new document is uploaded to their record.

O

organisation maintenance officer (OMO)

An employee of a healthcare provider organisation who  has authority to act on behalf of the healthcare organisation with respect to the HI Service and My Health Record system. 

P

participant

A participant in the My Health Record system is the System Operator, a registered healthcare provider organisation, a registered repository operator, a registered portal operator, a registered contracted service provider and the operator of the National Repositories Service.

participation agreements

Prior to 2016, healthcare provider organisations, contracted service providers, repository operators and portal operators were required to enter into, and remain a party to, a participation agreement with the System Operator to be registered to participate in the My Health Record system. The agreement included rights and obligations for both the organisation and the System Operator relating to the uploading of records to the My Health Record system, the allocation of liability between the parties, and the processes for notifying key events and changes. In 2016, the requirement to enter into a participation agreement was removed and the rights and obligations in it were transferred into the My Health Records Act 2012 and My Health Records Regulation 2012.

pathology report

A pathology report contains the findings of test results on samples of body fluid/waste or tissue material. Doctors and other healthcare providers use this information to for diagnosis and treatment of diseases and other conditions.

pending nominated representatives

Representatives who have been appointed as an individual’s nominated representative and have had an access code generated, but who are yet to log into the My Health Record system using the access code.

personal access code (PAC)

A code generated by the individual to provide a nominated representative with access to the individual’s My Health Record.

Note: this was previously referred to as the access code

personal controls

The controls that provide a single point within an individual’s My Health Record to view information about their personal settings.

personal health notes

Personal notes added by a consumer to their My Health Record. This can be considered their private health diary and is not visible to healthcare providers.

Note: this is a ‘healthcare recipient-only note’ as referred to in the My Health Records Act.

personal health summary

A document created by the individual that includes medications, allergies and adverse reactions. This document of the My Health Record is accessible by healthcare providers (unlike the personal health notes).

Note: this was previously referred to as consumer entered health summary

personal observations

Now called achievement diary

personally controlled electronic health record (PCEHR)

Former name of the My Health Record.

prescription and dispense records

Records that incorporate prescription and dispense information to provide a consolidated record of medications – which are available as two clinical documents (My Health Record Prescription Record and My Health Record Dispense Record) available in consumer, B2B and provider portals.

proof of record ownership (PORO)

Method of identification used by Services Australia to verify someone's identity.

Provider Digital Access (PRODA)

Services Australia service that allows a healthcare provider with an HPI-I to access the My Health Record National Provider Portal for read-only purposes.

provider portal

The interface through which healthcare provider organisations can access the My Health Record system and view an individual’s My Health Record without having to use a clinical information system. The National Provider Portal is a view only service.

R

record access code (RAC)

A code which can be used to restrict access to an individual’s My Health Record. The code is provided to a healthcare provider so that the healthcare organisation is granted access to an individual’s My Health Record.

registered contracted service provider (CSP)

An entity that provides information technology services, or health information management services, relating to the My Health Record system to a healthcare provider organisation under contract with that organisation, and has registered to participate in the My Health Record system.

registered individual

An individual who is registered in the My Health Record system and has a My Health Record.

registered portal operator (RPO)

A person who is the operator of an electronic interface that facilitates access to the My Health Record system, and is registered to participate in the My Health Record system.

registered repository operator 

A repository operator is an organisation (Federal Government, State Government or private) that is authorised to supply information to My Health Record.

residential care health summary

A document containing information about a residential care individual's environment, health and care, to support continuity of care during their transfer to a hospital.

residential care medication chart

A record of orders and administration of prescription and non-prescription medicines and nutritional supplements for an individual being transferred from a residential care facility to a hospital.

residential care transfer overview

An overview screen with information about an individual's transfer from a residential care setting to a hospital. The overview includes a summary of the individual’s information in My Health Record. This transfer information supports safe effective communication and continuity of care.

residential care transfer reason

A document generated by a residential care facility containing details of an individual's transfer from the residential care setting into a hospital. This includes provider information, reason for transfer and date of transfer.

responsible officer (RO)

A person with authority to act on behalf of a healthcare organisation with respect to the HI Service.

restricted access (healthcare provider organisation)

An access level that can be applied to healthcare provider organisations by an individual. This allows an organisation to have restricted access to an individual’s clinical documents.

restricted access settings

Settings that allow an individual to choose restrict documents or your record, you can change this to allow specific healthcare provider organisations access.

Note: this was previously referred to in the Concept of Operations as limited access

S

seed organisation

A healthcare provider organisation with an HPI-O that is the head of a network hierarchy which may or may not include subordinate network organisations.

shared health summary (SHS)

A clinical document summarising an individual’s health status and includes important information such as allergies/adverse reactions, medicines, medical history and immunisations. Only a nominated healthcare provider can create or update the shared health summary.

specialist letter

The document used by a treating specialist to respond to a GP about a referred patient. It is based on the usual practice where a specialist writes back to the GP.

System Operator

The participant with responsibility for establishing and operating the My Health Record system. The System Operator is presently the Australian Digital Health Agency.

V

Veteran and Australian Defence Force (ADF) status indicator

The Veteran and ADF status indicator is stored within the My Health Record for individuals who wish to indicate whether they are a current or former serving ADF member. This indicator is voluntary.