A need to clearly define the key elements of the GP health summary and its application in an electronic health record has prompted the Royal Australian College of General Practitioners (RACGP) to develop a set of seven factsheets to provide advice to general practice and their teams.

The 4th edition of the RACGP Standards for general practices requires that practices can demonstrate that at least 75 percent of their active patient health records contain a current health summary (criterion 1.7.2). To meet the requirements for a satisfactory summary, elements such as allergies and adverse reactions, current medicines list, current health problems, relevant past health history, health risk factors, immunisation, relevant family history and relevant social history need to be included. But what does 'current' or 'relevant' mean?

RACGP e-health spokesperson Dr Chris Mitchell said that there is a need to clearly define the core elements of the GP health summary as health information available through an accurate and current health summary will ensure safe and high quality care for patients.

"In the complex heath systems we work in, teamwork is essential and everyone in the team needs a shared understanding of what a health summary should include. These factsheets are a useful resource for the whole general practice team to increase patient safety and better continuity of care and will also be valuable for the wider primary care and hospital sector," he said.

"With over 125 million general practice consultations taking place in Australia annually, approximately 96 percent of GPs using computers for clinical purposes and 83 percent of the Australian population consulting a GP at least once a year, general practice is ideally placed to provide the content for the personally controlled electronic health record (PCEHR) health summary," Dr Mitchell said.

At the September United General Practice Australia meeting the group highlighted to Health Minister, Nicola Roxon, the need for immediate action in adopting the GP patient health summary as the basis for the PCEHR, and that this would be a catalyst for more rapid uptake of e-health initiatives by the profession.

The factsheets will provide guidance to the National E-Health Transition Authority (NEHTA) to design essential components of a shared health summary and Core Information Components (CIC) of the PCEHR and software specifications.

NEHTA's National Clinical Lead, Dr Mukesh Haikerwal, said it was highly likely that the GP health summary will form the basis of clinical information for electronic communication between healthcare providers and therefore be a key component for electronic health records with the roll-out of the PCEHR.

"We know that GPs can provide a GP Health Summary for the vast majority of Australians so it makes practical sense that this information is used when developing content for the PCEHR," said Dr Haikerwal

The following seven factsheets are available on the RACGP website:

- Allergies and adverse reactions
- Medical history
- Medicines list
- Health risks factors
- Immunisations
- Relevant family history
- Relevant social history.

All factsheets are available here.

To ensure that GPs can deliver the highest standard of care to their patients, the RACGP is ensuring that the NEHTA is informed of what is reasonable, workable and useful for GPs when leading the progression of e-health in Australia.

The RACGP would like to thank the RACGP clinical leads and e-health working group and NEHTA clinical leads who have provided valuable input in the development of these factsheets.

Source:
Royal Australian College of General Practitioners (RACGP)