National Health Reform

Concept of Operations: Relating to the introduction of a Personally Controlled Electronic Health Record System

4.2.4 Retention of records

The retention of information within the PCEHR System is dependent on the party holding the information. The following section highlights the proposed retention policies.

Information held by the PCEHR System Operator

Information held by the PCEHR System Operator, including information within the national repositories services, index service, audit trails, prior versions of clinical documents, etc., will be held according to the following retention policies:

• Active PCEHRs: While an individual continues to participate, their PCEHR will act as a lifelong record (from the time of its creation) and the PCEHR System operator will retain all clinical documents held within the national repositories service.
• Deactivated PCEHRs: If the PCEHR is deactivated, either via the individual withdrawing, Fact of Death being received, or the individual’s recorded age exceeding 130 years, the PCEHR System operator may archive any clinical documents held in the national repositories service after a ‘cooling off’ period (initially defined as 90 days).
• Archived PCEHRs: Any clinical documents archived by the PCEHR System Operator will be held for a minimum period as defined by PCEHR legislation (currently suggested as being a minimum of 15 years since last action on the record or until a minor turns 30, whichever period is longer). Clinical documents will not be retrieved from the archive unless disclosure is required under law.
• Other classes of information: Any other information held by the PCEHR System Operator, such as audit trail entries, system logs, prior versions of clinical documents etc., will be held for a period defined as part the PCEHR System Operator retention polices and meet all legal requirements.

Conformant Repositories

Clinical documents held within a conformant repository and indexed through the PCEHR System will be retained in line with the record retention policies of the repository operator and other locally applicable legislative requirements.

If the conformant repository archives or disposes of a clinical document, it will be required to leave an annotation within the PCEHR System index that the clinical document has been archived or disposed of.

If a PCEHR System user wishes to access an archived clinical document, they should contact the source directly.

Source systems

Information supplied by source systems (i.e. the system that generated the clinical document and uploaded it into the PCEHR System) will need to continue to comply with local record retention policies and any other local legal requirements as applicable.

Downloaded and printed information

Any information downloaded or printed from the PCEHR System and stored in a local record will be managed using local record retention policies and any other locally applicable legal requirements.

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