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Accommodating Patient Request to
access and amend the health record
Michael J. Warner, D.O., [email protected]
Access & Amend• When it comes to access (looking at, viewing, reading, reviewing)
and amend (correct, contribute to, co-author), who knows the rules?
A. Doctor
B. Nurse
C. Office receptionist
D. Administrator
E. CPC
Access & Amend• When it comes to access (looking at, viewing, reading, reviewing)
and amend (correct, contribute to, co-author), who knows the rules?
• CPC
• Certified Professional Coders have a unique skill set to easily
understand the concepts of access and amend.
• You are the “go to” person for this issue.
Access & Amend
• OBJECTIVES:
1. Understand laws/rules of access & amend
2. Know examples of how to apply access & amend to daily
routine.
3. Be aware of how healthcare is rapidly changing as we enter
the digital age of medicine.
Michael Warner, D.O., C.P.C.
Osteopathic physician (dual board certified family medicine & neuromusculoskeletal medicine)
Certified professional coder
Caretaker & patient
Author
Researcher
Head of non-profit
AACOM Health Policy Fellow
Access & AmendStandards for Privacy of Individually Identifiable
Health Information (HIPAA Privacy Rule)
Compliance required for all providers as of April 14, 2004 as a final
rule of the Health Insurance Portability & Accountability Act of 1996
(HIPAA)
45 C.F.R. § 164.524 = access
45 C.F.R. § 164.526 = amend
AccessHIPAA Privacy Rule
Patient should submit a written “request” to access or amend
AccessProvider has 30 days to respond with written notification.
Provider may deny if content could “harm the patient.”
Provider may request an additional 30 days with written notification.
HIPAA exempt: psychiatric notes, most work comp & MVA
May charge customary fee for photocopy & postage, CD, flash drive
May charge nominal fee for search/retrieval (Act 26 in Pennsylvania)
AmendHIPAA Privacy Rule
Patient should submit a written “request” to access or amend
AmendProvider has 60 days to respond with written notification.
Provider may deny
“link & notify” – check health record activity log to identify who to
notify. Receiver of notification must review record to see if Medical
Decision Making requires alteration.
Provider may not charge to act on request to amend the health record
Access & Amend
HIPAA Privacy Rule Enforcement
Office for Civil Rights (OCR)
complaint investigations www.ocrportal.hhs.gov 800-368-1019
compliance reviews
enforcement of policy – empowered to assign civil money penalties
and criminal prosecution against medical providers
(penalties skyrocket if evidence of “retaliation”)
Healthcare Documentation Timeline
We are entering a new age of healthcare = Digital Age
Pre Digital Age Digital Age
We are currently in transition
Healthcare Documentation Timeline
Sir William Olser
William Osler, M.D.
“Father of Modern Medicine 1849-1919
Egyptian stone carving
up to 3,000 B.C.
“Listen to the patient,
he is telling you
the diagnosis”
Healthcare Documentation Guidelines
S.O.A.P. note
S = subjective
O = objective
A = assessment
P = planLawrence Weed, M.D.
Standardized medical documentation
in the late 1960’s
Healthcare Documentation Guidelines
S.O.A.P. note
S = subjective
O = objective
A = assessment
P = plan
Standardized medical documentation
in the late 1960’s
CMS medical encounter
• History
• Examination
• Medical Decision Making
1995 & 1997 guidelines
data collection focus
The Digital Age
Our government foresaw the digital age of healthcare
The Digital Age Payoff
Digitalized health records will allow for data analysis
beyond claims data (ICD, cpt, HCPCS) and will
venture into the History, Examination and Medical
Decision Making.
Analytics will identify best practices and allow for personalized care.
Predictive algorithms will guide us to drastic improvements in
healthcare quality, cost and satisfaction.
The Digital Age better Payoff
Healthcare in the U.S.A. = trouble
Quality: #42 life expectancy/223#169 infant mortality
64/100 National Scorecard 2011 (67/100 in 2006)
Cost: $3 trillion per year17.5% GDP 2014, projected 34% by 2040
Satisfaction: 66% of Americans approve of the way the healthcare system works for them.
HIPAA
The Health Insurance Portability and
Accountability Act of 1996
Law written to prepare healthcare for information technology
Initial focus on how medical information is stored and transmitted
HIPAA Privacy Rule
The standards for Privacy of Individually
Identifiable Health Information (HIPAA Privacy Rule)
Final rule of HIPAA with compliance required by all providers April 2004
Clarified patient’s role: access and amend the health record
Electronic Health Record Adoption
The Health Information Technology for Economic and Clinical Health
(HITECH) Act of 2009 was enacted as part of the American
Recovery and Reinvestment Act of 2009.
Directed the Office of the National Coordinator (ONC established
2004) to promote the adoption and meaningful use of electronic
health records (EHR’s). $19.2 billion
EHR use is part of the Federal Health IT Strategic Plan.
Electronic Health Record Adoption
HITECH Meaningful Use:
financial incentives to promote the adoption and meaningful use
of interoperable health information technology (HIT) and qualified
electronic health records (EHRs).
MU1 = are you using an EHR? (electronic capture of data and provide patient with
electronic copies of health information)
MU2 = Portal (lists, results), 2 way communication (continuous quality
improvement at point of care and exchange of information)
MU3 = set for 2017, full access portal??, absorbed by MACRA
Electronic Health Record Adoption
Goal: Digitize health records
2008 17% doctors used EHR systems
2012 78%
2015 financial penalty if not using CEHRT
MACRA
The Medicare Access & CHIP Reauthorization Act
of 2015 (data capture started Jan. 1, 2017) calls for
patient access and amendment of the health record
as part of the physician payment formula.
Patient Generated Health Data (PGHD) is part of an
objective to coordinate care through patient
engagement.
Electronic Health Records
How is it working so far?
deleted files
wrong chart
power outage/ loss of Internet
click, type, scroll….
? Interoperable ?
Computers were supposed to make healthcare
more efficient!
Electronic Health Records
How is it working for patients?
wrong chart
inaccurate information
template story
narrative from previous encounters
University of Michigan Kellogg Eye Center Study
Compared waiting room report to EHR
JAMA Ophthalmology January 2017
Access & Amend
Use of Patient-Authored Prehistory to Improve Patient Experience and Accommodate Federal Law
Feb 2017 JAOA
Allowed the patient to complete a replica of the CMS History and we recognized it as a written request to amend the health record. A patient authored History is considered a form of Patient Generated Health Data (PGHD).
Access & Amend263, age 14-94, average age 66, 64% response, 60% male
Invited the patient to complete a PreHistory in preparation for a medical encounter. Invite help from family members, friends and caretakers.
Scanned the document as a pdf.
Transcribed the information into the History – until a PreHx is an automated feature of the EHR patient portal.
Gave patient copy of note at check out window
Patient-Authored PreHistory
Patient-Authored PreHistory
AccessHIPAA Privacy Rule
Patient (and/or authorized patient representative) should submit a
written “request” to access or amend
AccessProvider has 30 days to respond with written notification.
Provider may deny if content could “harm the patient.”
Provider may request an additional 30 days with written notification.
HIPAA exempt: psychiatric notes, most work comp & MVA
May charge customary fee for photocopy & postage, CD, flash drive
May charge nominal fee for search/retrieval (Act 26 in Pennsylvania)
Amend
HIPAA Privacy Rule
Patient (and/or authorized patient representative) should submit a
written “request” to access or amend
AmendProvider has 60 days to respond with written notification.
Provider may deny
“link & notify”
Provider may not charge to act on request to amend the health record
Access & Amend
HIPAA Privacy Rule Enforcement
Office for Civil Rights (OCR)
complaint investigations www.ocrportal.hhs.gov 800-368-1019
compliance reviews
enforcement of policy – empowered to assign civil money penalties
and criminal prosecution against medical providers
(penalties skyrocket if evidence of “retaliation”)
Access & Amend• When it comes to access (looking at, viewing, reading, reviewing)
and amend (correct, contribute to, co-author), who knows the rules?
A. Doctor
B. Nurse
C. Office receptionist
D. Administrator
E. CPC and the patient
Big change is coming to healthcare
Access and Amend laws seem easy, until you try to
accommodate the patient’s federal rights.
Application will require a certified profession coder’s
knowledge to organize and maintain processes to
allow for patients to “request” to access and amend
the health record.
Drills/ScenariosAccess:
What is your protocol or process?
How is the provider notified? Audit trail? Who monitors?
Authorization for release of protected health information form?
How do you identify the person?
What about authorized personal representatives?
What if the patient wants personal access?
What if request is to receive records in paper form vs. electronic?
KEY: Consistent and Referenced in your HIPAA compliance manual
Drills/ScenariosAmend:
What is your protocol or process?
How is the provider notified? Audit trail? Who monitors? Link & Notify?
What happens when the provider receives a “link & notify” notice?
MRI order for wrong shoulder?
Diabetes mellitus diagnosis, yet no Diabetes??
Abdominal pain diagnosis,
yet chart documents “no abdominal tenderness”
KEY: Consistent and Referenced in your HIPAA compliance manual
Patient Advocacy Initiatives Facebook and .org
YouTube: Patient Advocacy Show episode 1 Inaccurate
Health Records (like and comment!)
Thank you!
