Accommodating Patient Request to Access and Amend the Health Record

Accommodating Patient Request to access and amend the health record

Michael J. Warner, D.O., C.P.C. [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 & Amend Standards 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 Access

HIPAA Privacy Rule Patient should submit a written “request” to access or amend

Access Provider 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 should submit a written “request” to access or amend

Amend Provider 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

“Listen to the patient, he is telling you the diagnosis”

Sir William Olser Egyptian stone carving William Osler, M.D. up to 3,000 B.C. “Father of Modern Medicine 1849-1919 Healthcare Documentation Guidelines

S.O.A.P. note

S = subjective

O = objective

A = assessment Lawrence Weed, M.D. Standardized medical documentation P = plan in the late 1960’s Healthcare Documentation Guidelines S.O.A.P. note CMS medical encounter S = subjective • History O = objective • Examination A = assessment • Medical Decision Making

P = plan 1995 & 1997 guidelines Standardized medical documentation data collection focus in the late 1960’s 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 year 17.5% 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 & Amend 263, 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 Access HIPAA Privacy Rule Patient (and/or authorized patient representative) should submit a written “request” to access or amend

HIPAA Privacy Rule Patient (and/or authorized patient representative) should submit a written “request” to access or amend

Amend Provider 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

(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/Scenarios Access: 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/Scenarios Amend: 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 Thank you!

Patient Advocacy Initiatives Facebook and .org YouTube: Patient Advocacy Show episode 1 Inaccurate Health Records (like and comment!) [email protected]