OVERVIEW OF RELEASE OF HEALTH INFORMATION Presented by: Bunmi Ogunleye, MSc., CHES., RHIA

1. OVERVIEW OF RELEASE OF HEALTH INFORMATIONPresented by:Bunmi Ogunleye, MSc., CHES., RHIA OVERVIEW OF ROI - HAHIMA - BUNMI -

2. Releasing Patient’s Medical Record With patient confidentiality in mind, and with advancing technology, and regulatory requirements, Releasing patient’s medical records has become more involved and more complex than before. Critical thinking and effective decision making is a key ingredient to a good ROI practices. OVERVIEW OF ROI - HAHIMA - BUNMI -

3. REQUESTING MODES • Mail • Fax • Phone • E-mail • In-person • Exchange of information • E-Discovery OVERVIEW OF ROI - HAHIMA - BUNMI -

4. Elements of Valid Authorization • Patient’s identifying information • Name of the entity permitted to make the disclosure • Purpose of the disclosure • Specific information that must be disclosed, including time frame and format • Authorization signed & dated by patient / legal representative • Description of relationship, if not signed by patient • Name of person or entity to received the information • Statement that this information may be re-disclosed • Revocation statement • Date authorization will expire OVERVIEW OF ROI - HAHIMA - BUNMI -

5. PROCESSING REQUEST • Determine if authorization was valid • Determine if any restriction exist • Use minimum necessary standard: Copy only what was requested • Do not include driver’s license or insurance card. Those are considered third party information • Do not routinely copy correspondence except it was specifically requested • Do not copy record from external facilities. Except specifically requested and or for legal reasons. The requestor should contact the originating facility to obtain copy OVERVIEW OF ROI - HAHIMA - BUNMI -

6. REGARDING MINOR • NOTE: • EMANCIPATED MINOR: • Full access if emancipationship has been declared • Court, marriage, and or active military duty • CUSTODIAL PARENTS: • Full access • NON-CUSTODIAL PARENT: • Can not be denied access unless they have been prohibited by court order • STEP PARENTS • Have No legal authority to consent for treatment of a minor or obtain their PHI unless they have been appointed as the legal guardian or have legally adopted the minor • PORTAL ACCESS: Access to a minor’s PHI thru electronic portal continues to be questionable since the information may contained diagnosis or treatments qualified as emancipation. OVERVIEW OF ROI - HAHIMA - BUNMI -

7. CHECK THIS OUT 1. The actual authorization request form, in the patient’s medical record, can routinely be disclosed as part of patient’s legal medical record. • [A.] Yes • [B.] No OVERVIEW OF ROI - HAHIMA - BUNMI -

8. VALID Authorization Received Authorization Received Not VALID Ouch… IT HURTS NOTE: The actual authorization form is not a part of LHR OR DRS and should not be automatically be disclosed in future as a part of medical record. OVERVIEW OF ROI - HAHIMA - BUNMI -

9. TURNAROUND TIME TO RESPONDING TO REQUEST HIPAA • Process within 30 days or receipt • Off-site – process within 60 days of receipt • One 30 day extension per request permitted HITECH • All request must be processed within 30 days • One 30 day extension per request permitted • No separate turnaround time for off-site records OVERVIEW OF ROI - HAHIMA - BUNMI -

10. TEXAS HEALTH AND SAFETY CODE • A disclosure authorization is valid for 180 days unless otherwise stated or revoked • Process received request no later than 15 days after the date the request and or applicable copying fee payment received. • Provide access to review record during regular business hours • Fees may not be charged to examine records OVERVIEW OF ROI - HAHIMA - BUNMI -

11. AUDITS • Staff training new staff vs. existing staff • Turnaround time for patient care request vs. regular request • Amount billed vs. amount collected • Record requested vs. record provided • Accuracy and completeness of data entry • Was authorization valid? Was it present? • Quality and quantity of copied records • 30 days extensions • Backlogs and follow ups • Electronic disclosure: Remote access • Business associates OVERVIEW OF ROI - HAHIMA - BUNMI -

12. E-DISCOVERY • Only applies to electronically stored information (ESI) • It is mainly used during litigation • Information stored on servers, workstations, mobile devices, flash drives, USB drives and other electronic storage can be subjected to E-Discovery rule • Authenticity, reliability, usability, integrity, validity is very important • A continuous education along with a well developed operational process for responding to litigations is required OVERVIEW OF ROI - HAHIMA - BUNMI -

13. AHIMA’S GUIDANCE ON “LITIGATION RESPONSE” AHIMA identifies 5 key steps to developing a litigation response plan and process • Conduct an evaluation of applicable rules • Identify a litigation response team • Analyze issues, risks, and challenges • Develop organizational policy and procedures • Develop a system for ongoing monitoring and evaluation OVERVIEW OF ROI - HAHIMA - BUNMI -

14. AHIMA GUIDANCE CONTINUED Implement an ESI retention policy as part of overall document retention policy • An inventory of all the types of ESI that exist • What sources possess ESI • What type of ESI does each system store • How and where is each type of ESI stored • How long is each type of ESI stored • How is ESI to be destroyed • If any, when, why and how long is ESI destruction to be suspended • Conduct on-going ROI staff training and staff policy awareness • Set disciplinary action for non compliance • Employee to sign policy acknowledgment annually to coincide with performance evaluation • Audit, monitor and report compliance • Review policy annually and update as needed OVERVIEW OF ROI - HAHIMA - BUNMI -

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16. WHAT IS ACCOUNTING OF DISCLOSURE? HIPAA – Requires cover entities (CE), upon request, must provide patient with a record, of entities your facility have disclosed the patient’s PHI to ARRA – took it a step further: CE that maintains PHI in electronic format are required to account for disclosure made even for the purpose of TPO. ARRA – also require CE to account for disclosures of their BA or BA can make their own disclosures OVERVIEW OF ROI - HAHIMA - BUNMI -

17. ACCOUNTING OF DISCLOSURES INCLUDES Disclosures made without patient’s authorization • Made in writing • Made electronically • Made by phone • And or made orally OVERVIEW OF ROI - HAHIMA - BUNMI -

18. ACCOUNTING DOES NOT INCLUDE DISCLOSURES • Authorized by patient / legal representative • To carry out TPO (HIPAA) • To meet national security or intelligence requirements • Occurred before the compliance date April 14, 2003 • For facility directory purpose • For correctional institution or law enforcement officials • As part of limited data set • Pursuant to an authorization OVERVIEW OF ROI - HAHIMA - BUNMI -

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20. WHAT MUST BE INCLUDED IN YOUR TRACKING FOR ACCOUNITING OF DISCLOSURE PURPOSE • INCLUDES; • Date the information was disclosed • To whom it was disclosed, name of entity or person and address if known • Description of specific information that was disclosed • Disclosure format • Disclosure to or by Business Associate (BA) OVERVIEW OF ROI - HAHIMA - BUNMI -

21. CE MAY TEMPORARILY SUSPEND THE PATIENT’S RIGHT TO RECEIVE ACCOUNTING OF DISCLSOURE • ORAL SUSPENSION REQUEST RECEIVED FROM (45 CRF 164.512): • Health oversight agency • Law enforcement • document the statement including the identity of the agency and or official making the statement • Contact your administration and legal team • Temporarily suspend the individual’s right to an accounting of disclosure subject to the statement • Limit the temporary suspension to no more than 30 days from the date of the oral statement, unless a written statement is submitted during the 30 days OVERVIEW OF ROI - HAHIMA - BUNMI -

22. TURNAROUND TIME FOR RESPONDING TO A REQUEST FOR ACCOUNTING OF DISCLSOURE • CE must respond to the individual’s request for an accounting of disclosure no later than 60 days (30 days + 30 days) from the date request received. • If the CE is unable to provide the accounting within the time required (30days), the CE may extend the time to provide the accounting to no more than 30 days, • The CE must provide the individual with a written statement of the reason for the delay along with the date by which CE will provide the accounting • The CE may only extend one time on a request OVERVIEW OF ROI - HAHIMA - BUNMI -

23. FEES FOR ACCOUNTING OF DISCLOSURE • CE must provide the first accounting of discourse to an individual in any 12 month period without charge • CE may charge for subsequent request for an accounting of disclosure by same individual within the same 12 month period, • provided the cover entity informs the individual in advance of the fee, and • provides the individual with an opportunity to withdraw or modify the request in effort to avoid or reduce fee. OVERVIEW OF ROI - HAHIMA - BUNMI -

24. ACOUNTING OF DISCLOSURE TIPS • Track PHI disclosed three years prior to the date an Accounting of disclosure requested was received • CE or BA must determine and educate staff / providers on how to track the required information • Get assurance from your EHR vendors that your EHR system meets the new disclosure requirements • If no HER system, educate providers and staff making disclosures to document the disclosure into a central tracking system • Ensure consistent procedure across the organization • It was recommended to have your accounting of disclosure request submitted and process by HIM versus been received and processed by different departments OVERVIEW OF ROI - HAHIMA - BUNMI -

25. [ ] DESIGNATED RECORD SET[ ] LEGAL HEALTH RECORD[ ] MINIMUM NECESSARY___ ___ ___ ____[ ] LIMITED DATA SET OVERVIEW OF ROI - HAHIMA - BUNMI -

26. DESIGNATED RECORD SET • Maintain an updated matrix to distinguish each document used in the treatment and or payment of the service qualifies as a designated record set and or legal health record and whether they can routinely be disclosed • Identify the storage mode of each document, (paper, or electronic) • Identify the source system where the information is located • Identify consistent method of disclosure upon received valid authorization OVERVIEW OF ROI - HAHIMA - BUNMI -

27. LEGAL HEALTH RECORD Check with your Organization’s legal counsel Definite answer to this question will make it easy in responding to an Any and All Record request. OVERVIEW OF ROI - HAHIMA - BUNMI -

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29. BUT, does not de-identify the information. Commonly use for Research with approved IRB, and or Public Health disclosures OVERVIEW OF ROI - HAHIMA - BUNMI -

30. Limited data set excludes • Name • Phone # • Fax Number • E-mail address • SS# • Postal Address except city, town, state and zip • Medical record # • Account # • Implanted Device # and serial # • Full face photographic image and any comparable image OVERVIEW OF ROI - HAHIMA - BUNMI -

31. EXCHANGE OF ELECTRONIC HEALTH INFORMATION OVERVIEW OF ROI - HAHIMA - BUNMI -

32. BACKGROUND OF ELECTRONIC HEALTH INFORMATION EXCHANGE • HITECH – HEALTH Information Technology for Economic and Clinical Health Act is a Title XIII of division A and Title IV of division B of ARRA (American Recovery and Reinvestment Act of 2009) • The HITECH Act amended the public Health Service Act and created Title XXX • Title XXX (Health Information Technology and Quality) was enacted to improve health care quality, safety, and efficiency through the promotion of HIT and Electronic Health Information Exchange. OVERVIEW OF ROI - HAHIMA - BUNMI -

33. HITECH ADVISORY COMMITTEES HIT POLICY COMMITTEE (HITPC) HIT STANDARD COMMITTEE (HITSC) Responsible for advising the National Coordinator for Health Information Technology regarding: [] Standards [] Implementation specifications [] Certification criteria HITECH ACT grant The Secretary the authority and discretion to adopt standards, implement specifications and certifications recommended by HITSC and endorsed by National Coordinator. The Secretary is required to publish all determinations in the Federal Register OVERVIEW OF ROI - HAHIMA - BUNMI -

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35. ELECTRONIC HEALTH RECORD DISCLOSURE METHODS • SAVE TO FILE: • Electronically save copies of record in litigation • RELEASE TO INSPECTOR • Similar to chart review. Provide secure limited access • RELEASE TO MY CHART • Release directly to patient account. Password protected • QUICK DISCLOSURE • Release by clinician to public Health • FAX • Fax within workstation without printing • EPICCARE LINK • Provide secure, remote access, password protected • CARE EVERYWHERE • Share records between organizations with similar electronic medical record systems • CARE ELSEWHERE • Share records between organizations with differ electronic medical record systems thru HIE connect (meet HL7 requirement) • TRANSITION OF CARE (ToC): (allows providers to electronically access and retrieve clinical data for continued patient care (patient participation, facility participation thru HIEs OVERVIEW OF ROI - HAHIMA - BUNMI -

36. RELEASE OF INFORMATION DATABASE • Is a valuable tool for ROI staff and the leadership once request is entered in the system • Check and update release status • Assign a request (denote type of request) • Name, address, phone and fax number of requestor and patient • Line item Audit trails • Enter comment • Generate letters • Managed quick disclosures • Preview record • Track disclosed vs. requested information • Run reports • Productivity report • Turnaround time • Incomplete request • On hold request • Completed request • Revenue collected outstanding balance • Frequent requesters OVERVIEW OF ROI - HAHIMA - BUNMI -

37. ROI SYSTEM GENERATED LETTERS • Payment reminder notice • Payment must be received prior to disclosure • Authorization is invalid • Does not have record of the patient been treated at facility • Does not have record for the date requested • All inclusive authorization is required • Notice of intent required • Certificate of assurance required • Notify requester there will be a delay processing request • Request extension time to completing received request • Required criteria to gain remote access to PHI OVERVIEW OF ROI - HAHIMA - BUNMI -

38. FAXING FUNCTIONALITY RETURN ON INVESTMENT AND IMPACT TO ROI • Decreased toner usage • Decreased paper usage • Fax and printer equipment cost containment IMPACT TO ROI OPERATIONS • Improved turnaround time • Improve productivity • Improve staff and customer satisfaction • Improve expenditure OVERVIEW OF ROI - HAHIMA - BUNMI -

39. MEANINGFUL USE • IMPACT TO ROI OPERATIONS • Timely electronic access to medical record • obtain electronic copy OVERVIEW OF ROI - HAHIMA - BUNMI -

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41. STAGES OF MEANIGFUL USE • STAGE 1 • STAGE 2 • STAGE 3 OVERVIEW OF ROI - HAHIMA - BUNMI -

42. COMMON MEANINGFUL USE DATA SET • Patient name • Date of Birth • Sex • Race • Ethnicity • Preferred language • Smoking status • Medications • Problems • Medication allergies • Laboratory test • Laboratory values • Vital signs – height, weight, BMI and blood pressure • Procedures • Care team members OVERVIEW OF ROI - HAHIMA - BUNMI -

43. HITECH NEW CHANGES AFFECTING DISCLOURE OF PHI • Compound authorizations • Access to decedent’s record • Immunization disclosures • Restrictions • Electronic access OVERVIEW OF ROI - HAHIMA - BUNMI -

44. Yield or Stop forreceived roirestrictions OVERVIEW OF ROI - HAHIMA - BUNMI -

45. PATIENT’S RIGHT TO RESTRICT DISCLOSURE • HITECH – Gives patient right to restrict an organization from disclosing their medical record to a health plan: • If the service provided was paid for by the patient in full out of pocket • The request must be submitted in writing and full payment must be made for the request to valid. • Patient can restrict portion or entire record for same service date or subsequent service date(s) • HIPAA – Gives patients right to request restriction for use and disclosure of their PHI • CE were not required to agree to restriction for Treatment, Payment and Operations)TPO, however, • They must abide by the restriction request they agree to • Request must be submitted in writing OVERVIEW OF ROI - HAHIMA - BUNMI -

46. EHR Lessons Learned • Impact of Cut and Paste to EMR disclosures • Print group configuration • Report • Measure to keep electronic health information from improper disclosures • Measures to ensure minimum necessary information was electronically exchanged with authorized parties • Tracking of disclosure procedures for accounting of disclosure. • Identify authorized users within electronic exchange of information • Procedure for identifying and managing who store PHI OVERVIEW OF ROI - HAHIMA - BUNMI -

47. SOME COMMON ROI TERMINOLOGY ACRONYMS TERMS Authorization Adult Emancipated minor Durable Power of Attorney Proxy Metadata Court Order Subpoena Psychotherapy note Legal Executor or Administrator of an estate • Health Information Exchange (HIE) • Meaningful Use (MU) 1,2,3 • Code of Federal Regulations (CFR) • Health Level Seven (HL7) • Implementation Guide (IG) • Public Health Service Act (PHSA) • Certified Electronic Health Record Technology (CEHRT) • Clinical Decision Support (CDS) • Center for Disease Control and Prevention (CDC) • Center for Medicaid & Medicare Services (CMS) • Health Information Organization (HIO) • Release of Information (ROI) • Protected Health Information (PHI) • Health Information Portability and Accountability Act IHIPAA) • Office of National Coordinator (ONC) OVERVIEW OF ROI - HAHIMA - BUNMI -

48. REFERRENCES • 45 CRF 164. • 164. 502, Minimum Necessary • 164.508 Use and disclosure for which authorization is not required • 164.522 Right to request restriction • 164.526 Amendment of phi • 164.528 Accounting of disclosures • Fundamental of Law for Health Informatics and Health Information Management, second edition. • Journal of AHIMA 84, no. 11 November – December 2013 • AHIMA Release of Information Toolkit May 2013 • Please read “ Modifications to the HIPAA Privacy, Security, Enforcement, and Breach Notification Rules under the HITECH Act, and Genetic information non-discrimination Act”, in the Code of Federal register • AHIMA “Mandates Encourage E-Discovery” journal of AHIMA 83, no. 5 (May 2012):68 OVERVIEW OF ROI - HAHIMA - BUNMI -

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