Release of Information Processes and the Legal Health Record Practice Brief

1. Release of Information Processes and the Legal Health Record Practice Brief Lois Hooper August 9, 2010

2. Objectives Review Release of Information issues and hot topics Understand interrelation between Privacy Officer and Health Information Management Review highlights from DRAFT Release of Information Handbook Review key points of the Legal Record Practice Brief

3. PLEASE� Hold questions until the end Many of your questions may be answered during the presentation Time is reserved at the end of the session for questions

4. Release of Information Processes �Release of Information� is MORE than Release of Information Provides direct customer service to Veteran First and Third Party requests In-Person Authentication Coordination of forms completion Preparing bills for copies, when appropriate Preparing records for legal action Assisting with amendment requests All other duties as assigned

5. Release of Information Structure Release of Information unit generally aligned under Health Information Management Works hand-in-hand with Privacy Privacy provides guidance and training of applicable laws and statues Health Information Management performs associated business functions

6. Release of Information Hot Issues Information sensitive to the Veteran VERY LITTLE information is actually �sensitive� to the Veteran Not used to withhold information for convenience of provider or facility Every Veteran has a RIGHT to his/her own information Joint Health Information Management/Privacy Fact Sheet available

7. Release of Information Hot Issues Release of Compensation & Pension (C&P) Exams Compensation & Pension exams owned by VBA but included in VHA health record VHA can release Compensation & Pension exams when requested Amendment requests sent to VHA program office and coordinated with VBA

8. Release of Information Hot Issues cont. Utilizing iMedConsent� for Veteran signature Currently tested in three facilities for Release of Information forms Adding form 10-0483 (Acknowledgement of Notice of Privacy Practices for Non-Veterans)

9. Release of Information Hot Issues cont. Processing Requests for Deceased Veterans Requests must be entered in BOTH DSS Release of Information and FOIAXpress Dual entry effective 5/12/10 FOIAXpress captures requests for annual report DSS Release of Information captures requests for accounting of disclosures

10. Release of Information Hot Issues cont. To Scan or not to scan VA form 10-5345a for My HealtheVet is REQUIRED to be scanned per VHA Handbook 1907.02 PREFERRED that all authorization forms be scanned Forms must be available and accessible Scanning allows for quick retrieval

11. Release of Information Hot Issues cont. Medical Clerks Releasing Information Some Veterans Integrated Service Networks and facilities interpreting this as part of the Primary Care Medical Home Not a recommended practice Local Health Information Management, or Privacy Officer, or both, must ensure facility management understands technical and legal requirements for Release of Information

12. Release of Information Hot Issues cont. Release of Information via Secure Messaging The same requirements for Release of Information apply to secure messaging Providers MAY send a copy of certain information to the Veteran provided the information is directly related to patient care Consent is not required for patient education

13. Release of Information Hot Issues cont. In-Person Authentication Health Information Management and Release of Information involvement required May coordinate In-Person Authentication duties with My HealtheVet Coordinator As My HealtheVet functionality grows, more Veterans seeking In-Person Authentication Health Information Management and Release of Information must be ready to address the increased need

14. Release of Information Hot Issues cont. In-Person Authentication cont. Training available on the Employee Education System My HealtheVet page http://vaww.vistau.med.va.gov/vistau/MHV/admin.htm

15. My HealtheVet What is the role of the Release of Information office? What about sensitive record review? How to account for disclosures?

16. My HealtheVet cont. What is the role of the Release of Information office? Main area of involvement is In-Person Authentication When available, electronic copies of information will be downloaded to the Veteran�s My HealtheVet account

17. My HealtheVet cont. What about sensitive record review? Automated solution suggested Provider responsible for checking box ONLY if information cannot be downloaded via My HealtheVet Information is not denied Veteran prompted to contact local Release of Information office if information cannot be downloaded

18. My HealtheVet cont. How to account for disclosures? Veteran provides written request for information when signing VA form 10-5345a Form only signed once for all downloads My HealtheVet system will automatically track and account for disclosures

19. Release of Information Resources VHA Privacy Office Page http://vaww.vhaco.va.gov/privacy/vhapo.htm Contains links to Fact Sheets, FAQs and minutes DSS Release of Information Software Manager Administrative and User Manual PowerPoint Trainings

20. Release of Information Resources VHA Health Information Management Home Page http://vaww.vhaco.va.gov/him/index.asp Contains links to My HealtheVet In-Person Authentication training Guidance in VHA Handbook 1907.01 Links and training for Release of Information to Social Security Administration

21. Release of Information Handbook Brand new Handbook Draft ready for concurrence Developed with input from the Health Information Management Field Leadership Council, Privacy Advisory Council, and several Health Information Management field volunteers Pulls together guidance from a variety of sources

22. Release of Information Handbook cont. Meant to assist the field in standardizing processes and responsibilities May be used to support personnel requests Demonstrates complexity of Release of Information position Provides links to key resources Enforces Health Information Management�s direct customer service responsibilities

23. Release of Information Handbook cont. Outlines requirements for Establishment of priority system to ensure requests are completed within specified time frames Development of tools and processes for quality reviews Need to include all Release of Information activities in outlying Community Based Outpatient Clinics and other areas under Health Information Management

24. Release of Information Handbook cont. Delineates responsibilities for Release of Information units within Health Information Management Emphasizes the need for qualified staff in Release of Information Outlines Release of Information process Establishes requirement for at least two personnel within Release of Information have capability to burn CDs

25. Release of Information Handbook cont. Emphasizes requirement to utilize the DSS-ROI software manager Establishes requirement to enter requests daily in DSS-ROI Provides a checklist for determining valid third party request

26. Release of Information Handbook cont. Includes suggested productivity standards Standards based on input from the field Standards suggest MINIMUM productivity for standard requests as 18 per day Standards much lower than American Health Information Management Association suggested standards Complexity of requests and processes taken into consideration when developing standards

27. Release of Information Handbook cont. Tort claims not included in productivity standards Subjective nature of Tort requests Tort requests reviewed for quality and completeness Will discuss Torts more later in the session

28. Release of Information Handbook cont. Establishes suggested accuracy levels 95% accuracy rate for each Release of Information technician and for the unit overall Accuracy to be reviewed on a routine basis by supervisor or lead Additional accuracy reviews may be performed by the Privacy Officer Review findings utilized to educate the Release of Information staff

29. Legal Health Record Practice Brief Developed with the Office of General Counsel Office of General Counsel coordinated input from Regional Counsel Last Updated October 2009

30. Legal Health Record Practice Brief cont. Valid request from Regional Counsel must be received Request may be mailed or scanned and sent via encrypted email Documents and information included in the legal record is ONLY for time frame specified in request

31. Legal Health Record Practice Brief cont. Practice brief minimum content and format must be adhered to for Tort claims Local Regional Counsel may require additional information Regional Counsel must be assured it has all of the information needed in regards to Tort claims

32. Legal Health Record Practice Brief cont. Practice Brief only applies to Regional Counsel requests for potential or unresolved Tort claims Does not apply to Office of Medical-Legal Affairs Requests VHA Handbook 1100.17 outlines process and format for PAID Tort claims

33. Legal Health Record Practice Brief cont. Information required from both paper and Computerized Patient Record System (CPRS) Practice Brief outlines documents needed, location, and any special considerations Most information in CPRS can be pulled from DSS ROI

34. Legal Health Record Practice Brief cont. Information from remote sites must be pulled via remote data view Health Summary Remote site �work copy� is acceptable Information from DSS can be burned to a CD

35. Legal Health Record Practice Brief cont. Unsigned, un-cosigned, retracted, and/or deleted documents must be included All information, paper and electronic, must be indexed and contain identifying information on each page

36. Legal Health Record Practice Brief cont. IMPORTANT � Every site must assess instruments or equipment not interfaced with CPRS Need to ensure information contained in instruments or equipment used for patient care is included in the Legal Health Record Best Practice � Develop a spreadsheet for naming and tracking all standalone devices

37. Questions??

38. Contact Lois.Hooper@va.gov