Agreed - never change the clinical record. The key is that all providers
down the road need to know "there is more to this story".
As a clinical information systems vendor, we work very closely with our
customers on HIPAA issues. The model our customers and we have
collaboratively arrived at is a combination of institutional policy for
reviewing the amendment request, and then (when appropriate) creating a
transcription type called "Patient Amendment" and entering the
transcription per normal channels.
Since the clinical system groups transcriptions by encounter at the acute
care level, plus allows transcriptions to be accessed as part of the
overall clinical record, clinicians "down the road" will see a permanent
record called "patient amendment" and know there is "more to know" about
the patient and their care. Since clinicians generally review a patient's
record prior to visit and/or rounds, their attention is drawn to the new
transcription as part of their "normal" routine, vs. establishing a
"special routine" via a flag or some other alert feature.
In other cases (e.g., wrong data entered for patient), most of our
customers already have procedures in place for reviewing and correcting
data entered in error, and only "qualified" users for the data to be
corrected, e.g., clinical personnel, billing personnel, can amend or alter
the record.
The trick with this is how to track who received the data prior to the
amendment, and who needs to be alerted to the amendment and perhaps receive
a copy of the amendment. Does anyone have a model for this part of the
process?
thx. DAL
Deborah A. Lelinski
IDX Carecast/LastWord HIPAA Program Manager
206.689.0967
[EMAIL PROTECTED]
www.idx.com
"Bill Bernath"
<Bill.Bernath@bc To:
<[EMAIL PROTECTED]>, <[EMAIL PROTECTED]>, <[EMAIL PROTECTED]>
bsnc.com> cc:
Subject: RE: How to handle Patient
Requested Amendments?
03/27/2002 05:05
AM
I'm with Larry on this one - I guess the other statement we are making is
that amendments of medical records will be made through the provider, so
they should get to us as normal transaction activity. Our position is that
we will only provide amendment capabilitiies for the data that we originate
and maintain. As a plan, that is not very much. All other requests will
be referred to the originator. Hope that helps - b
Bill Bernath
Blue Cross Blue Shield of North Carolina
Privacy Office
(919) 765-7006
[EMAIL PROTECTED]
>>> "Larry Nielsen" <[EMAIL PROTECTED]> 03/26/02 05:41PM >>>
By NO MEANS should you change your own history files. The term is
'amendment' not 'change'. This implies (and should be) an additional file
and pages within the original file with the patient's comments.
Larry Nielsen
Systems West
801-733-5800
-----Original Message-----
From: Jim Moores [mailto:[EMAIL PROTECTED]]
Sent: Tuesday, March 26, 2002 10:38 AM
To: [EMAIL PROTECTED]
Subject: How to handle Patient Requested Amendments?
Hi All,
Those of us on the Privacy Project Team at my company are discussing
how
should we record subscriber requested amendments.
Some think we should maintain a file where the subscriber is allowed to
record their comments / side of the events vs actually changing our files.
(Like the Credit Card Companies do, when the post the card holder's side of
the story). Would we have to have flags that further restrict (beyond
normal HIPAA rules) who we would disclose the transaction data to if the
member requested that we delete the information?
Another group says we should actually change history files. If we
truly
change or delete data that we've acted upon, what are the implications to
back end financial reporting (i.e. 1099's, data previously reported doesn't
balance to current data, we can't substantiate a cost plus bill, etc). For
example, what happens if the member tells us, I told the doctor that he
wasn't supposed to submit that claim to you for payment... I want you to
delete the claim! (real example... appropriately de-identified... :-)). I
can just see the IRS saying, what do you mean you didn't report a payment
to
a doctor just because the member requested that the claim be deleted!
For either scenario, what about the data that we've already disclosed,
before we received the "amendment" request to delete the data? Do we have
to follow the data with the requested changes?
Are there any other payers that have or are confronting this issue?
Jim
Jim Moores - HIPAA Team Leader - Privacy
Antares Management Solutions
23700 Commerce Park Road
Beachwood, Ohio 44122-5832
[EMAIL PROTECTED]
Phone: (216)292-1605
Fax: (216)292-1619
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