Assessment of US Hospital Compliance With Regulations for Patients' Requests for Medical Records.

Importance: Although federal law has long promoted patients' access to their protected health information, this access remains limited. Previous studies have demonstrated some issues in requesting release of medical records, but, to date, there has been no comprehensive review of the challenges that exist in all aspects of the request process. Objective: To evaluate the current state of medical records request processes of US hospitals in terms of compliance with federal and state regulations and ease of patient access. Design, Setting, and Participants: A cross-sectional study of medical records request processes was conducted between August 1 and December 7, 2017, in 83 top-ranked US hospitals with independent medical records request processes and medical records departments reachable by telephone. Hospitals were ranked as the top 20 hospitals for each of the 16 adult specialties in the 2016-2017 US News & World Report Best Hospitals National Rankings. Exposures: Scripted interview with medical records departments in a single-blind, simulated patient experience. Main Outcomes and Measures: Requestable information (entire medical record, laboratory test results, medical history and results of physical examination, discharge summaries, consultation reports, physician orders, and other), formats of release (pick up in person, mail, fax, email, CD, and online patient portal), costs, and request processing times, identified on medical records release authorization forms and through telephone calls with medical records departments. Results: Among the 83 top-ranked US hospitals representing 29 states, there was discordance between information provided on authorization forms and that obtained from the simulated patient telephone calls in terms of requestable information, formats of release, and costs. On the forms, as few as 9 hospitals (11%) provided the option of selecting 1 of the categories of information and only 44 hospitals (53%) provided patients the option to acquire the entire medical record. On telephone calls, all 83 hospitals stated that they were able to release entire medical records to patients. There were discrepancies in information given in telephone calls vs on the forms between the formats hospitals stated that they could use to release information (69 [83%] vs 40 [48%] for pick up in person, 20 [24%] vs 14 [17%] for fax, 39 [47%] vs 27 [33%] for email, 55 [66%] vs 35 [42%] for CD, and 21 [25%] vs 33 [40%] for online patient portals), additionally demonstrating noncompliance with federal regulations in refusing to provide records in the format requested by the patient. There were 48 hospitals that had costs of release (as much as $541.50 for a 200-page record) above the federal recommendation of $6.50 for electronically maintained records. At least 6 of the hospitals (7%) were noncompliant with state requirements for processing times. Conclusions and Relevance: The study revealed that there are discrepancies in the information provided to patients regarding the medical records release processes and noncompliance with federal and state regulations and recommendations. Policies focused on improving patient access may require stricter enforcement to ensure more transparent and less burdensome medical records request processes for patients.

Reflexiones sobre el «conjunto mínimo de datos» de los informes clínicos / Reflections on the clinical reports «minimum data set»

El Real Decreto 1093/2010 (3 de septiembre de 2010) establece el conjunto mínimo de datos que deben contener, entre otros, los informes clínicos de alta y de consultas externas elaborados en instituciones del Sistema Nacional de Salud. Hasta entonces regía la Orden Ministerial 221/1984, que solamente exigía la elaboración de un informe de alta a los pacientes atendidos en un establecimiento sanitario en régimen de hospitalización. A pesar de la importancia de dichos documentos, su calidad dista de ser la deseable, especialmente la de los informes de consulta que «entre otras cosas» no se realizan en un elevado porcentaje de casos. Recientemente la Sociedad Española de Medicina Interna (SEMI), en colaboración con otras sociedades científicas, han emitido unas recomendaciones para la elaboración de los informes de alta. En el presente trabajo se llevan a cabo una serie de reflexiones sobre las implicaciones del nuevo decreto, especialmente para el caso de los informes de consulta externa(AU)

Royal Decree 1093/2010 (3 September 2010) establishes the minimum data set that the clinical reports of discharges and outpatient visits elaborated in the facilities of the National Health System should contain, among others. Until then, the Ministerial Order 221/1984, that only required the drawing up of a discharge report for patients seen in a hospital-regime health care establishment, was in force. In spite of the importance of these documents, their quality is far from that desired, especially that of the reports on visits, which, among other things, are not performed in a high percentage of the cases. Recently the Sociedad Española de Medicina Interna (SEMI) (Spanish Society of Internal Medicine), in collaboration with other scientific societies, issued some recommendations for the drawing up of the discharge reports. In this present work, a series of thoughts are made on the implications of the new decree, especially in the case of the reports of the outpatient clinics(AU)

Getting up to code. While some wait for vendors to save them from ICD-10, savvy CIOs are taking the reins early.

For mandates, a passing grade is good enough--don't over-do. Alert the CEO early, but wait for a plan before going to the Board. Partner with end-user departments. Don't rely on your vendor to prepare for government mandates. Utilize information from CHIME, AHIMA and peers.

Record limbo. Hybrid systems add burden and risk to data reporting.

Maintaining dual paper and electronic systems is often a necessity in the transition to digital record systems. The challenge in reporting data is keeping track of what data reside where.

HIPAA transition: challenges of a multisite medical records validation study of maternally linked birth records.

Numerous researchers have expressed concern over the impacts on medical records availability of the newly effective Medical Information Privacy rule, as authorized by the Health Insurance Portability and Accountability Act (HIPAA). The increased costs associated with compliance with the rule, and the increased potential for financial liability, raises the possibility that hospitals may be less likely to participate in such research, resulting in a decrease of the validity of multisite studies designed to represent an entire population. Our multisite medical record validation study, designed to assess the accuracy of maternally linked birth records, provides an overview of a number of HIPAA implementation challenges. We found that the new HIPAA rule presents new challenges for those who rely on the release of medical record information for epidemiologic research. At the very minimum, increased compliance costs associated with human subjects protection and increased administrative burden for researchers would seem to be inevitable as medical institutions address the requirements of the new HIPAA rule by instituting more complex and thus more cumbersome procedures. Researchers should anticipate increased costs and plan accordingly when budgeting for human subjects review processes.

The HIPAA headache. It just won't go away. An exclusive survey of privacy officers says full compliance with the 1-year-old regulations is still elusive.

After a year of HIPAA, there's still some adjusting to do. Some don't grasp the value of accounting to patients about disclosures, but HHS' Richard Campanelli, left, says it offers patients reassurance that their data was safeguarded. Baylor's Donna Bowers, on the cover, says caregivers are now understanding that "Maybe (patients) do care that I'm asking all these personal questions in front of all these people."

Beyond HIPAA: the complexities of electronic record management.

After all the planning and implementation, how can you ensure your electronic records hold up in court? Here's an overview of the many ramifications of electronic records. Learn how to protect your facility while preserving record integrity.

[Medical record management and risk management processes. State of the art and new normative guidelines about the organization and the management of the sanitary documentation in the National Health System or Hospital Trusts]. / La gestione della cartella clinica ed i processi di risk management. Stato dell'arte e nuovi orientamenti normativi circa l'organizzazione e la gestione della documentazione sanitaria nelle Aziende Sanitarie od Ospedaliere.

Recent health care reforms, the start of accreditation processes of health institutions, and the introduction also in the health system of risk management concepts and instruments, borrowed from the enterprise culture and the emphasis put on the protection of privacy, render evident the need and the urgency to define and to implement improvement processes of the organization and management of the medical documentation in the hospital with the aim of facilitation in fulfilment of regional and local health authorities policies about protection of the safety and improvement of quality of care. Currently the normative context that disciplines the management of medical records inside the hospital appears somewhat fragmentary, incomplete and however not able to clearly orientate health operators with the aim of a correct application of the enforced norms in the respect of the interests of the user and of local health authority. In this job we individuate the critical steps in the various phases of management process of the clinical folder and propose a new model of regulations, with the purpose to improve and to simplify the management processes and the modalities of compilation, conservation and release to entitled people of all clinical documentation.