Issue Date: January 1, 2003


Vol. 7 •Issue 1 • Page 8
HIPAA Privacy Requirements

This article presents an operational approach to leveraging clinical system automation and workflow design.

Health care organizations are facing the arduous task of redesigning the operational processes associated with patient care delivery in order to increase compliance with the privacy regulations of HIPAA. While HIPAA requirements may appear daunting, practical operational solutions can be achieved by combining a robust clinical system's application toolset with a creative workflow design. Given the right tools and workflow design process, health care organizations can address HIPAA requirements at each juncture in the patient encounter cycle, ranging from pre-registration to the actual bedside encounter.

Every clinical system contains a fundamental toolset that can be used to create or alter system functionality to better support a health care organization's operational processes, such as HIPAA privacy requirement compliance. The key to an organization's success when employing this approach for HIPAA is to ensure that its clinical system's toolset is truly robust enough to provide the latitude and flexibility necessary for adapting to new workflow designs.

In the following sections, this article will identify potential operational challenges posed by HIPAA's privacy requirements and possible solutions that could be constructed through the automation toolsets of a computerized patient record (CPR) plus creative workflow design.

Consents and authorizations

How can you capture information at the first patient encounter that will meet the ongoing operational needs of all departments for HIPAA compliance?

Under the revised HIPAA final regulations, covered health care entities are no longer required to obtain consents. However, many organizations still intend to obtain patient consents in order to permit the receipt, use and release of patient identifiable information in accordance with state laws for treatment, payment and health care operations (TPO).

Furthermore, the HIPAA privacy rule requires covered entities to obtain an authorization for uses and disclosures for purposes other than TPO. It is possible for providers to develop a process of addressing the consents and authorizations upon patient entry into the organization. It is easy enough to develop a paper process in theory to comply with state requirements or organizational policy, but in order to actually improve the operational efficiencies and not create a bureaucratic process, providers must look to automation application changes and workflow process redesign.

If the CPR toolset allows for the documentation of whether the registration area obtained all the necessary consents and authorizations, the documentation can be stored online as part of the patient's electronic medical record. The status of each required form could be accessed for review at key junctions of the care delivery process on an as-needed basis. This will significantly improve the timeliness of confirming status for required forms and enable better cycle time associated with decisions contingent upon properly obtaining authorizations and consents.

Consents for TPO can be documented by registrars at the first encounter and displayed later for business office and medical records personnel who need to confirm completion of forms prior to releasing information for TPO purposes.

Procedure-specific releases (i.e., informed consent forms) can be documented in the CPR by nursing staff during the patient intake assessment process and then accessed online by physicians when needed for confirmation prior to performing invasive procedures.

Missing consents and authorizations will always be a challenge in health care because there are many ways of admitting or treating patients without obtaining consent signatures up front. If the forms are documented online, then the lack of signatures can be identified via automation in the form of reports and online work queue notifications. Through the use of automation toolsets, missing patient documents can be identified easily, thus improving compliance with HIPAA, state laws or organizational policy in an efficient manner.

Role-based access to information

How can a CPR be leveraged to ensure that access to patient information is limited to a defined scope of data based on the role of the employee?

Under HIPAA, covered entities are required to ensure that the scope of access to patient information within the organization is limited to the "minimum-necessary" level rather than providing full access to all patient information without regard to what is needed by the employee or contractor to perform his or her job. With an electronic medical record, it is easy to store and retrieve information. However, if a CPR is not installed with role-based access in mind, an organization can increase its risks of breach. It is important to conduct operational workflow analysis to confirm the activities associated with specific personnel so that they can be assigned an appropriate scope of information for access through the CPR.

Once a workflow has been documented, the CPR's toolset can then be leveraged. By creating a hierarchical design that prioritizes the scope of information from least to most sensitive with regard to re-disclosure, the toolset can then be used to assign security levels to each scope definition of information. Approved security levels can be assigned to each employee type to ensure that the employee has appropriate and minimally necessary access limitation for his or her role.

Protocol-based release of information

How can an organization ensure that re-disclosure or release of information conforms to a pre-approved protocol and is also determined by a role-based access level?

Under HIPAA, organizations are required to exercise reasonable and appropriate measures for managing the access to and release of information. While this can be done technically with most CPR systems, it can be greatly strengthened if done in conjunction with a workflow analysis design using protocol-based procedures for determining what can be released and by whom. If the CPR is leveraged to manage requests for release of information by routing the requests to the appropriate resources within the organization in an automated fashion, the process can result in both strong HIPAA compliance as well as significant operational efficiencies. This can be accomplished using online work queues in a CPR; if structured as a basic part of the organic functionality, the work queues may significantly increase operational efficiencies.

Another consideration involving protocol access and release of information comes into play with the actual printing of records from a CPR. If the role-based scope of access is tied to security levels — and the scope is correlated to a specific printing function the reprinting of a medical record can also be limited to a protocol-defined scope of information based on the personnel role involved. This can further ensure that if a request for information is erroneously channeled to the wrong resource without the appropriate security levels, then the risk of having that information re-disclosed outside of the approved protocol is minimized.

Patient information policies and procedures

How can covered entities (health care providers) automate the process of obtaining patient signatures for acknowledging the information management practices of the organization?

Under HIPAA final regulations, a health care provider must obtain an acknowledgement from the patient that he or she has received the entity's Notice of Privacy Practices no later than the date of the first service delivery after April 14, 2003 (except in emergency cases). While this acknowledgment may be documented manually, the use of a CPR's automation toolset can greatly improve the accuracy and operational efficiencies of the process. For example, the printing of acknowledgement statements — as well as the required consents and/or authorizations — as an automatic report at the end of a registration process ensures production of all the required forms as a reminder to the registration staff.

This process can also trigger the correct forms to print based on various criteria such as patient type. Due to the frequent turnover of registration personnel in a health care setting, it is difficult to ensure that all staff have an accurate understanding of the different types of forms that require signatures. This process can be automated to minimize the risk of error.

Amendments to patient records

How can an organization ensure that it responds to patient requests for record amendments in a timely manner compliant with HIPAA-specified time periods?

Under HIPAA, a health care provider is required to process a request and respond within a specific time period when patients want to update their records. While the provider does not have to comply with the amendment request, it must manage the process in a timely manner.

By using the automation toolset of a CPR, the provider can document all requests of this type online and have them routed to an online work queue for a supervisory-level resource to review. By entering the request online (with date and time received), the provider can produce automatic reporting to management personnel of all requests for which a timely response has not been received.

Accounting of disclosures

How can an organization use the CPR to automate the reporting of disclosures and comply with HIPAA's requirement to provide an accounting of information release?

Under HIPAA, providers are required to provide an accounting of disclosures for purposes other than TPO and other limited disclosures. Requests for information involving a patient's record must be recorded in a way that allows subsequent reporting in response to a patient's request for an accounting. By using the CPR's toolset, organizations can procedurally document all requests and disclosures online by type of disclosure. When this is done, a demand report can be produced to reflect such releases whenever a patient requests an accounting. An automated approach is much more accurate and efficient since it does not require pulling the record from the storage area upon receipt of requests for information or accountancy. Requests are handled via the nearest keyboard.

Restrictions to disclosures

How can an organization use the CPR to help manage restrictions on releasing information to specific individuals or entities?

Under HIPAA, providers are required to respond to requests from patients to restrict disclosure of information to specific individuals or entities. While providers do not have to comply with the restriction, if they say they will comply, then they are legally bound to do so. By using the CPR toolset to document these restrictions in a specific section of the online chart, registration and medical records clerks can easily create a record of requests for restrictions. These requests can be automatically sent via online work queue to a supervisory resource within the medical records department who can determine whether to agree to the restriction. That decision must be communicated back to the patient; communication can be accomplished via automatic report generated in response to the supervisor documenting the decision.

If a restriction is agreed to and subsequently removed by the patient, the same process of documentation and online work queue can be utilized by the organization to manage the operational aspects of this requirement. The organization retains an audit trail record of restrictions with dates of activation and suspension — a necessity when a restriction is lifted and the patient subsequently questions why information was released to the previously restricted recipient. Further, once the restriction is documented online, it can be referenced from any PC or access device without pulling a paper chart from storage. This procedure represents a more efficient operational process and promotes greater HIPAA compliance.

Privacy officer role\

How can a CPR be used to augment the role of a privacy officer?

Under HIPAA, the privacy officer is a cornerstone of compliance. In order for a privacy officer to be effective in a CPR environment, however, the CPR must be leveraged in ways that help identify actual or potential breaches of patient information. This can be achieved if the CPR provides for three basic capabilities:

Chart access audit. Auditing access to a patient's record should be fundamental to most CPR systems. A CPR system usually has the ability to run a demand report of all attempts to access a patient's record.

Staff assignments. CPR systems typically allow for staff to be assigned to or associated with the care of a specific patient. When a provider uses this function, it greatly improves the reporting accuracy on chart access audits. Assigning staff to a specific patient's care can generate the chart access audit reports for circumstances in which personnel not assigned to the patient's care accessed information.

Reprinting of records. How can an organization identify when a chart is reprinted in order to determine if the reprint was for an authorized purpose? Although most CPR systems allow for an audit reporting capability, this is only partially helpful in managing the release or re-disclosure process. If a CPR has the ability to print all or parts of the record, then an organization should selectively decide where that function can be used and by which personnel. Since most clinical personnel using a CPR will want to print chart sections on occasion, it is necessary to develop a means to audit who has printed from a patient's chart in order to determine if that printing was appropriate. This can be easily achieved by programming the CPR to log all printing functions by staff who are not assigned to the care of patients. The log can then be used to report and monitor the printing of charts.

Business associates

How can an organization use the CPR to manage the information release process to business associates?

Under HIPAA, providers are required to secure signed agreements with business associates that govern the use and disclosure practices of information they share with their business associates. Since there are usually many business associates added and deleted every day in a health care setting, it is difficult for the clerical staff to keep up with whether they are authorized to re-disclose information to a specific business associate.

By using the CPR toolset, organizations can help simplify this process. If the list of approved business associates is maintained in a user-defined database online, it can be linked to functions so that medical records personnel or other departmental areas can reprint records. Utilizing this process, a provider can display the approved list of recipient organizations each time it responds to a request for information.

Long-term benefits

Is it really better to use a CPR toolset and workflow redesign approach for improving means of compliance with HIPAA?

While many health care organizations have already begun the journey toward deploying a CPR, many organizations still have the paper record process in place. HIPAA is coming and it does not require a CPR. However, it does stimulate providers to migrate toward more electronic platforms in order to support electronic data interchange — the foundation of anticipated cost savings and one of the primary reasons for HIPAA.

If an organization has embarked on the CPR journey or plans to do so in the near future, it should strongly evaluate how that CPR can be leveraged to not only improve operational efficiencies, but also to demonstrate greater compliance with the newly finalized HIPAA regulations. Otherwise, the organization is likely to maintain two separate and duplicative operational processes and end up becoming less efficient operationally upon deployment of the CPR.

Mr. Walker is a partner and COO with Negly, Ott & Associates, Inc., Savannah, Ga. You can contact him at rod.walker@noac.com.

The following people contributed to this article:

Pelvia Woods, RN, clinical systems consultant at Negley, Ott & Associates.

Dinetia M. Newman, Esquire, partner at Phelps Dunbar LLP in Tupelo, Miss.

Kimberly L. Loden, Esquire, associate at Phelps Dunbar.

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