Physicians create electronic health records (EHRs) when patients come for treatment. These documents are easy to forget for most patients — not so much for healthcare providers and administrators.
Handling sensitive patient information is a critical part of your job. How do you ensure that your electronic health records are compliant and accessible?
We created this comprehensive guide to record management and retrieval. Use the following information to improve your health exchange processes for enhanced care coordination and budget savings.
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What Are Electronic Health Records?
Today, most medical records exist in a digital format. Healthcare practices usually organize them into EHRs or electronic medical record systems (EMRs). These two systems sound the same, but there’s one significant distinction.
Electronic medical records are available for use within the healthcare facility that created them. Their design discourages users from sharing them outside their native system, making it difficult to release them to other patients or professionals.
Electronic health records function the opposite way. Healthcare providers can release these records to other practices.
Which Records Are Better: Electronic or Paper?
Electronic alternatives to paper medical records reduce the risk of data loss during fires, floods, or other disasters. Still, they are not without their own vulnerabilities.
Mass medical record breaches are at an all-time high. Without powerful encryption and security protocols, patient data may be at risk of being compromised by cybercriminals.
A 2015 breach from Anthem Blue Cross affected a surprising 78.8 million people. Protecting these large medical data repositories without limiting access to authorized individuals is challenging for healthcare and government leaders.
While modern healthcare organizations prefer digital record management solutions, exploring trusted systems and educating your staff before making the switch is vital.
Data Silos and Information Blocking
Healthy data is transmissible. Data silos present unique challenges in the healthcare industry.
Essentially, data silos separate sensitive information from itself so hackers cannot steal a mass of information from a single breach. Data silos can establish secure barriers in this way but also create headaches for authorized individuals seeking information.
Let’s look at an example. Google Authenticator is the standard for protecting access to secure accounts. It generates temporary login codes on a specific linked device whenever the user logs in.
It’s harder for hackers to get into accounts backed by Google Authenticator, but they add an extra step to the login process for valid users. In a professional setting, security safeguards can be much more stringent than using Google Authenticator. It’s challenging to strike a good balance between accessibility and security, which has led to the creation of critical laws governing the release of protected health information.
Medical Record Regulations
Medical records contain private information, and cybercriminals always look for ways to access it. Early in developing electronic health records, the United States Department of Health and Human Services (HHS) began working to ensure that medical records are safe and accessible.
In 1996, HHS wrote the Health Insurance Portability and Accountability Act (HIPAA), the first major legislation to protect medical information.
HHS later developed several rules, including:
Additionally, legislators passed the Health Information Technology for Economic and Clinical Health (HITECH) Act as part of the American Recovery and Reinvestment Act (ARRA). The HITECH Act reinforced the Privacy and Security Rules. It also introduced the tiered penalty structure for HIPAA noncompliance.
The HITECH Act is responsible for the widespread use of electronic health record systems. It increased financial incentives for the meaningful use of certified electronic health record technology (CEHRT). Before HITECH, only about 10% of healthcare providers used electronic health records.
These standards outline how to handle protected health information (PHI). Failure to comply can result in major financial and criminal penalties, up to $1.5 million per violation per year.
The Privacy Rule
The HHS wrote the Privacy Rule in 2003 to enhance patient confidentiality and the right to access their PHI. The rule gives patients the right to request, examine, and correct their medical records when needed. It also allows them to prevent the disclosure of their PHI to certain parties, such as lawyers and health plans.
Legislators added another layer of protection by establishing the “Minimum Necessary” standard, which limits disclosed PHI to only specifically requested records and relevant information.
The Security Rule
The 2005 Security Rule created secure standards to help safeguard PHI. Amendments highlight:
- Physical system recommendations
- Technical safeguards
- Administrative responsibilities
Each element targets potential weaknesses within a healthcare practice. This rule is flexible based on the facility’s size, type, and capabilities.
The Breach Notification Rule
In 2009, the HHS added the Breach Notification Rule to encourage covered entities and their business associates to take responsibility after a data breach. It requires them to notify patients about compromised medical records or hacks.
The size of the breach determines what actions a covered entity must take.
What Are Covered Entities and Business Associates?
The HHS created unique terms encompassing a wide array of healthcare providers and collaborators. They refer to most professionals bound to these standards as covered entities or business associates.
A covered entity is the primary demographic HHS addresses with HIPAA. It includes any healthcare or administrative professional who handles protected health information. The three main categories are healthcare providers, health plans, and healthcare clearinghouses.
Covered entities can’t navigate the entire electronic health records exchange process alone. Several non-medical aspects of running a healthcare facility require professionals from different backgrounds. The HHS categorizes them to protect PHI while in the hands of such individuals.
Common examples include:
- Lawyers
- IT professionals
- Third-party administrators
- Independent medical transcriptionists
- And more
In order to work for covered entities, all business associates must sign a Business Associate Agreement (BAA). This unique contract explains legal expectations and binds the business associate to maintain HIPAA compliance.
Why Do Patients Request Records?
Patients request medical records to build their personal health records. Documentation helps patients coordinate treatment with their healthcare providers and reinforce lawsuits related to an injury.
The average medical records request can take requestors up to two hours. Factors like follow-up calls contribute to the lengthy process.
When a healthcare provider receives a medical records request, HIPAA allows 30 days to fulfill it. However, a patient with an integrated personal health record can pull and share files in minutes. Healthcare providers can improve the overall patient experience by simplifying their retrieval methods.
Why Do Legal Professionals Request Records?
Law firms and courts require medical records for malpractice claims, worker’s compensation settlements, and other legal cases. The process for requesting electronic health records is more complicated than for the average patient.
Attorneys must submit a signed authorization form from the client to access data. ChartRequest makes this simple by allowing legal professional users to send patients a digital form to authorize electronically. Patients can refuse to sign this form if they don’t want their medical records disclosed.
Courts could also issue a subpoena directly to the healthcare provider. A subpoena will include the specific records requested and the due date. While the healthcare provider or patient can object to subpoena requests, they must have a valid reason to withhold records.
Coordinating Care With Another Provider
Care coordination is one of the most cost-effective ways to improve patient outcomes and reduce medical errors. Communicating with another healthcare professional allows you to:
- Ask any questions that arise while looking at medical records.
- Explain your concerns before an appointment.
- Share updates and results to reduce unnecessary tests and treatments.
- Ask for advice or second opinions.
Care coordination requires strong referral management skills to achieve the best results. Creating a list of trusted specialists when patients need additional care is important. It’s worth contacting any healthcare providers on this list before sending patients referrals.
With ChartRequest, healthcare providers can more easily manage referral and care coordination. You can use the platform to refer patients to other healthcare providers, exchange protected health information, and chat without picking up a phone.
The ease of communication and information sharing we provide healthcare providers helps mitigate the administrative costs of coordinating care. By minimizing the inconvenience and time required to handle these exchanges, we grant them additional time to discuss important issues.
Training Staff To Handle the Release of Information
HHS developed HIPAA to encompass healthcare facilities of all shapes and sizes. The law is strict yet flexible. As such, creating a perfect one-size-fits-all guide to training staff for your specific practice isn’t easy.
All healthcare staff must have an annual HIPAA training session to remain compliant. The HHS assembled a list of HIPAA training resources to help administrators prepare their staff.
With recent work-from-home developments after the COVID-19 pandemic, healthcare staff can perform some tasks remotely. This strategy requires the individual to adhere to the physical and technical requirements in their own home office.
Medical Record Retention
HIPAA requires that you store medical records for a minimum of 6 years. Some records, such as any pertaining to cancer treatment, have longer retentions. In this example, the minimum is 30 or 8 years after death.
Furthermore, some healthcare providers set minimum standards surpassing state and HIPAA rules. Electronic health records don’t take nearly as much physical space as paper records – a modern hard drive can hold up to 20 terabytes of information.
HIPAA-compliant cloud services enhance the storability of electronic health records by allowing covered entities to back up and archive medical records. The need to make space for the storage of medical records is no longer as essential.
If you need to delete expired electronic health records, it’s essential to do so properly. The computer doesn’t remove data from the hard drive when somebody deletes a file. Instead, it marks the memory blocks as open spaces and eliminates the path to find them.
What Are the Benefits of Using Release of Information Software?
Healthcare providers prefer to use software to help manage the release of protected health information. For those seeking the top ROI solution on the market, look no further than ChartRequest.
Our customized workflow accomodates users based on type — so your patient, legal, and healthcare requestors will each enjoy a unique version of the ChartRequest platform.
The ease of exchange ChartRequest provides breaks down information barriers and reduces the input required by healthcare staff. You can also connect via the provider chat built-in to every request.
In addition to saving you time and money, ChartRequest streamlines HIPAA audits. Our double QA process, ” minimum necessary” approach, and automatic audit logging reduce medical errors and help ensure HIPAA compliance.
Partner with ChartRequest today for simple electronic health record solutions.
