Rasmussen Hospital Health Information Management Poli 536836

Rasmussen Hospital Health Information Management POLICY AND

Rasmussen Hospital Health Information Management POLICY AND

Identify and correct the errors in the following areas: 1. Policy paragraph 2. Procedure sections A, B, and J. Explain POLICY: Workforce members can use or disclose protected health information (PHI) without the consent or authorization of patients for purposes other than treatment, billing or health care operations. Access, use, and disclosure of PHI will not be limited to the minimum necessary to perform their roles, regardless the extent of access provided.

PROCEDURE:

Paper For Above instruction

The Rasmussen Hospital’s Health Information Management policy and procedures aim to clearly delineate the guidelines for access, use, and disclosure of patient information in compliance with federal and state regulations, primarily HIPAA. In analyzing the provided policy and procedures, the goal is to identify and address inaccuracies to enhance clarity, enforce legal compliance, and ensure proper handling of protected health information.

Analysis of the Policy Paragraph

The original policy states: “Workforce members can use or disclose protected health information (PHI) without the consent or authorization of patients for purposes other than treatment, billing or health care operations. Access, use, and disclosure of PHI will not be limited to the minimum necessary to perform their roles, regardless of the extent of access provided.”

This policy has several critical issues. Firstly, it incorrectly implies that workforce members can use or disclose PHI without restrictions for purposes other than treatment, billing, or healthcare operations. Under HIPAA, such disclosures outside these purposes require patient authorization unless an exception applies, such as public health activities or court orders. Secondly, the policy states that access, use, and disclosure will not be limited to the "minimum necessary," contradicting HIPAA's core principle of minimum necessary access, which mandates that workforce members access only the information necessary for their specific roles. This inconsistency potentially leads to over-disclosure and non-compliance with privacy regulations. Therefore, the corrected policy should clarify that authorized access is limited to the minimum necessary to perform job functions, and any disclosures outside the permissible purposes require explicit patient authorization or are subject to exception under law.

Analysis of Procedure Sections A, B, and J

Section A

Original text: “Confidential patient records will be released only upon receipt of consent from the patient, legal guardian, or authorized representative. 1. If the patient is a minor, the parent should sign the consent form. There should not be any exception to this rule. 2. Any authorization signed by a deceased patient's family member shall be honored. 3. If the patient is unable to sign the authorization by reason of physical or mental incapacity, the authorization should be signed by an authorized representative or legally appointed guardian.”

This section contains a notable error. It states that confidential records will only be released upon receipt of consent, implying that all disclosures require patient or authorized representative consent. However, HIPAA allows for certain disclosures without patient consent, such as for treatment, payment, or healthcare operations. Additionally, the assertion that "there should not be any exception" in the case of minors is misleading. In practice, minors' records can be released without parent consent in specific circumstances, such as for certain reproductive health or mental health services, depending on state law. Regarding deceased patients, only authorized individuals or legal representatives can sign authorization for release, but the policy incorrectly states "signed by family member" without specifying the legal basis. Furthermore, the policy must specify the circumstances under which informed consent is required, when exceptions apply, and clarify that disclosures without consent are governed by HIPAA and state laws.

Section B

Original text: “Authorizations to release information should be completed in entirety. They must include the following information: 1. First and last name of the patient. 2. Name of person, agency, or organization that will be releasing information. 3. Name of person, agency, or organization to which the information is to be released. 4. Specific information to be released. 5. Purpose of disclosure 6. Signature and date of patient, parent/guardian or authorized representative. 7. Notice that the authorization is valid for a specified period of time.”

This section appears accurate but could benefit from clarification that the authorization process must comply with HIPAA requirements, which include ensuring that the authorization is voluntary, identifiable, and specific regarding the scope, purpose, and duration. It also should specify that incomplete or ambiguous authorizations may be rejected or require clarification and that additional notices may be necessary if the information involves sensitive categories (e.g., substance abuse or mental health).

Section J

Original text: “Request from insurance or quality improvement organization. Information may not be sent to an organization for treatment, payment or health care operations. Employees must not comply with requests for information from Public Health reporting entities, oversight organizations, or family members.”

This section contains significant errors. It states that information may not be sent to organizations for treatment, payment, or health care operations, which contradicts HIPAA, where disclosures for payment, treatment, and healthcare operations are explicitly permitted without patient authorization. The statement that employees must not comply with requests from public health entities or oversight organizations is also incorrect; disclosures to such entities are often required by law. The proper approach is that disclosures to payers, healthcare organizations, and public health agencies are permissible provided they align with legal requirements and are supported by valid authorizations or applicable law.

Conclusion and Recommendations

The core issues lie in the misinterpretation of HIPAA regulations, misstatement of consent scope, and restrictions on disclosures that are not aligned with federal law. To correct and improve the policy, it is essential to explicitly state that access and disclosures are limited to lawful purposes, and that any disclosures outside these purposes require patient authorization unless an exception applies. The procedures should incorporate clear guidelines for handling consents, requests, and disclosures, emphasizing compliance with HIPAA's minimum necessary standard and legal exceptions. Additionally, staff training on legal requirements for disclosures and proper documentation practices should be reinforced to ensure compliance and protect patient privacy.

References

  • HIPAA Privacy Rule, 45 CFR Parts 160 and 164. (2021). U.S. Department of Health & Human Services.
  • Buchanan, R. (2019). Privacy and Confidentiality in Health Care. Journal of Medical Ethics, 45(7), 434-437.
  • Gellman, R., & Turner, J. (2020). Health Data Privacy and Security. American Journal of Health-System Pharmacy, 77(14), 1172-1178.
  • HHS.gov. (2024). Summary of the HIPAA Privacy Rule. U.S. Department of Health & Human Services. https://www.hhs.gov/hipaa/for-professionals/privacy/laws-regulations/index.html
  • Snyder, J., & McGinnis, S. (2021). Legal Aspects of Medical Records. Oxford University Press.
  • Office for Civil Rights (OCR). (2023). HIPAA Administrative Simplification Regulations. U.S. Department of Health & Human Services. https://www.hhs.gov/hipaa/for-professionals/administrative-simplification/index.html
  • Centers for Medicare & Medicaid Services (CMS). (2022). Health Information Privacy and Security. CMS.gov.
  • California Department of Public Health. (2020). Regulations on Confidentiality of Medical Records. California Code of Regulations, Title 17.
  • National Committee on Vital and Health Statistics. (2021). Report on Privacy and Confidentiality. OSTP.
  • Stein, M. (2018). Ethical and Legal Issues in Health Care. Routledge.

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