Winter 2022

ROI Report: Know the ‘Rights’ for Accepting Patient Records
By Diane Donohue, RN, MHA, CCDS
For The Record
Vol. 34 No. 1 P. 6

As COVID continues to hinder in-person contact, more patients are struggling to obtain their medical records. The reasons vary. Often, it’s because there are staffing shortages, but access also has been limited due to medical record departments being closed to the public or patients lacking the capabilities to complete a request for the records. This means the task is falling on facilities to secure the release of information and the records that go with it.

The most important part of release of information, besides obtaining the authorization, is confirming that processes fall into best practices. When physicians do not have the information they need during an initial appointment to effectively create a treatment plan, the processes for obtaining medical records must come under scrutiny.

When health care professionals are learning the basics of patient care, emphasis is placed on patient “rights”: the right person, time and frequency, medication, route, and dose, as well as the right to refuse. When it comes to release of information, HIM professionals must keep the following rights in mind:

• the right patient information;
• the right patient authorization;
• the right provider/facility;
• the right record request;
• the right delivery method; and
• the right destination.

The Right Patient Information
When physicians receive outside referrals, their teams need to make every effort to obtain as much pertinent information as they can prior to the first appointment to ensure that the visit is productive. To obtain the correct records, facilities need to confirm they have the right information, including the correct spelling of the patient’s name, any aliases, the correct contact information, and any additional information that may be needed that would identify the correct patient in a same-name situation.

The Right Patient Authorization
Once all the correct patient demographics are gathered, it’s time to gain patient authorization. While every patient signs a HIPAA form, a signature must also be obtained to acknowledge that they are consenting to be part of a health information exchange or authorizing to use or disclose protected health information. Both forms should include instructions on how the patient can revoke their authorization.

There are situations where continuity of care covers the authorization of the patient’s release of information; this occurs most often in internal referrals.

The Right Provider/Facility
When making the request, verify that the right provider/facility is indicated. Doing so will reduce delays in obtaining records. Ensure it’s the correct physician and the correct correlating address for that physician.

The Right Records Request
What specific patient information is being requested? HIM professionals must determine what records are needed based on the patient’s diagnosis. Often facilities create checklists of the historical records they will need, in order to give optimal treatment to the patient who has been referred. Within these record requests, facilities need to identify the types of records: medical, images, and pathology. This variety of request types makes it vital organizations have the correct processes in place to receive the records being requested.

The Right Delivery Method
The right delivery method can be the difference between having the information available to the physician prior to the first appointment or not. When examining processes, look at each document type independently.

Medical records can be delivered via e-mail, fax, or electronically. Each has its own opportunities. With e-mail delivery, there is the chance the documents will wind up in the junk folder or a firewall will block it altogether. There is also the risk of sending it to the wrong e-mail address.

The next option is to send patient information via fax. This can be risky for several reasons. For example, the information could get mixed in with other patient information that is being sent. Someone could inadvertently pick it up with their faxes and the information ends up being mixed in with other documents. If there’s not a fax machine dedicated to patient documents, with someone keeping a watchful eye over it, it stands to reason that there are going to be instances in which records get misplaced.

Another consideration when dealing with fax machines is cost. Printing and scanning large records can take a sizable chunk of time and money away from the organization.

Lastly, there’s electronic health information exchange. Most companies use HL7 or HL7 FHIR to complete data exchange electronically. As long as the patient information is correct and integrations are in place for the exchange, this is the most efficient way to exchange records, since the records are dropped directly into the EMR’s outside record tab.

Facilities also must identify how they will receive images, which can be mailed on a disc or sent electronically to the designated department. If a facility chooses to have images sent via mail, ensure that a tracking number is assigned. For direct-to-facility picture archiving and communication system, or PACS, ensure integrations are in place for the exchange.

Pathology is the last type of record that needs to be addressed when it comes to retrieving records for a patient. These will always be exchanged via mail/courier. Be sure your process includes a tracking number and a mechanism to ensure that the pathology record goes to the right location within the facility.

The Right Destination
Once a facility determines how it is going to receive records, it must confirm the correct address, whether physical or electronic. If it is going to be via electronic exchange, ensure integrations are in place and working. If it is physical, what is the process for getting it into the medical record and to the physician? Is the HIM department being utilized in the most productive manner possible?

Facilities could be requesting hundreds of records daily with multiple locations for each request. Ensuring there’s a process in place that covers all the “rights” will help facilities meet best practices for release of information and record retrieval.

Are the records being obtained secure and do they meet HIPAA guidelines? Release of information includes not only the authorization to obtain the information but also the secure management of that information once it is in the organization’s possession. If at any point there appear to be glitches in the process, it’s time to conduct a step-by-step review to ensure that the current process is optimal.

Don’t get stuck in a rut. Facilities need to review their current processes for release of information and record retrieval and make the necessary upgrades to give patients the best care possible.

— Diane Donohue, RN, MHA, CCDS, is the clinical customer success manager at New York-based eHealth Technologies, a provider of medical record retrieval and organization services and image-enabled health information exchanges.