1. School of Health Sciences Unit 6 Legal Aspects of Health Information and Health Care Statistics HI 135 Instructor: Alisa Hayes, MSA, RHIA, CCRC

2. Introduction Instructor Alisa Hayes, MSA, RHIA, CCRC Contact Information AIM:AlisaCHayes Email: ahayes@kaplan.edu Office Hours By appointment School of Health Science

3. Chapter 11 Specialized Patient Records Certain types of health information require special handling: Substance abuse and mental health care Home care Genetic Information HIV information Therapeutic and emotional information Strict legal requirements School of Health Science

4. Chapter 11 Specialized Patient Records Drug and Alcohol Abuse Two federal laws Rules and regulations have been promulgated Apply to all treatment programs that receive federal assistance Includes entities whose sole purpose is substance abuse diagnosis and treatment General medical facilities with specialized unit and staff may also be included School of Health Science

5. Chapter 11 Specialized Patient Records Substance Abuse Confidentiality Regulations restrict disclosure of patient-specific information HIM should adopt uniform method of answering inquiries Patients must be given notice Programs may develop own notice or use sample Documentation in patient record is essential School of Health Science

6. Chapter 11 Specialized Patient Records ROI for Substance Abuse Records Federal regulations govern Three categories under these regulations: Disclosure with written patient authorization Disclosure without patient authorization but pursuant to the regulation Disclosure made subject to a valid court order School of Health Science

7. Chapter 11 Specialized Patient Records Disclosure without authorization (exceptions) Limited exceptions under regulations Medical emergencies Medical personnel providing emergency care FDA notice to patients of error/dangerous drugs Research activities Qualified researcher conducting approved work Security ensured and redisclosure prohibited Audit activities By qualified organizations only Limit use with disclosure back to program only Ensure security of information and destruction post-audit School of Health Science

8. Chapter 11 Specialized Patient Records Disclosure of Substance Abuse records for legal process Discovery requests Subpoena or subpoena duces tecum Court order authorizing disclosure Components of valid order Develop Litigation Response Plan School of Health Science

9. Chapter 11 Specialized Patient Records State Laws on Substance Abuse records Federal law directly regulates State laws play a role, too State may be equal, more restrictive, or less restrictive than federal law Stricter law will apply if conflict between federal and state law State law will apply if matter not addressed by federal law School of Health Science

10. Chapter 11 Specialized Patient Records Mental Health and Developmental Disability Care Settings for care Inpatient psychiatric facilities Residential treatment facilities Therapist offices Need to protect health information similar Two main differences Additional requirements for record content More stringent privacy protection School of Health Science

11. Chapter 11 Specialized Patient Records Psychiatric facility Medicare conditions of participation State mental health code requirements Joint Commission requires documentation Of patient’s legal status Involvement of family members in treatment Two separate records exist Official record as required by law Clinician’s psychotherapy notes School of Health Science

12. Chapter 11 Specialized Patient Records Home Health Care Records Subject to multiple requirements If agency receives Medicare funds, conditions of participation govern State law: statutes and regulations Accrediting standards and professional guidelines Do not have the force of law Establish standard of care in negligence case Joint Commission Community Health Accreditation Program HIM should be familiar with legal, regulatory, and accreditation expectations School of Health Science

13. Chapter 11 Specialized Patient Records Genetic Information Information obtained from a genetic test or DNA sample Looking into patient’s future health Human Genome Project Information used to assist patient Regulations to prevent potential misuse School of Health Science

14. Chapter 11 Specialized Patient Records Genetic Information Nondiscrimination Act (GINA) Federal law includes additional protections Strengthens HIPAA and state law Prohibits insurance company misuse of genetic information Cannot determine eligibility or use to set premiums Cannot require genetic testing Prohibits employer and labor union misuse Cannot use genetic information in hiring, firing, assignment decisions Cannot request or purchase genetic information School of Health Science

15. Chapter 11 Specialized Patient Records HIV Public health threat Retrovirus suppresses immune system Transmitted through sexual contact, exposure to blood, or blood components Disease may progress to AIDS and death Climate of fear and misunderstanding No vaccine and no cure Federal and state laws to address Testing requirements Confidentiality concerns School of Health Science

16. Chapter 11 Specialized Patient Records HIV Testing Tests to detect HIV antibody/antigen Enzyme-linked immunosorbent assay (ELISA) Detects presence of HIV in serum or plasma IF ELISA is positive, this must be confirmed Western Blot assay Radioimmunoprecipitation assay (RIPA) Indirect immunofluorescence assay (IFA) Confirmation of positive test is considered seropositive HIV School of Health Science

17. Chapter 11 Specialized Patient Records HIV : Issues Related to Voluntary Testing Consent for testing: Delivery of pretest information/counseling Disclosure of results – post test counseling HIV : Issues Related to Mandatory Testing Forced testing – no right to refuse Court-ordered testing Mandated by state laws (vary) HIV : Issues Related to Anonymous Testing Fear of testing and discrimination State laws to encourage testing System that assigns unique identifier Cannot be used for blood donation eligibility School of Health Science

18. Current Week 7/11/12-7/17/12 Unit 6: chapter 11 (pp. 226-249) Legal scenarios for release of PHI School of Health Science

19. Next Week 7/18/12-7/24/12 Read Koch chapters 1,2, 3 Respond to DB question(s) Participate in seminar or complete option 2 Complete self-tests and chapter tests (non- graded) Quiz ANY QUESTIONS??? School of Health Science