Confidentiality in Medical Practice (HIPAA) in Health Information Technology (HIT)
Posted: Friday, February 13, 2009
by Rose-Marie Chaperon
Chaperon Consulting, LLC
In 1996, the United States Congress enacted the Health Insurance Portability and Accountability Act (HIPAA), there are five components to HIPAA. Title I of HIPAA protects health insurance coverage for workers and their families when they change or lose their jobs. Title II of HIPAA, known as the Administrative Simplification (AS) provisions, requires the establishment of national standards for electronic health care transactions and national identifiers for providers, health insurance plans, and employers. The Administration Simplification provisions also address the security and privacy of health data. The standards are meant to improve the efficiency and effectiveness of the nation's health care system by encouraging the widespread use of electronic data interchange in the United States health care system. Title III provides for certain deductions for medical insurance, and makes other changes to health insurance law. Title IV: Application and Enforcement of Group Health Plan Requirements Title IV specifies conditions for group health plans regarding coverage of persons with pre-existing conditions, and modifies continuation of coverage requirements. Title V: Revenue Offsets and lastly Title V includes provisions related to company-owned life insurance, treatment of individuals who lose U.S. Citizenship for income tax purposes and repeals the financial institution rule to interest allocation rules. In this paper, I will concentrate on HIPAA Title II as related to Health Information Technology ( HIT ), and how the broad use of health information technology will improve health care quality; prevent medical errors; reduce health care costs; increase administrative efficiencies; decrease paperwork; and expand access to affordable care.
Health care is a vital service that daily touches the lives of millions of Americans at significant and vulnerable times: birth, illness, and death. In recent decades, technology, pharmaceuticals, and know-how have substantially improved how care is delivered and the prospects for recovery. American markets for innovation in pharmaceuticals and medical devices are second to none. The miracles of modern medicine have become almost commonplace. At its best, American health care has been known to be the best in the world, personally I beg to differ. In my opinion with the improve health information technology such as Electronic Medical Record ( EMR ) the health care industry can improve its practice in protecting patients from medical errors.
An electronic medical record ( EMR ) is a medical record in digital format. In health informatics an EMR is considered by some to be one of several types of EHRs (electronic health records), but in general usage EMR and EHR are synonymous. They can also be described as an automated, on-line medical record containing clinical and demographic information about a patient that is available to providers, ancillary service departments, pharmacies, and others involved in patient treatment or care. There are many advantages to having an EMR system. EMR does not interfere with Doctor-Patient Relationship, computer word processor versus pen with paper. There is no difference in patient satisfaction. The computer does not degrade the clinical encounter. It does not perceived to make encounter impersonal finally yet importantly, it is not perceived to divert attention from patient and does reduce confidentiality. There are many companies out there, who offer EMR products, after much research, these companies are synonymous in cost in implementation requirements.
The process involved in conversion of these physical records to EMR is an expensive, time-consuming process, which must be done to exacting standards to ensure exact and accurate capture of the content. Because many of these records involve extensive handwritten content, some of which may have been generated by any number of healthcare professionals over the life span of the patient, there exists a high probability of some of the content being illegible following conversion. In addition, the material may exist in any number of formats, sizes, media types and qualities, which further complicates accurate conversion. Consideration should be given to developing a procedure to sample and verify images at a high ratio to determine the accuracy and usability of the scanned images prior to disposal of the physical records, if they are disposed of at all. As with any new system there are major concerns, is there adequate protection of privacy of the individuals whose records are being managed electronically. This class of information (in the US ) is referred to as Protected Healthcare Information ( PHI ) and its management is addressed under the Healthcare Insurance Portability and Accountability Act (HIPAA) as well as many State-specific privacy laws. The organization/individuals charged with the management of this information are required to ensure adequate protection is provided and that access to the information is only by authorized parties. Can Electronic Medical Record Systems transform health care? It will be proven that EMR can improve patient safety, Release of Information and overall healthcare operation. Electronic medical records are probably more secure than the paper record we used to have, in the 21st century, EMR is the way of the future. (Wong, 2007)
In order to reduce healthcare coast we must reduce fraud in the healthcare industry, Fraud is the intentional deception or misrepresentation that an individual knows to be false or does not believe to be true and makes, knowing that the deception could result in some unauthorized benefit to himself/herself or some other person. (Department of Human Services, 2006) The most frequent kind of fraud arises from a false statement or misrepresentation made, or caused to be made, that is material to entitlement or payment under the Medicare program. The violator may a physician or other practitioner, a hospital or other institutional provider, a clinical laboratory or other supplier, an employee of any provider, a billing service, beneficiary, Medicare carrier employee or any person in a position to file a claim for Medicare benefits. Under the broad definition of fraud are other violations, including: the offering or acceptance of kickbacks, and the routine waiver of co-payments.
Fraud schemes range from those perpetrated by individuals acting alone to broad-based activities by institutions or groups of individuals, sometimes employing sophisticated telemarketing and other promotional techniques to lure consumers into serving as the unwitting tools in the schemes. Seldom do perpetrators target only one insurer or either the public or private sector exclusively. Rather, most are found to be defrauding several private and public sector victims, such as Medicare, simultaneously. According to a 1993 survey by the Health Insurance Association of America of private insurers' health care fraud investigations, overall health care fraud activity broke down as follows: 43% Fraudulent diagnosis, 34% Billing for services not rendered, 21% Waiver of patient deductibles and co-payments, 2% Other, In Medicare, the most common forms of fraud includes: Billing for services not furnished, Misrepresenting the diagnosis to justify payment, soliciting, offering, or receiving a kickback. Unbundling or "exploding" charges, falsifying certificates of medical necessity, plans of treatment, and medical records to justify payment, billing for a service not furnished as billed; i.e., up-coding (Department of Human Services, 2006)
Information Technology plays an important role in reducing health care fraud. A national health information network and electronic health records can be used to fight healthcare fraud, which costs the government an estimated $51 billion to $170 billion annually, according to two reports released today. The reports, commissioned by the Office of the National Coordinator for Health Information Technology and HHS , looked at the role of automated coding software in preventing healthcare fraud and examined ways that a nationwide interoperable health information technology infrastructure could help prevent and detect fraud. (Broader, 2005) A task force that included providers, payers, IT vendors and government leaders created a set of guiding principles on technology's role in fighting fraud. Among the recommendations, the group called for: A Nationwide Health Information Network to "proactively prevent, detect and reduce healthcare fraud rather than be neutral to it (Broader, 2005) .
Health care fraud in the United States remains a serious problem that has an impact on all health care payers, and affects every person in this country. Health care fraud cheats taxpayers out of billions of dollars every year. Tax dollars alone do not show the full impact of health care fraud on the American people. Beneficiaries must pay the price for health care fraud in their copayments and contributions. Fraudulent billing practices may also disguise inadequate or improper treatment for patients, posing a threat to the health and safety of countless Americans, including many of the most vulnerable members of our society.
HIPAA required the Attorney General and the Secretary of HHS to establish a Health Care Fraud and Abuse Control Program (HCFAC), providing a coordinated national framework for federal, state, and local law enforcement agencies, the private sector, and the public to fight health care fraud. This focus coordinates the administrative approach, provides significant directed funding, and strengthens criminal laws and administrative powers related to health care fraud. The Program seeks to achieve the following objectives: To punish wrongdoing. To deter others from committing fraud and abuse to protect patients against abuse and neglect, to protect the integrity of the Medicare Trust Fund, and other Federal health care programs, to educate patients and providers about the need to prevent health care fraud and to foster compliance within the industry. (US Department of Justice, 1998)
HIT Increases administrative efficiencies, to date, the health information technology literature has shown many important quality- and efficiency-related benefits as well as limitations relating to general liability and empirical data on costs. Studies from 4 benchmark leaders demonstrate that implementing a multifunctional system can yield real benefits in terms of increased delivery of care based on guidelines (particularly in the domain of preventive health), enhanced monitoring and surveillance activities, reduction of medication errors, and decreased rates of utilization for potentially redundant or inappropriate care. However, for providers considering a commercially available system installed as a package, only a limited body of literature is available to inform decision making. The available evidence comes mainly from time-series or prepost studies, derives from a staff-model managed care organization or academic health centers, and concerns a limited number of process measures. These data, in general, support the findings of studies from the benchmark institutions on the effect of health information technology in reducing utilization and medication errors. (Basit Chaudhry, 1999)
Decrease paperwork is making Health Information Technology Personal. The advantages of health information technology over paper records are readily discernible. However, without better information, stakeholders interested in promoting or considering adoption may not be able to determine what benefits to expect from health information technology use. In addition, how best to implement the system in order to maximize the value derived from their investment or how to direct policy aimed at improving the quality and efficiency delivered by the health care sector as a whole.
Health information technologies can be tools that help individuals maintain their health through better management of their health information. Health IT will help consumers gather all of their health information in one place so they can thoroughly understand it and share it securely with their health care providers so they get the care that best fits their individual needs. Health IT can help to improve public health one individual at a time by building partnerships between health care consumers and providers across the country. (Basit Chaudhry, 1999)
To expand access to quality and affordable care some studies have concluded that as much as 30 percent of all medical treatment is unnecessary or duplicative. Several initiatives aimed at increasing quality and making care more affordable have gained traction over the last few years. There is a need for guide to highlight a number of quality incentives, pay-for-performance, electronic medical records and programs aimed at preventing fraud, waste and abuse. To encourage widespread adoption of evidence-based medicine and improve overall health and healthcare, an increasing number of pay-for-performance initiatives are being implemented. Increasingly in the private and public sectors, physicians are being rewarded for adhering to evidence-based standards of care to increase the quality of care and reduce unnecessary medical treatments. More physicians are also adopting and using electronic medical records. (Medical Cost Reference Guide, 2005)
If we imagined a system of care where no known safety lapses ever occurred, where there were no errors, where relevant clinical decision support was reliably and conveniently available, and where patient data were accessible seamlessly throughout the system, we could still identify major opportunities for improvement. Some examples might be: Providing care and information specifically tailored to the needs, preferences, and medical challenges of each individual. Applying prevention strategies for individuals and populations providing care in ways that are easier to access. Proactively reaching out to patients whose condition may not be responding to standard approaches Eliminating wasted effort and material from the health care system and collaborating fully with patients and families or caregivers.
In describing ideas about health IT functionality for improving the quality of patient care, we start with the needs of patients, both individual patients, and populations, or groups, of patients. A useful health IT system would provide comprehensive support to clinicians addressing an individual patient's current health status or health concerns, as well as their entire span of health care needs both today and over time. Similarly, health IT can help clinicians improve the care they provide to whole groups of patients by providing an expanded view of health management of more than one patient at a time. This concept and the methodology to support its activation are less familiar to many clinicians, because it is practically impossible to accomplish in a paper-based system. However, just having an electronic system does not insure that population management functionality will be available. Ideally, health IT will support the work of primary care providers related both to individual patients and to groups of patients, both at a single point in time and over the course of time.
Health Information Technology decreases the frequency of medical errors, reduces healthcare costs and improves patient care, all of which are important for the future of the healthcare industry. These benefits outweigh any potential risks to HIPAA. However, that's not to say privacy and security standards established by HIPAA are not placed at risk through the use of electronic health records. I believe that empowering consumers to make their own healthcare decisions with HIT will both ingratiate the technology to individuals and help maintain the privacy and security benchmarks set in place by HIPAA.
References:
Basit Chaudhry, M. D. (1999, 05 07). Systematic Review: Impact of Health Information Technology on Quality, Efficiency, and Costs of Medical Care . Retrieved 11 02, 2008, from Annals of Internal Medicine: http://www.annals.org/cgi/content/full/0000605-200605160-00125v1
Broader, C. (2005). Senior Editor. New Gloucester, ME: Healthcare IT News.
Department of Human Services. (2006, 02 04). Medicare Fraud Definition. Retrieved 11 04, 2008, from Information Governence Resources: http://library.findlaw.com/1998/Feb/19/131383.html
Medical Cost Reference Guide . (2005, 06 28). Retrieved 11 03, 2008, from BCBS: http://www.bcbs.com/blueresources/mcrg/chapter5/
Title II: HIPAA Administrative Simplification . (2005, 11 07). Retrieved 10 13, 2008, from Department of Health Care Services: http://www.dhcs.ca.gov/formsandpubs/laws/hipaa/Pages/1.10HIPAATitleInformation.aspx
US Department of Justice . (1998, 04 17). Retrieved 10 08, 2008, from USDOJ: http://www.usdoj.gov/dag/pubdoc/health98.htm
Wong, A. (2007). Health Technology Review. EMR comes with strings attached , 3.
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