Managing External Health Information

Gain an understanding of the best practices on how to request external health information.

As we move into a new era of health care with the increased exchange of medical records to provide better, more coordinated care, the question of what information received from outside an organization should be included in a medical record takes on new importance. What with health homes, personal health records, and health information exchanges, as well as increased involvement by patients using digital tools like smartwatches and smartphone apps, there is a torrent of information being directed at medical records, and it is essential to understand what belongs there and what should be rejected, and how. This information may come in the form of unsolicited health information, for example, information that is volunteered by patients or by other health care providers, either at the time the patient arrives for treatment or thereafter, and in some cases even after the patient has been discharged. It may also come in the form of information deliberately requested from outside parties, but the receiving provider may be unsure about whether to incorporate that information into its legal patient record. It is time to establish the necessary processes for filtering and managing incoming information to provide the appropriate patient care and protect the organization from claims of malpractice for not acting on information that may have been in a record but may not have been known to exist. Understanding what is in the medical record is essential for satisfying HIPAA patient rights for access of records and understanding how you receive and manage incoming information is required for protecting information under the HIPAA privacy and security rules. This topic will address these issues and offer practical guidance for those responsible for managing these health records.