Preventing HIPAA violations
The Health Insurance Portability and Accountability Act, commonly known as HIPAA, has been in effect for a decade. In the last law column, we looked at how the HIPAA privacy rule has been enforced; in this column we provide some tips for avoiding HIPAA violations.
First, it’s essential to understand what is being protected by HIPAA. The privacy rule applies to protected health information, or PHI, which the U.S. Department of Health and Human Services defines as “information, including demographic data, that relates to:
- the individual’s past, present or future physical or mental health or condition;
- the provision of health care to the individual; or
- the past, present or future payment for the provision of health care to the individual; and
- that identifies the individual or for which there is a reasonable basis to believe it can be used to identify the individual.”
This information can be in any form — electronic, paper or oral.
Criminal penalties, including up to 10 years of jail time, may result if PHI is knowingly obtained or disclosed, or when information is gained under false pretenses or with the intent to sell or use the information for personal gain. However, most enforcement actions are civil, and many are the result of accidental release of PHI. Civil penalties include monetary fines and corrective actions, such as changing a procedure, training or instituting safeguards on personal information.
One example of a civil action involved a doctor’s office mistakenly faxing a patient’s medical records to his work, rather than his new physician. The records contained PHI about the patient — specifically, that he was HIV-positive. After an investigation, the Office of Civil Rights concluded that while the slip was not intentional, the physician’s office needed to revise their faxing policies, strengthen the privacy language in their fax cover sheets and make all employees take HIPAA training to avoid similar mistakes in the future.
Five tips for staying compliant
1. Never access a patient’s records unless you are managing that patient and need to access the record for those purposes. Numerous HIPAA violations have taken place when healthcare practitioners accessed records of relatives, friends or in at least one case, an ex-husband, in order to get information. Even if you are the healthcare proxy for that person, it is not acceptable to access records in that way — and probably also violates your employer’s internal policies.
2. Use discretion when talking about a patient. HIPAA violations can arise when healthcare practitioners discuss a patient’s health status in public areas, such as a waiting room, in front of other people.
3. Ensure that protected health information is safeguarded. The OCR has held that even insurance cards, presented at a pharmacy, are considered PHI and must be treated as such. Obviously patient medical records, test results and diagnostic information are all PHI.
4. Do provide health information where it is authorized. HIPAA violations also can occur when a practitioner or other entity withholds PHI from those who are entitled to such information. For example, a doctor’s office violated HIPAA by refusing to provide a minor patient’s mother with his health records. In another case, a medical practice hired by an insurance company to conduct an independent medical exam on an injured individual refused to provide the medical records to that individual. OCR held that the individual had a right to the information regardless of who was paying for the exam.
5. Use care in labeling files. One practitioner’s office was fined for using large red stickers with the word “AIDS” on the outside of files of patients who were HIV positive. Since the stickers were visible to everyone in the waiting room, as well as the office staff, this was a violation.
The bottom line is this: PHI must be treated with great care in all its forms, whether paper records, faxes, computer records, pharmacy logbooks or oral discussions. Being aware of what information is protected will help you avoid HIPAA snafus.
Ann W. Latner, JD, a former criminal defense attorney, is a freelance medical writer in Port Washington, N.Y.
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Virtual health assistants: A prescription for retail pharmacies
The aging population, financial stress and the Patient Protection and Affordable Care Act has forced the entire medical delivery system into a game of musical chairs. The music has started, and each component of the healthcare delivery system is aggressively looking to have a chair.
All of the national and regional retail pharmacy chains have invested enormous capital in developing strategies to enhance their position in this increasingly fluid and uncertain environment. They have consolidated to leverage size, set up full-fledged primary care clinics to address some of the glaring gaps in the medical delivery system — for example, Walgreens’ Take Care Clinics recently announced it began offering chronic care services, while CVS Caremark’s MinuteClinic made a similar announcement about a year ago — and have invested in huge data analytics programs to increase efficiencies, improve buying power, drive therapy adherence and improve revenues. The stubborn irony is that despite these gargantuan efforts to ultimately better address the needs of the patient, we still face the long-standing probability that the patient will indeed be the component left without a chair.
Data from a recent study based on medical and pharmacy claims of 1.2 million members conducted by Prime Therapeutics and Blue Cross Blue Shield of Minnesota revealed that there were considerable savings for people adherent to statins. Unfortunately, it also reported that 54% of the patients that should be on a statin are nonadherent.
The report did not go into the reason for nonadherence, nor did it need to. Numerous studies have made it abundantly clear that there is no single reason for nonadherence, and that most of the reasons are behavior-based. There are hundreds of programs being offered by health plans, pharmacies, drug companies and employers that attempt to address the issue of nonadherence by encouraging and facilitating behavior change, particularly for patients with chronic diseases. The themes of these programs are common: improve long-term medication possession ratios and show a related improvement in hemoglobin A1c, blood pressure or reduced hospital admissions. But these programs share an inherent problem; the high cost of human resources needed to make the programs effective also means there are severe limitations to how many patients they can influence.
A retail pharmacy prescripition for this challenge is the virtual health assistant, or VHA. VHAs are predicted to burst onto the radar screens of the entire industry and completely transform a pharmacy’s ability to engage, empower and inspire patients to better health.
Much more than a simple app or website widget, VHAs have been proven to engage patients by encouraging a trusted relationship that, in turn, gives healthcare entities a stronger platform from which to influence behavior and adherence. Armed with the ability to sustain this engagement over the long term, VHAs can provide retail pharmacies with an extraordinarily clear window into the underlying reasons each individual patient is nonadherent and enable the use of sophisticated big-data-driven behavioral economics models to tailor interventions to the unique circumstances of each individual patient.
The fuel for this transformation will be the coalescence of raw computer processing power, smart device ubiquity, improved voice recognition technology, artificial intelligence, cloud computing and the emergence of sophisticated natural language processing, or NLP. Of these, NLP is the key component that enables the conversational interface required to engage the patient. Put simply, NLP can quite literally change the music to ensure that the patient has the best possible opportunity to have a chair before, during and after the music stops.
Without a relationship, there is no influence
Current technology-driven strategies to improve adherence include smart device apps, medication text reminder systems, smart medication bottles, auto-ship policies, low co-pay levels, interactive voice response outreach and other tactical efforts to assist patients. A VHA provides a more strategic option because of its ability to enable all of the above and do more. Dr. Timothy Bickmore has been studying these agents and calls them “relational agents” because he has determined that people actually develop a trusted relationship with avatars due to their ability to make an emotional, social and visual connection with patients. This unique human-like connection leads to what Bickmore has characterized as a “therapeutic alliance.” Thus, VHAs offer patients an “x factor” that no technology before it has ever been able to add to the equation.
This “x factor” affords VHAs with the opportunity to inspire patients to meaningful and sustained behavior change. When you consider the 24/7 proactive connection a smart device enables to VHAs, they can extend the relationship with patients of the friendly, trusted neighborhood pharmacist.
This should not surprise us. Most toddlers have their favorite inanimate object that they cling to for support. How many children cry when this same object is not around to help them fall asleep? In actuality, this attachment to non-human objects goes well beyond just toddlers. Later in life, pets and “things” become very important to us. In fact, a recent survey shows that 55% of people would give up caffeine and 70% would give up alcohol before giving up smartphones.
Once the therapeutic alliance is established, the VHA is positioned to change behavior. Of course, behavioral change is something that psychologists have studied for centuries. One contemporary, BJ Fogg has created a model that is one easy way to look at behavior change. The Fogg Behavior Model (FBM) is B=MAT where B=Behavior, M=Motivation, A=Ability and T=Trigger. Behavioral change involves these three basic elements.
Intelligent agents can help motivate and initiate triggers as well as encourage patients by engaging them in active dialogue at the most teachable moments.
In addition to providing technology with which to address the behavioral aspects of medication adherence, VHAs can effectively get retail pharmacies deep into the business of wellness, prevention and disease management. They can gather and track patient-generated health data, monitor and facilitate pharmacovigilance activities, increase health literacy and help patients manage unrealistic expectations.
Once implemented, the tasks and activities a VHA can facilitate become almost endless and include the ability to:
- Proactively and discreetly inquire about sexual dysfunction due to antihypertension drugs and provide possible remedies;
- Score patients using interferons on a depression scale and notify the appropriate healthcare provider when appropriate;
- Provide on-going measurements of disability progression for a patient with multiple sclerosis and suggest the patient discuss treatment adjustments with the pharmacist in real time;
- Provide a periodic pain measure for a rheumatoid arthritis patient so other treatment options can be explored;
- Monitor (e.g., using the GPS capability of a smartphone) physical capabilities and limitations of cardiac and respiratory disease patients;
- Remind and assist HIV patients with complicated medical regimens;
- Help cancer patients understand and tolerate the unavoidable side effects of their treatment and utilize motivational interviewing and virtual coaching techniques to help them “get through it”; and
- Act as coaches to motivate and improve exercise efforts; they can even ask what music a person wants to hear after reminding him or her to take a walk or jog — and find it online to purchase if it is not on the device.
This technology already exists and is being used by a number of large enterprises, including Aetna and the U.S. Army, to accomplish the seemingly mutually exclusive goals of improving customer service while lowering the cost of high value interaction with customers. And as surprising as it may sound, this technology can be integrated into current systems and databases with a relatively low impact on already stretched IT departments.
Those pharmacies that become early adopters of virtual health assistants can gain a significant head start in finding a chair for themselves and for patients when the music suddenly stops.
From the author: I don't disagree... but it is not happening now. My youngest brother died of an avoidable death due to non-adherance to therapy for coronary disease. No pharmacist had ever bothered to call him... I went to his daughter's graduation a few weeks later. I understand that you are probably a pharmacist. I get it. You think that pharmacists can connect with people. Yes they could if there were enough of them and they had the time. (I suggest you read: http://www.nejm.org/doi/full/10.1056/NEJMp1203869) My background was starting 5 HMO and being an NCQA surveyor, president of a health department, and for several years I ran the clinical operations for one of the largest disease management companies in the US. We could get people to goal for diabetes, HBP, CHF, asthma, but it cost a LOT. Average talk times was 30-40 minutes depending on the disease and age of the patient. Pharmacists are not capable of spending that amount of time and still fill prescriptions...nor would they want to. We had an enormous turn over of nurses due to the repetitive nature of the conversations. An agent could do it with ease. We have tried a lot of things to improve adherence over the 41 years since I started medical school... we have techniques that are proven to work. Motivational interviewing, Prochasta's model of behavioral change, etc. But, we do not have the people nor the funding to change the behavior of the nearly 120,000,000 people in the US with diabetes and pre-diabetes... and that is just one condition! Tell me you can scale the people driven solution with existing funding to these 120,000,000 people and I will hand you the reins. But remember, my brother never got a call...
When you consider that nonadherence to medication regimens costs, conservatively, $290 billion per year in avoidable health care costs, the expense of humans working with patients is not the problem. If VHA can manage health behavior change and machines can dispense drugs, why do we need pharmacists? Adherence is complex . Education alone is not enough (if it were, health care professionals wouldn't smoke or be overweight). Identifying factors that affect an individual's problem with medication adherence is only part of the problem. Responding to these in a way that allows the patient to feel understood and cared for is another major component. Patients also must be dealt with in a way that allows them to draw their own informed conclusions about their health without pushing a health care provider's agenda down their throats. VHAs can be a tool but will not replace the complex interactions and caring afforded by human interaction that is needed to affect adherence in a substantial way. Moreover, adherence to medication regimens is only one behavior to be assessed and influenced. Lifestyle changes are also critical. If pharmacists can demonstrate a significant reduction in the $290 billion with better outcomes, the cost of human interactions will not be problematic. If they cannot do this, VHAs and dispensing machines may replace them.
Sports physicals critical to promoting children’s health
As summer fun winds down, families make preparations for return to school. For the retail clinician, summertime is back-to-school season. Sports physicals or pre-participation physical evaluation (i.e., PPE) represent an important service in the retail health setting and an important opportunity to impact the child’s health. The required PPE is one of the most common reasons teens seek primary care and may be the only time otherwise healthy teens seek care. While the overarching goal of the PPE is to promote safe sports and physical activities, the PPE provides a real opportunity to evaluate health, promote such vaccines as HPV and meningitis, and provide preventive counseling.
The PPE should be ideally administered when the child is not ill and six to eight weeks prior to beginning the sport or practice season to allow for further evaluation or rehabilitation of any problems that could be discovered at the time of the exam. While the medical history is best taken from an adult parent or caregiver with long-standing knowledge of the child, adolescents should be seen apart from the parent for part of the exam to allow the clinician to inquire about risk-taking behaviors. Retail clinicians should set the stage for this early in the evaluation. In addition to a complete medical history, a standard head-to-toe exam with a brief musculoskeletal assessment is required. The most common conditions warranting further evaluation or referral to a personal care provider or a specialist will be identified during the cardiac and musculoskeletal exam.
Remembering that since the sports physical might be the only time this child or teen interacts with a healthcare provider during the year, the PPE is an excellent opportunity to provide preventive counseling and health guidance for both the patient and parent. With the understanding that time constraints limit the amount and content of counseling, pertinent topics should be individualized and based on the history obtained during the course of the PPE. Topics might include: safety (e.g., seatbelt use and safe driving, helmets and protective equipment); importance of proper rest and hydration, sun protection, steroid avoidance (i.e., tobacco, alcohol and drug use should be addressed at any teen health visit); breast/testicular self-exam; and abstinence or condom use encouraged to prevent pregnancy, HIV transmission and other sexually transmitted infections.
Retail clinicians may refer to the chapter on Sports Physicals in a new industry textbook “Convenient Care Clinics: The Essential Guide to Retail Clinics for Clinicians, Managers, and Educators.”
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