Health Care Informatics

LESSON 8 Legal Issues with Health Information LECTURE NOTES ______________________________________________________________________________________

At some point in time, there will be a demand for access to a patient’s health record by

organizations or individuals who are not authorized to review the record. This may occur during

the review of a negative patient outcome by an attorney while considering some type of

litigation. It might also be requested by a patient’s family for use in reviewing the course of

treatment of the patient, or it might be requested from another provider in order to conduct a

“second opinion” for a recommended treatment. Providers must exercise great caution when

reviewing such a request since laws, rules, regulations, and protocols do vary by location and for

the circumstance that might be presented.

As noted in prior lessons, the health information record, regardless of whether this is a paper-

based system or an electronic system, is considered to be a legal document of the services

provided to the patient and the outcomes achieved. Any destruction, including deleting portions

of the record, rewriting the record after an event, or other such actions that change the original

information, should not be done and is considered to be an illegal act by the individual

conducting the action.

In some instances, the health information professional can be required to provide a copy of the

“legal record” of a specific patient. In order to comply with such a request, there are specific

rules, laws, and standards that need to be considered prior to the release of this private

information. If the patient is capable, the patient can sign a written request for a copy of the

record or can give permission to release the record to a third party.

If the patient is deceased or not capable of providing an adequate release of the record, other

requirements must be followed in order to comply with both the request and the privacy

requirements. The organization and health information professional must have procedures for

handling such requests and must have the request reviewed and approved by legal counsel before

the information is released.

On an occasional basis, the health informational professional is subpoenaed to bring a health

record to court and testify as to the nature of the record, including its completeness, the details

included in the record, and other factors that might influence or impact a question of law. Any

request for a record or a demand for an appearance in legal proceedings should be carefully

reviewed by legal counsel to assure that only the information requested is provided and released.

Further, the health information professional should be prepared for any oral testimony to be

provided, again by qualified legal counsel.

If an unauthorized breach of access to a patient’s health record does occur, besides potential

regulatory action, the patient may have a personal cause for action or litigation to this

occurrence. This may be in the form of a civil action and could result in a judgment imposed on

the individual or organization that caused the breach.

If information is gathered by the health information professional or a health care organization for

quality improvement purposes, this use of health information can be protected from use in legal

proceedings if properly protected according to the requirements of the laws in the legal

jurisdiction. A review by legal counsel is necessary in order to protect the quality improvement

information from legal discovery.