Form 1 record Retrieval Protocol

SSA ATTACHMENT 19 THE HEALTHY COMMUNITIES STUDY

MEDICAL RECORD RETRIEVAL PROTOCOL FOR

PHYSICIANS/MEDICAL SECRETARIES

This document provides an overview of the protocol for collecting children’s medical records from their primary care providers. Protocol materials include the medical office call guidelines/script. This script will be used to contact the child’s primary medical service provider in all 279 communities and in the Repeat In Person Assessment (RIPA) communities three years after the initial visit.

During the home visit, the EMSI field interviewer will request the parent/caregiver’s authorization to access the child’s medical record using the medical record release authorization form (located in SSA Attachment 7). Parents will provide the study with contact information for their child’s primary care provider(s). Medical records for each child participant will be abstracted to develop longitudinal BMI trajectories for the previous 10 years. Any indication of nutritional, physical activity, or sedentary activity counseling will also be abstracted from medical records. The presence of other chronic conditions and prescribed medications for those conditions (e.g. asthma, diabetes) will also be abstracted.

At the conclusion of each community assessment, EMSI will contact one medical provider per child to access his/her medical chart (for participants where consent to access medical records was given). Providers will be selected based on being the provider that the child has seen most often. EMSI staff will obtain the medical charts by contacting each medical office to submit the request for the medical record, and, where necessary, to arrange for reimbursement of any administrative fees the providers may charge for copying or providing these records. The estimated time required by the PCP’s office to review the request for the medical record comply with the chart request is 10 minutes, which covers reading the request, locating the medical chart, and providing the appropriate sections to EMSI.

We anticipate that EMSI will be able to obtain the medical records for 70% of the children due to parental refusal to consent to release the medical record or difficulty in locating the medical office or the child's medical record.

MEDICAL OFFICE CALL GUIDELINES/SCRIPT

Public reporting burden of this collection of information, including the call requesting the medical record and providing a copy of the medical record, is estimated at 10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to S. Sonia Arteaga, Ph.D., project officer at hcs@nhlbi.nih.gov

INTRODUCTION

• “Good (MORNING/AFTERNOON/EVENING), may I speak with the person who handles release of medical records?”

• ONLY IF M/R not available: “You might be able to help me….”

RECORDS AND SPECIAL ATTENTION

• “The parent/legal guardian of one of your patient’s has authorized the release of their child’s medical records as part of their participation in the Healthy Communities Study, which is sponsored by the National Institutes of Health. The parent/legal guardian has indicated that we should be able to locate records at your office going back to xxxx year. Do you have a chart for (PATIENT NAME)?”

• If NO records found:

• “Could you search by the patient’s (social security number/DOB)?”

• “Does Dr. (_______) practice in your office?”

• “Does the Dr. practice anywhere else?” IF YES, “Could you tell me the phone number of his other practice?”

• Check special attention to see if there is any other information listed that may be helpful in locating records.

• “Could records be in storage?”

• “Do you have (DR. NAME) on staff?”

• IF THERE IS A SPECIAL ATTENTION: “Can you check the chart to see if it includes __(S/A)__?”

SENDING REQUEST

• If Request WAS Auto Faxed: “We faxed over a request for medical records on (PATIENT NAME). Have you received the faxed request?”

• If request was NOT received, verify fax number and refax.

• If Request WAS NOT Auto Faxed: “I need to fax a request to you for copies of records. May I verify your fax number?”

• If faxes not allowed: “Who should I attention this request to?”

• “While I have you on the phone, can you please verify your address for me?”

IF FACILITY ADVISES THAT THEY REQUIRE THEIR OWN AUTHORIZATION

• “The authorization we have available to send to you has already been signed by your patient’s parent/legal guardian, has your facility name, your patients name and the DOB. Your patient’s parent/legal guardian signed this authorization when they participated in our study and they are aware records are being sent to us.”

• IF carrier’s auth is NOT HIPAA compliant: Skip to acceptance statement.

• IF the carrier’s authorization is HIPAA compliant: “The authorization also contains all the core elements that are required to be HIPAA compliant.”

• Acceptance Statement: Will you be able to accept this authorization since your patient did sign this one?”

COPY SERVICE AND PROCESS TIME

• “Do you use a copy service?”

• If yes:

  • “What copy service do you use?”

  • “When does the copy service copy records?”

  • “When will my chart be ready for copy?”

• If no:

  • “When will you be able to fax the records for your patient back to our toll free fax number?”

  • If records can’t be faxed: “When will you be mailing records?”

FEES

• Negotiate Payment amount

• Telepro: “These records are needed to complete the data collection on your patient for this study . Will $10 cover your copying costs?”

• IF FACILITY ADVISES OF DIFFERENT AMOUNT:

  • “We only need records from (DATES OF SERVICE NEEDED). Can you tell me how many pages are in the chart for this time period?”

  • If OVER the Fee Limit: I’m only authorized to pay up to $10.Will you be able to accept this amount?”

• If yes: Continue to “Payment Method”.

• If no: “I will have to obtain approval before submitting. If this payment is approved, who should the check be made payable to?”

• IF FACILITY ADVISES THEY WILL NEED TO SEND A BILL: “Please call me as soon as you’re able to do a page count and determine the fee since I do have a limit as to how much I can pay.”

• Payment Method

• “Can I pay by credit card?”

• If yes:

• Prepayment is needed: “Let me give you our credit card number.”

• Fee is Undetermined: “Please call me as soon as the fee is determined so that I can give you our credit card information”

• If NO:

• “Who should the check be made payable to?”

CLOSING REMARKS

“Thank you for your help today (clerk’s name). Have a nice day!”

GUIDELINES AND SCRIPT FOR MESSAGES

“This message is for the person that handles release of medical records. This is (YOUR NAME) with (the Healthy Communities Study). I’m calling regarding a request for medical records for your patient (PATIENT NAME). Please return my call at (800#) between the hours of 8:00am to 5:00pm CST. When calling please refer to case # (CASE#) “

********Make sure you do not leave the social security number, date of birth, amount of policy or specific record information even if recording requests the information be left********

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