Jamie Walden

Guide to CMS Age Friendly Hospital Structural Measure

Medical Nurse Filling Document

Guide to CMS Age Friendly Hospital Structural Measure

The CMS Age Friendly Hospital Structural Measure is now mandatory, with significant financial penalties for noncompliance. Discover essential domains and how your hospital can prepare.

Table of Contents

As of January 1, 2025, hospital quality and compliance leaders face an urgent challenge to comply with the Centers for Medicare and Medicaid Services’ (CMS) Age-Friendly Hospital Structural Measure. This measure, now a mandatory component of the fiscal year 2025 Hospital Inpatient Prospective Payment System (IPPS) final rule under the Hospital Inpatient Quality Reporting (IQR) Program, requires hospitals to demonstrate patient-centered care specifically tailored for older patients with multiple chronic conditions.

While hospitals are not required to answer “yes” to each attestation item, they are required to report whether or not these practices are in place—and those responses will be publicly posted on CMS Care Compare beginning with the 2025 reporting year. A hospital that reports “no” may still receive full IQR credit, but it risks reputational damage, scrutiny from payers and accrediting bodies, and lost ground in competitive markets.

Hospitals that fail to comply with the reporting requirements risk significant financial penalties, including reductions in Medicare reimbursement, making immediate preparation and compliance critically important. Hospitals could lose up to 29.3% of their annual Medicare payment update (see examples below), underscoring the critical need for proactive compliance.

This measure specifically applies to Medicare-participating hospitals under the IQR Program. The Age Friendly Structural Measure is built on the work of several organizations, including the American College of Surgeons (ACS), the Institute for Healthcare Improvement (IHI) and the American College of Emergency Physicians (ACEP), and is intended to mandate that hospitals demonstrate patient-centered care for patients with multiple chronic conditions.

CMS Age Friendly Hospital Structural Measure

The Rationale Behind the New CMS Age Friendly Hospital Structural Measure

The attestation-based structural measure broadens the scope of hospitals’ quality reporting efforts by moving away from narrowly defined or siloed quality reporting metrics. It introduces a wider umbrella that integrates previously separate measures into a cohesive, age-friendly framework. This framework covers key pillars such as defined healthcare goals, medication management, frailty screening, social vulnerability, and top-down, age-friendly hospital leadership.

At a time when hospitals are increasingly treating older patients with complex medical, behavioral and psychosocial needs, CMS’ Age Friendly Hospital Structural Measure is built around three core components, according to ACS, IHI, and ACEP, the organizations behind its creation:

  • Following an essential set of evidence-based practices.
  • Causing no harm.
  • Aligning with the “4Ms” framework, which encompasses What Matters; Medication; Mentation; and Mobility.

“The elements of the ‘4 Ms’ help organize care for older adults’ wellness regardless of the number of chronic conditions, a person’s culture, or their racial, ethnic, or religious background,” CMS says.

Potential Penalties for Noncompliance with the Age Friendly Hospital Structural Measure

Hospitals that fail to comply with the Age Friendly Hospital Structural Measure face significant consequences under the CMS IQR Program. Hospitals stand to lose up to 29.3% of their Medicare payment update if they fail to meet the Age Friendly Hospital Structural Measure requirements. The American College of Surgeons, which helped develop the measure, created a post detailing the potential financial penalties below.

  • Hospital A (800-bed hospital)
    • Previous Year Medicare Revenue: $383,970,642
    • Full 2.9% Update: $395,105,791 (+$11,135,149)
    • Reduced 2.05% Update: $391,842,040 (+$7,871,398)
    • Loss of approximately $3,264,000 by not meeting IQR requirements
  • Hospital B (186-bed hospital)
    • Previous Year Medicare Revenue: $23,824,476
    • Full 2.9% Update: $24,515,386 (+$690,910)
    • Reduced 2.05% Update: $24,312,878 (+$488,402)
    • Loss of approximately $202,500 by not meeting IQR requirements
  • Hospital C (25-bed hospital)
    • Previous Year Medicare Revenue: $2,686,037
    • Full 2.9% Update: $2,763,932 (+$77,895)
    • Reduced 2.05% Update: $2,741,100 (+$55,064)
    • Loss of approximately $22,830 by not meeting IQR requirements

In addition to financial penalties, hospitals that fail to meet the measure will be publicly reported as noncompliant on the CMS Care Compare website. This transparency can influence patient choices, damage the hospital’s reputation, and impact its competitiveness in the healthcare market. Furthermore, noncompliance may raise concerns with accrediting bodies and third-party payers.

To avoid these consequences, hospitals must prioritize timely and accurate reporting of the Age Friendly Hospital Structural Measure using the Hospital Quality Reporting (HQR) system. Proactive engagement with leadership, staff training, and the implementation of evidence-based protocols are essential to ensuring compliance.

Detailed Breakdown of the Five Age Friendly Structural Measure Domains

Domain 1: Eliciting Patient Healthcare Goals

This domain focuses on obtaining a patient’s health-related goals and treatment preferences which will inform shared decision making and care aligned with patient goals.

Attestation Statement for CMS Age Friendly Hospital Measure Domain 1
A.Established protocols are in place to ensure patient goals related to healthcare (health goals, treatment goals, living wills, identification of healthcare proxies, advance care planning) are obtained/reviewed and documented in the medical record. These goals are updated before major procedures and upon significant changes in clinical status.

Domain 2: Responsible Medication Management

This domain aims to optimize medication management through monitoring of the medication record for drugs that may be considered inappropriate in older adults due to increased risk of harm.

Attestation Statement for CMS Age Friendly Hospital Measure Domain 2
A.Medications are reviewed for the purpose of identifying potentially inappropriate medications (PIMs) for older adults as defined by standard evidence-based guidelines, criteria, or protocols. Review should be undertaken upon admission, before major procedures, and/or upon significant changes in clinical status. Once identified, PIMS should be considered for discontinuation, and/ or dose adjustment as indicated.

Domain 3: Frailty Screening and Intervention

This domain aims to screen patients for common age-related issues like frailty, including cognitive impairment/delirium, physical function/mobility, and malnutrition for the purpose of early detection and intervention where appropriate.

Attestation Statement for CMS Age Friendly Hospital Measure Domain 3
A.Patients are screened for risks regarding mentation, mobility, and malnutrition using validated instruments (ideally upon admission, before major procedures, and/or upon significant changes in clinical status).
B.Positive screens result in management plans including but not limited to minimizing delirium risks, encouraging early mobility, and implementing nutrition plans where appropriate. The plans should be included in discharge instructions and communicated to post-discharge facilities.
C.Data are collected on the rate of falls, decubitus ulcers, and 30-day readmissions for patients >65. These data are stratified by demographic and/or social factors.
D.Protocols exist to reduce the risk of emergency department delirium by reducing length of emergency department stay with a goal of transferring a targeted percentage of older patients out of the emergency department within 8 hours of arrival and/or within 3 hours of the decision to admit.

Domain 4: Social Vulnerability

This domain seeks to ensure that hospitals recognize the importance of social vulnerability screening of older adults and have systems in place to ensure that social issues are identified and addressed as part of the care plan.

Attestation Statement for CMS Age Friendly Hospital Measure Domain 4
A.Older adults are screened for geriatric specific social vulnerability including social isolation, economic insecurity, limited access to healthcare, caregiver stress, and elder abuse to identify those who may benefit from care plan modification. The assessments are performed on admission and again prior to discharge.
B.Positive screens for social vulnerability (including those that identify patients at risk of mistreatment) are addressed through intervention strategies. These strategies include appropriate referrals and resources for patients upon discharge.

Domain 5: Age-Friendly Care Leadership

This domain seeks to ensure consistent quality of care for older adults through the identification of an age-friendly champion, typically a clinical leader or administrative figure, and/or interprofessional committee tasked with ensuring compliance with all components of this measure.

Attestation Statement for CMS Age Friendly Hospital Measure Domain 5
A.Our hospital designates a point person and/or interprofessional committee to specifically ensure age friendly care issues are prioritized, including those within this measure. This individual or committee oversees such things as quality related to older patients, identifies opportunities to provide education to staff, and updates hospital leadership on needs related to providing age friendly care.
B.Our hospital compiles quality data related to the Age-Friendly Hospital measure. These data are stratified by demographic and/or social factors and should be used to drive improvement cycles.

CMS Age Friendly Hospital Measure Reporting Requirements and Timeline

The CMS Age Friendly Hospital Measure offers a total of five possible points, with one point awarded for each of the domains successfully attested to. The hospital or health system determines whether it performed each of the elements that comprise the domain.

CMS does not allow partial points. For successful attestation, hospitals and health systems must affirmatively attest to each statement within a domain. For example, in Domain 3, if a hospital attests to statements A, C and D – but not statement B – then the hospital would not receive a point for the domain.

However, CMS has confirmed that hospitals will receive full IQR credit simply for submitting their attestation, regardless of whether the answers are “yes” or “no.” This makes the measure pay-for-reporting, not performance-based—at least for now.

However, attestation responses will be publicly reported on CMS Care Compare beginning with the 2025 reporting year. This means that even if hospitals receive IQR credit for reporting, their “no” responses will be visible to patients, payers, and accrediting bodies—creating reputational and strategic risk.

The first reporting year for the measure is calendar year 2025. The payment determination year for 2025 results is calendar year 2027. To report, hospitals must submit information for the Age Friendly Hospital Measure once per year using a CMS-approved web-based data collection tool specifically designated for the IQR program as part of the Hospital Quality Reporting (HQR) system.

CMS Age Friendly Hospital Measure Implications for Hospitals and Healthcare Leaders

The Age Friendly Measure assesses a hospital’s commitment to improving care for older patients with chronic conditions with a focus on patient goals, medication management, frailty, social vulnerability and leadership. Aligning goals and operations with the Age Friendly Measure requires:

  • Strength in Leadership: One of the five domains of the Age Friendly Hospital Measure specifically focuses on leadership. The domain calls for a “champion” and/or an “interprofessional committee” to bring focus and lead the way on the multiple attestation goals.
  • Knowledge of the Details: Hospital staff must have ready knowledge of the multiple domains that comprise the Age Friendly Hospital Measure. Full domain and attestation details are available in the Federal Register and within other resources, such as QualityNet.
  • Create a Path for Success: Leaders must identify which domains and attestations the hospital may already cover and conduct a gap analysis on the domains that it can successfully attest to.

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Dalana Pittman

Sepsis Protocol: How Hospitals Can Boost Outcomes and Track Core Elements

Tracking core elements of sepsis protocol

Sepsis Protocol: How Hospitals Can Boost Outcomes and Track Core Elements

Sepsis remains one of the costliest and deadliest challenges in healthcare, claiming hundreds of thousands of lives each year. In this article, you’ll discover how evidence-based protocols and leadership-backed strategies can help hospitals detect sepsis sooner, streamline patient care, and ultimately save lives. By examining recent survey data and the CDC’s newest guidelines, the piece offers actionable insights to strengthen your sepsis management efforts.

⏰ 7 min read

Table of Contents

An effective Sepsis Protocol is essential in reducing sepsis-related mortality and improving patient outcomes. It begins with critical leadership support and follows evidence-based practices designed to track key clinical data and enhance coordinated care within hospitals.

Hospital leaders across the U.S. are making inroads in the effectiveness of their sepsis management strategies, but health officials suggest that more can be done.

Whether it is the advocacy of executive leadership, education for healthcare personnel, or access to data that would bolster sepsis protocol efforts, hospitals can take steps to improve their functioning around this costly – and deadly – condition that impacts millions of people per year.

Assessing the Impact of Sepsis on Protocol Development

The consensus definition of sepsis is “life-threatening organ dysfunction caused by a dysregulated host response to infection,” according to a widely cited JAMA article. Most often, bacterial infections are the root cause of sepsis. However, the CDC notes that viral infections, such as COVID-19 and the flu, can also cause the condition, which can lead to rapid tissue damage, organ failure, and fatality.

The incidence and costs of sepsis are high. Approximately 1.7 million people are hospitalized due to sepsis annually, resulting in 350,000 deaths or a discharge to hospice care per year. For those who survive, a past sepsis episode places them at heightened risk of new disease onset, hospital readmission, job loss, and death. From a cost perspective, research shows that sepsis is linked to $40 billion in Medicare expenditures annually.

While public health initiatives, such as the Surviving Sepsis Campaign and its international guidelines for improving sepsis protocol, have come to the fore over the past two decades, significant gaps and barriers still exist. However, those gaps create an opportunity for hospital leaders to improve care and patient outcomes across the spectrum. The Surviving Sepsis Campaign, a joint initiative of the Society of Critical Care Medicine and the European Society of Intensive Care Medicine, offers multiple sepsis guidelines and tools that enhance facilities’ efforts to improve clinical care, identify sepsis early in its disease state, and generally augment sepsis protocol.

Sepsis & Septic Shock Checklists Thumbnail

Strengthen Your Sepsis Protocol With Free Sepsis & Septic Shock Checklists

Sepsis is a high-stakes emergency that requires swift, coordinated action to reduce mortality and complications. That’s why American Data Network has created free, easy-to-use Sepsis and Septic Shock Checklists—so your care teams can quickly recognize warning signs, implement essential treatment protocols, and save lives. Simply download, print, and laminate these checklists for immediate access in busy departments like the ER or ICU. Empower your clinicians with the key criteria for rapid diagnosis, timely interventions, and clear guidance to bolster patient safety at every step. Download the Sepsis & Septic Shock Checklists now to strengthen your sepsis protocol and improve outcomes.

Downloadable Resource: Sepsis & Septic Shock Checklists

Survey Results Show Progress and Opportunity for Sepsis Protocol Enhancement

According to recent research, many hospitals could use interventional guidance to improve sepsis protocol. A 2023 National Healthcare Safety Network (NHSN) survey found “modest initial progress in resourcing U.S. hospital sepsis programs” compared to the previous year. However, the survey also found that “many opportunities remain to further strengthen hospital sepsis programs to optimize patient care and outcomes.”

The NHSN survey included responses from more than 5,200 hospitals and it found that:

  • 78% of hospitals reported having a specific sepsis committee.
  • 59% of hospitals said they had “sufficient” time dedicated to sepsis leadership efforts.
  • 67% reported that they had enough resources via data analytics.

All of those areas saw improvements in 2023 compared to 2022. However, some key areas of optimal sepsis protocol remain under-resourced. For instance, only 22-23% of hospitals reported that they provided sepsis education during onboarding and yearly sepsis education for certified nursing assistants and patient care technicians. Also, under one-third of hospitals (32%) reported “standardized processes for verbal hand-off,” according to the survey.

Executive leadership remains a big challenge as well. Smaller facilities, in particular, struggle to provide the vital leadership commitment they need to bolster sepsis protocol. While 78% of larger facilities (more than 500 beds) “indicated that sepsis program leaders were provided sufficient specified time to manage the hospital sepsis program,” just 41% of the smallest facilities reported the same, according to the NHSN survey.

7 Core Elements of an Effective Sepsis Protocol

The NHSN survey helped inform the CDC about facilities’ general awareness and aptitude with best-practice sepsis protocol. In August 2023, the agency released the Hospital Sepsis Program Core Elements, a lengthy, multifaceted roadmap centered around seven core elements meant to “aid in the fast recognition of sepsis, facilitate the implementation of evidence-based management of sepsis and support the recovery of patients after sepsis,” according to the CDC. Those seven core elements, along with a brief description, are:

1. Hospital Leadership Commitment

Dedicating the necessary human, financial, and information technology resources.

2. Accountability

Appointing a leader or co-leaders responsible for program goals and outcomes.

3. Multi-professional Expertise

Engaging key partners throughout the hospital and healthcare system.

4. Action

Implementing structures and processes to improve the identification of management of, and recovery from sepsis.

5. Tracking

Measuring sepsis epidemiology, management, and outcomes to assess the impact of sepsis initiatives and progress toward program goals.

6. Reporting

Providing information on sepsis management and outcomes to relevant partners.

7. Education

Providing sepsis education to healthcare professionals, patients, and family/caregivers.

Leadership Buy-In: A Cornerstone of a Successful Sepsis Protocol

The CDC considers buy-in from hospital leadership one of the most important elements of a successful sepsis program. For hospitals just getting started in building an optimal sepsis protocol, the agency posits that they should first identify a sepsis program leader; ensure support from the leadership or executive team; perform a “needs analysis” to pinpoint existing protocols and treatment processes, as well as gaps in such protocols; and from there develop sepsis program goals, both short- and longer-term.

Other facilities may be farther along in their sepsis program journey, but as the NHSN survey shows, there remains room for improvement.

Five Essential Areas for Improving Sepsis Practices

The CDC cites research into five ever-important areas, primarily related to staff education, empowerment, and collaboration, that are “critical for improving the delivery of recommended sepsis practices.” In short, those five areas are:

  1. Staff knowledge. Hospital staff knowing what to do and why.
  2. Treatment focus. Hospital staff being aware of risks and benefits of treatment options.
  3. Collaborative spirit. Hospital staff working closely together in a collaborative effort across roles.
  4. Empowerment and support. Hospital stuff must have the backing of leadership team.
  5. Adequate staffing. Simply put, hospitals must have enough staff to run an effective program.

Leveraging the CDC’s Hospital Sepsis Program Core Elements

The seven “core elements” that comprise the CDC’s hospital sepsis program contain a plethora of details about each one, as well as “priority examples” that give hospital leaders an inside look at how to establish or bolster an effective sepsis protocol. For example, within the “Hospital Leadership Commitment” core element, the agency offers multiple priority examples of what that commitment looks like, e.g., “providing resources, including data analytics and information technology support, to operate the program effectively,” and “appointing a senior administrator (e.g., Chief Clinical Officer, Chief Medical Officer or Chief Nursing Officer) to serve as an executive sponsor for the sepsis program,” among many others.

Under the “Accountability” core element, the agency says that “we strongly recommend sepsis programs be co-led by a physician and a nurse.” Within the “Action” core element, the CDC urges hospitals to implement “a standardized process to screen for sepsis” and provides a link to hospital-based screening tools, as well as numerous sepsis management examples from organizations such as MD Anderson Cancer Center and Intermountain Healthcare.

With the strength of such guideline documents as the CDC’s core elements and others, hospital leaders can move sepsis protocol forward and deliver improved clinical care for some of the most at-risk patients.

/by
Jamie Walden

How AI in Medical Diagnostics Is Transforming Healthcare and Reducing Medical Errors

AI in Medical Diagnostics

How AI in Medical Diagnostics Is Transforming Healthcare and Reducing Medical Errors

AI in Medical Diagnostics is reshaping clinical workflows by enhancing early disease detection and reducing human error. This article delves into how machine learning, deep learning, and NLP bolster diagnostic accuracy, streamline operations, and support more informed decision-making. It also addresses regulatory considerations, data privacy, and the evolving role of clinicians in an increasingly AI-driven landscape.

⏰ 6 min read

Table of Contents

Artificial Intelligence (AI) is reshaping countless aspects of healthcare—from streamlined patient record management to personalized treatments. One of its most promising applications is AI in Medical Diagnostics, where the technology’s ability to analyze massive datasets can help reduce diagnostic errors, prevent unnecessary costs, and improve patient outcomes. This article explores how AI is transforming diagnostics, the tools it uses, and what the future may hold.

What Is AI in Medicine?

In the realm of Artificial Intelligence in Healthcare, the goal is to replicate and augment human intelligence using computer systems. AI can be broadly defined as algorithms and models that learn from data, identify patterns, and make predictions. Key subfields of AI driving advances in healthcare include:

  • Machine learning: Uses statistical models to learn from data without explicit programming, helpful in spotting complex or hidden trends.
  • Deep learning: Employs multi-layered neural networks to interpret large volumes of data—especially useful in medical imaging analysis and identifying subtle details in scans.
  • Natural language processing (NLP): Allows machines to understand and generate human language, aiding in everything from reviewing medical records to analyzing clinical notes.

According to Dr. Andrew Auerbach of UCSF, writing in JAMA Network Open (September 9, 2024), an impending surge of research will focus on diagnostic errors in medicine and how AI can identify and address them to drive diagnostic improvements.

Why Diagnostics Matter

In healthcare, diagnostic errors are common, often with costly or even catastrophic consequences when a diagnosis is missed, delayed, or wrong. According to a recent report from the US Government Accounting Office, diagnostic errors affect more than 12 million Americans each year, with associated costs likely in excess of $100 billion.

The stakes are high: accurate and timely diagnoses determine the patient’s treatment path, influence public health strategies, and shape healthcare expenditures. Despite advances in medical science, physicians can only process so much data. That’s where AI-based diagnostic tools come into play, offering faster, more accurate insights drawn from a breadth of patient data that far exceeds human capacity.

AI in Medical Diagnostics

How AI Enhances Diagnostic Accuracy

AI in Medical Diagnostics offers a unique advantage: the ability to scrutinize vast datasets for subtle markers and trends that human observers might miss. By processing vast amounts of data from imaging, electronic health records, and other sources, AI systems provide enhanced decision support. Here’s how:

  1. Early Detection of Abnormalities
    AI can flag tumor-related tissue changes on an MRI or CT scan before they’re recognizable to the human eye. Early intervention improves patient outcomes, leading to medical error reduction strategies that go beyond diagnosing a disease late in its course.
  2. Pattern Recognition
    Machine learning models can identify complex relationships among variables in patient data. For instance, they might detect an elevated stroke risk in patients presenting with dizziness or spot risk factors for sepsis in hospitalized patients—often earlier than manual methods.
  3. Reduction in False Positives
    Deep learning for medical imaging helps radiologists and pathologists verify findings, decreasing the likelihood of unnecessary biopsies or follow-up tests. This not only saves money but also reduces patient anxiety.
  4. Enhanced Clinical Decision Support
    Natural language processing in medicine can parse clinical notes, patient histories, and research papers to deliver relevant information directly to physicians, offering real-time guidance that augments human expertise.

Real-World Applications

AI-driven diagnostics have shown promise across numerous medical specialties:

  • Lung Cancer Screening: AI algorithms analyze CT scans, identifying early warning signs linked to a higher risk of developing cancer.
  • Pneumonia Detection: Systems distinguish COVID-related pneumonia from community-acquired pneumonia using chest radiography, often with higher accuracy than human radiologists.
  • Cardiovascular Diseases: Models interpret ECG data to uncover hidden patterns of heart disease, including early markers for hypertrophic cardiomyopathy.
  • Diabetes Management: Automated tools detect diabetic retinopathy with high sensitivity, supporting timely and cost-effective interventions.
  • Breast Cancer Diagnosis: Radiology AI applications read mammograms, reducing false positives from reducing false positives from 11% to 5% and helping oncologists detect early-stage cancers.
  • Neurological Conditions: From Parkinson’s disease to ALS and early Alzheimer’s detection, AI can sift through detailed brain imaging to spot subtle signs of degeneration before clinical symptoms fully develop.

In each of these examples, AI in Medical Diagnostics not only speeds up the process but can also improve patient safety by preventing medical errors and guiding clinicians toward the most effective treatments.

Learn more about essential strategies for preventing medication errors and enhancing patient safety in this detailed guide: Essential Strategies for Preventing Medication Errors.

Challenges and Future Outlook

Despite its promise, artificial intelligence in healthcare faces hurdles:

  • Regulatory Approval & Market Adoption
    Bringing AI diagnostic tools to market requires rigorous testing and clearing various approval stages. A small market or slow adoption can delay widespread deployment.
  • Clinician and Patient Trust
    AI is currently an assistive tool; the final diagnosis remains the responsibility of the physician. Trust in AI’s recommendations—and seamless integration into physicians’ workflows—will be crucial for broader acceptance.
  • Privacy & Security
    With more data moving online, cybersecurity and privacy concerns must be rigorously addressed to maintain patient confidence in AI tools.
  • Ethical and Bias Concerns
    If the data used to train AI systems is biased, diagnostic recommendations may also be skewed, disproportionately affecting certain demographic or genetic groups.

The Road Ahead

For at least the next few years, AI in Medical Diagnostics will continue functioning as a supportive “second opinion” rather than a complete replacement for physicians. Radiology, pathology, and dermatology are likely to see the earliest routine AI-driven methods. As data infrastructures evolve and computational power grows, the role of AI-based diagnostic tools will expand, reshaping how healthcare systems identify, prevent, and treat diseases worldwide.

AI in Medical Diagnostics: Final Insights

AI in Medical Diagnostics represents a leap forward in reducing diagnostic errors and improving patient outcomes. By harnessing machine learning, deep learning, and natural language processing, healthcare providers can analyze patient data at unprecedented scale and speed. Though challenges remain—ranging from regulatory approval to data privacy—the ongoing integration of AI-based tools offers hope for earlier detection of diseases, reduction of false positives, and better-tailored treatments. Ultimately, this synergy between human expertise and AI innovation will shape a healthier future, one accurate diagnosis at a time.

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Jamie Walden

HIPAA Right to Access: Compliance for Medical Records

HIPAA Right to Access

HIPAA Right to Access: Essential Compliance for Medical Records

Are you fully compliant with the HIPAA Right to Access regulations? Learn how to avoid hefty penalties, meet critical timelines, and empower your patients with seamless access to their medical records. This article provides actionable insights and real-world cases to help hospital leaders stay ahead of compliance challenges.

⏰ 6 min read

Table of Contents

Of all the headlines that HIPAA compliance garners, the attention-grabbers are often cybersecurity and data breaches. But a spate of recent civil monetary penalties that have hit hospitals and facilities, reaching into the hundreds of thousands of dollars, highlight a separate area of concern: the HIPAA Right to Access standards.

At its core, the HIPAA Right to Access provision requires that hospitals and provider groups grant timely access to the health information of individual patients and their personal representatives. The delivery of the patient’s health information also must be provided at a “reasonable cost,” according to the Office for Civil Rights (OCR). The HIPAA Right to Access standard is one of OCR’s newer enforcement initiatives aimed at delivering quality improvement in healthcare.

What is a HIPAA Right to Access?

The HIPAA Right to Access is a provision under the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule that ensures individuals can access their protected health information (PHI) held by covered entities like hospitals, clinics, and health plans.

Key components of the right to access HIPAA provision include:

  1. Timely Access: Records must be provided within 30 calendar days of the request.
  2. Reasonable Costs: Fees for copies must be limited to actual costs for labor, supplies, and postage.
  3. Format Options: Patients can request records in paper or electronic format, as long as the format is readily producible.
  4. Personal Representative Access: Authorized representatives can access or request records on a patient’s behalf.

This rule aims to empower patients to make informed decisions about their healthcare by ensuring transparency and accessibility.

Why the HIPAA Right to Access Matters

According to Office for Civil Rights (OCR) Director Melanie Fontes Rainer, the agency receives “thousands of complaints each year” pertaining to the HIPAA Right to Access rule. “Access to medical records empowers patients and their families to make decisions about their health care and improve their health overall,” Rainer said in a recent settlement announcement.

Recent penalties highlight the urgency for healthcare organizations to prioritize compliance. For instance:

The Optum Medical Care settlement marked the 46th enforcement action related to HIPAA Right to Access provisions since the OCR settled its first case in 2019, an $85,000 settlement with Bayfront Health St. Petersburg, which occurred after the agency launched its enforcement program earlier that year.

With HIPAA Right to Access provisions a key compliance focus for the OCR, hospital leaders must be fully aware of what the standard entails, how their organizations can stay in line with various regulations, and remain in compliance with the provision to achieve the OCR’s aims of attaining quality improvement in healthcare.

Key HIPAA Right to Access Provisions You Need to Know

Understand the “Designated Record Set.”

Under the Right to Access provision, patients possess general rights that hospitals and medical groups must comply with. The Privacy Rule requires that, upon request, covered entities (CE), such as health care providers and health plans, grant access to the patient’s protected health information (PHI) in the form of a “designated record set,” which has its own set of definitions. By law, as it relates to a provider CE, the designated record set consists of:

  • Medical records and billing records.
  • Other records that are used in the course of medical decision-making, such as clinical laboratory tests, medical images (e.g., X-rays), clinical case notes or disease management case files.

While CEs are required to be able to share the various elements that make up the designated record set, they are “not, however, required to create new information, such as explanatory materials or analyses, that does not already exist,” OCR explains.

Two broad categories are excluded from HIPAA Right to Access medical record sharing: psychotherapy notes and any information that is being used or is anticipated to be used in a civil, criminal or administrative action.

Know the Right to Access Timelines.

Many of the penalties that OCR has doled out under the HIPAA Right to Access provision in recent years have rested on the timeliness factor. OCR maintains a clear timeline: CEs must provide access to the requested PHI no later than 30 calendar days from the date of the request. Ideally, the request would be met sooner: “The 30 calendar days is an outer limit and covered entities are encouraged to respond as soon as possible,” the OCR states.

Focus on Form and Format.

CEs must defer to the form and format that the requestor identifies so long as that format is “readily producible.” If the patient (or representative) requests a paper copy of PHI, the CE is expected to provide the PHI in a paper copy format, even if the CE maintains the PHI electronically. If the patient (or representative) requests an electronic copy, OCR expects the CE to furnish an electronic copy, even if the CE maintains only paper records (again, if it is “readily producible”). If it is not readily producible, the CE may provide a hard copy format.

Fees Are OK, But They Are Limited.

CEs are permitted to charge the patient (or representative) a “reasonable, cost-based fee” but that fee is limited to specific tasks: the labor involved in copying the PHI; supplies used for creating an electronic copy; postage; and preparation of an explanation or summary, if requested. OCR permits CEs to charge a flat fee not to exceed $6.50 when sharing electronic PHI. Alternatively, CEs may charge for fees larger than that if the CE calculates costs or uses a schedule of allowable costs.

Sharing with Third Parties and Personal Representatives.

OCR allows an individual’s personal representative to request and receive PHI and also to request a transmission of the PHI to third parties. Generally speaking, the patient’s personal representation is “a person with authority under state law to make health care decisions for the individual,” according to the OCR. Under the HIPAA privacy rule, a parent is considered a child’s personal representative.

For CEs, they must comply with requests to send PHI to a third party. “The same requirements for providing the PHI to the individual, such as the timeliness requirements, fee limitations, prohibition on imposing unreasonable measures, and form and format requirements, apply when an individual directs that the PHI be sent to another person or entity,” OCR states.

Avoiding costly penalties by staying in line with HIPAA Right to Access standards is critical for hospital leaders and a key component of their mission in achieving quality in healthcare.

To learn more about the Right to Access standards, view a series of FAQs and recent clarifications to the provision.

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Stephanie Iorio

Preserving Data Integrity in Healthcare: Insights for Professionals

A physician accesses a medical record in a secure blockchain

Healthcare data integrity is crucial for accurate patient care and avoiding errors. Challenges include unauthorized access and outdated systems. Solutions involve data governance policies, EHRs, and blockchain technology. Standardization, training, and collaboration are key. American Data Network offers solutions for accurate clinical data abstraction, enhancing patient safety and data integrity.

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Jamie Walden

Closing the Skill Gap: 5 Tactics to Improve Your Healthcare Quality and Patient Safety Teams’ Competencies

The Healthcare Quality Competency Framework, developed by NAHQ, reveals significant skill gaps in critical areas of healthcare quality and safety. This article explores 5 actionable tactics to help your team close these gaps and ensure your facility meets its quality and safety goals. Discover how to assess competencies, foster continuous learning, and leverage strategic outsourcing to enhance your team’s capabilities.

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