Existing Wording: CDex Improve Care Coordination Use Case: For this use case, receiving clinical information as it becomes available is better because the information is more timely and can be acted upon sooner. In order for the record to be complete, the information needs to come from many/all providers, but typically from outpatient providers and usually from network providers. Payers may use HIEs as a source of information, if available. The information is available as information gathered in the patient medical record through use of an electronic medical record (EMR) system. The information may be shared with or accessed by the payer as a progress note or visit summary.

Proposed Wording: For this use case, receiving clinical information as it becomes available is better because the information is more timely and can be acted upon sooner. In order for the record to be complete, the information needs to come from many/all providers, but typically from outpatient providers and usually from network providers. Payers may use HIEs as a source of information, if available.

A provider may share or authorize access to information, such as a progress note or a visit summary, gathered in the patient medical record through use of an electronic medical record (EMR) system with a payer for HIPAA defined treatment purposes.

See https://www.hhs.gov/hipaa/for-professionals/privacy/guidance/disclosures-treatment-payment-health-care-operations/index.html.

Comment:

Payers must not have the option of accessing treatment information independently of the patient's provider's decision to share that treatment information. See OCR definition of Treatment: "Treatment" generally means the provision, coordination, or management of health care and related services among health care providers or by a health care provider with a third party, consultation between health care providers regarding a patient, or the referral of a patient from one health care provider to another. See https://www.hhs.gov/hipaa/for-professionals/privacy/guidance/disclosures-treatment-payment-health-care-operations/index.html.

Summary:

Payers must not have the option of accessing treatment information independently of the patient's provider's decision to share that treatment information.