1. Informed health plan enrollee, consumer, and patient consent to the release of medical records has primacy in the provision of health services and is of fundamental importance to all parties involved in the provision and management of health services.

2. Clinical information, which is appropriately shared, should not affect, influence, or harm a person's non-treatment aspects of life. The misuses of clinical data combined with stigma against mental illness and addictive disorders have occurred and have led to adverse occurrences in the lives of individuals who have sought treatment and have prevented individuals who would have benefited from treatment from accessing care.

3. Continuity of care also is of fundamental importance for quality integrated healthcare. It is clinically appropriate to share clinical information within a health plan's administration to promote the health and well being of the individual patient. These clinically appropriate situations involve persons with multiple episodes of care, multiple treating providers, and multiple medication prescriptions. It is clinical best practice, in the promotion of holistic, integrated, and coordinated care, to share clinical information within a health plan's administration. It is important to share clinical information to avoid mediation contraindications. The appropriate sharing of clinical information for the purpose of continuity of care should be clearly defined at the time that the individual enrolls in a health plan and at each time that clinical information is being shared with providers outside of the health plan's administration.

4. There should be strong penalties imposed and enforced on those who illegally disclose personal health information.

5. Clinical accountability from a medical record is another fundamentally important concept. To protect privacy and to promote accountability for care delivered, two levels of accountability are proposed ö one level involves the treating provideröpatient relationship, a second level involves the provideröhealth plan relationship.

   Two levels of clinical accountability are proposed: the accountability of a health plan to provide each member with information regarding the limits and consequences on access to medical information that are a consequence of healthcare administration. The accountability of the individual provider to provide each patient with information regarding the limits and consequences of access to medical records that are a consequence of the provision of treatment.

   At the time of health plan enrollment and periodically (e.g., every 12 months) health plan enrollees, consumers, and patients should be informed about their rights to informed consent, any exceptions or conditions placed upon this concept, and any possible consequences of not consenting. Health plans, their management agents, their providers, and plan enrollees shall have clear contractual responsibilities in these areas.

   Possible consequences of an enrollee, consumer, and patient not consenting to the release of information may be a health plan's refusal to pay a provider's bill, a provider declining to treat an individual, and excluding the provider and health plan from complete legal liability for decisions reached.
   
   The treating provider should be responsible for informing the patient of these obligations. A patient should be informed prior to receiving services of the type of medical information that needs to be provided to the health plan for payment and that the patient should sign a consent form allowing the release of such information prior to any services being rendered.

   Within the health plan's administration, the treating provider is accountable to the health plan for delivering clinically appropriate and effective treatment. As a network participant the provider agrees to share clinical information as specified in contractual relationships. It is important that the medical record contain an assessment, diagnosis, and treatment plan.

6. The components of the medical record should be differentiated, by what information is needed by the provider in treating the patient vs. the information needed to authorize medically necessary care. An example of this is the possible use of psychotherapy notes.

   For example, a history of child sexual abuse may have significantly impacted the patient's functioning and behavior. The sharing of this information may be important for purposes of clinical continuity and coordination of care and clinical accountability. The sharing of details ö who, when, where, etc. ö is not important to good clinical administration. Disclosure of information should be limited to the minimum amount of information necessary to accomplish the purpose for which the information is used. The clinician should provide information necessary to qualify for payment, to explain the severity of illness, and to document clinical progress. The sharing of actual detailed clinical notes is usually not necessary to this process.

7. Medical records should be protected, regardless of the medium. The patient may not veto a clinician's or plan's use of computer technology as a medium for storing or transmitting medical records. If a disclosure history is to be maintained, this can most effectively be done through a computerized system which provides time, date, and user information which is unalterable. AMBHA emphasizes that strong penalties for illegal disclosure should exist. Data security is a fundamental responsibility of health plans, their management agents, and their providers. Medical data should be restricted to those involved in the clinical delivery and management of care. Data security, not whether the record is on paper or is on a computer, is what is important.

AMBHA 1998 Members:
American Psych Systems, Bethesda, MD; CNR Health, Inc., Milwaukee, WI; CORPHEALTH, Fort Worth, TX; FPM Behavioral Health, Winter Park, FL; Green Spring Health Services, Columbia, MD; Human Affairs International, Salt Lake City, UT; Managed Care Washington, Seattle, WA; Merit Behavioral Care, Park Ridge, NJ; Options Healthcare, Inc., Norfolk, VA; PacifiCare Behavioral Health, Laguna Hills, CA; PLAN 21^*, Houston, TX; Value Behavioral Health, Falls Church, VA.

Further Information:
E. Clarke Ross, D.P.A.
Executive Director, AMBHA
February 1998