Question about providing an electronic copy of a medical record

Question about providing an electronic copy of a medical record

Recently a question was asked about providing a patient medical record in electronic format:

If you store patient information in your systems electronically, should a copy of the medical record be provided to the patient in electronic format and if so what constitutes electronic format (i.e. CD ROM, thumb drive, email PDF)?

Healthcare Compliance Pros Response

Under the HIPAA Privacy Rule, covered entities are required to provide access to PHI in the form or format requested by the individual, if it is readily producible in such form or format. If the PHI is not readily producible in the form or format requested, access must be provided in a readable hard copy form, or in the alternative, some other form or format as agreed to by the covered entity and the individual. (45 C.F.R. 164.524(c)(2).)

If the individual requests access to their PHI be provided in an electronic form or format, covered entities may choose to do so in electronic form. This may benefit the requesting individual and covered entity. Some examples include:

  • Electronic copies may be downloaded to USB thumb-drives or copied compact disks.
  • Individuals may be offered an immediate ongoing view of their designated record set through the use of a personal health record or patient portal.

Under the Privacy Rule, the right of access also affords covered entities the option of making alternative agreements with individuals as to the form or format of access provided.

Further, to the extent that individuals request access to their PHI in hard-copy form, the covered entity must provide such access, even if the information is stored in an electronic record. You may require the patient to submit a written request for copies of their health information; and you may charge for the reasonable costs for copying and mailing the records. You cannot charge a fee for searching for or retrieving medical records.

Based on the facts restated above, you are not required to purchase new technology in order to produce data in a specific desired format. However, you should have the capability of providing patients with some form or format of the medical records in an electronic format (HHS suggests MS Word and PDF among other possible options). The patient may choose to obtain a paper copy, if the digital formats that you have "readily producible" do not meet the patient's needs. Just like paper copies, a patient may be charged for digital copies of their data (other than the costs for retrieval of that data).

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