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Asking Patients for Consent

 

Tips for Providers About Patient Consent

Consent policy

Under the State of Vermont consent policy, participating providers shall only access data on the VHIE for patients who have signed a written consent form. VITL has developed a model consent form for participating organizations to use that meets all the requirements of the state policy. Providers must keep a record of the consent.

IMPORTANT: Do not attempt to view protected health information (PHI) on the VHIE for patients who have not given your organization consent. There are severe penalties for accessing PHI inappropriately, which may include criminal prosecution, termination of employment, fines, and imprisonment.

Asking patients for consent

The key to obtaining a high rate of patient consent is to ask each patient, and to do it in a consistent manner. Using a script is a good way to ensure consistency.

Option #1:

“Our organization is part of a new health information network in Vermont. This is a secure, online service which allows our office to receive and share information like medication history, allergies, and test results from other offices and facilities. It helps your doctor and any specialists who treat you have all of your information in one place and provide you with better care. It’s free to participate – here’s some additional information and a consent form. Once you complete the form, please return it to me.“

Option #2:

“Would you like to consent to allow our clinical staff access to your statewide electronic medical record?“

If the patient answers yes, please provide him or her with the consent form and ask him or her to fill in all the blanks, sign, and return it to you.

What to do With Signed Consent Forms

A workflow process for handling signed consent forms should be established to ensure that a record of the patient consent is kept in compliance with the State of Vermont policy. The workflow may also include marking the patient’s electronic or paper record, so that you’ll be able to look up in the future whether the patient has already given consent.

What if a Patient Does Not Give Consent?

Patients have the right to decline to give consent, and should not be pressured into signing a consent form. Under the State of Vermont policy, patients cannot be denied treatment because they declined to sign a consent form. If a patient does not wish to grant consent when asked, or is unsure, please ask if the patient has any questions that you may answer. Also please direct the patient to the educational brochure provided by VITL.

How Often Should a Patient Be Asked?

Once a patient gives consent to your organization, that consent is good until the patient revokes it by filling out and signing a revocation form. If a patient has not given consent yet, or has declined to give consent, it is up to your organization to decide how to handle those situations. VITL suggests that patients who have not given consent be asked once or twice a year after the initial request, so that they are occasionally reminded about the availability of health information sharing.

Obtaining Consent for Minors

Generally, unless a minor is established as a legally emancipated minor, a parent or legal guardian must provide consent for a provider to access a minor’s health information on the VHIE. However, there are a number of situations when a minor may consent to treatment and therefore should be providing the consent to access his or her record which may include information related to that treatment.

These situations may include:

  1. minors age 12 or older consenting to treatment for sexually transmitted diseases, drug dependence or alcoholism.
  2. minors age 14 or older seeking voluntary inpatient treatment for a mental health condition.
  3. minors of any age seeking treatment related to reproductive health or sexual abuse.

Because information regarding treatments for which the minor has consented may be mixed with information regarding other treatment received by the minor, VITL suggests that providers obtain written consent from both the parent or legal guardian and the minor age 12 or older to access the minor’s protected health information on the VHIE.

Links

Support

If a patient has a question that you cannot answer, refer them to VITL’s toll-free consent hotline: 1-888-980-1243.

FAQs from Patients

Q.  How do I benefit by giving consent to view my health information?

A.  Your health care provider will have more complete information about your health history, which is very important when determining what could be causing your medical problems, and for recommending treatment. If your health care provider can see the results of tests you’ve had at other health care facilities, it may mean that the tests don’t have to be unnecessarily repeated. Health care providers, including those participating in the Vermont Blueprint for Health and other health care reform initiatives, can also better coordinate your care if they can see your complete record.

Q.  What information will be shared?

A.  If you give permission, your health care provider will be able to view all of the information about you that has been contributed to the Vermont health information network by other health care organizations where you received care. This may include: prescribed medications; past medical procedures and treatments; a list of current and former medical conditions; lab test results; radiology exam reports; hospital discharge summaries; and patient demographics. If you had mental health or substance abuse treatment, in some cases information about that may also be included.

Q.  How secure is my information?

A.  The Vermont Health Information Exchange (VHIE), the network where patient data is managed, has many different safeguards, such as data encryption and password protection to keep your information secure and confidential.

Q.  Can I see what information about me is available on the health information network?

A.  Yes. If you ask us, we can show you which information is available. We can also give you a form to fill out to request the information.

Q.  Can I decide which individual doctors within an organization may see my information?

A.  Vermont’s consent policy is known as a global opt-in policy. Once you provide your consent, any authorized health care provider at any organization who is involved in your care can view your information. Patients cannot choose which individuals can view their information.

Q.  If I do give consent to view, can I change my mind later?

A.  Yes, you can change your mind at any time. To withdraw consent, you must tell us and sign a revocation form, which we can give you. Patients may also request an audit of providers who viewed your health information, or request to view their health information in the VHIE. Contact VITL at 1-888-980-1243 to request these forms.

Q.  Can I decide which types of information will be shared?

A.  Once you give consent, the providers involved in your care may view any and all information about you that is available on the health information network.

Q.  Will my employer or insurance company be able to see my information?

A.  Employers do not have any access to the Vermont health information network. Insurers may use data from the network to check the quality of health care you’ve received, but only if you give your insurer a separate written authorization.

Patient Rights

  1. You can decide if your health care providers can see and use your medical records from other providers on the exchange. You can change your mind at any time.
     
  2. You can call Vermont Information Technology Leaders, Inc. (VITL) at 802-223-4100 or complete a Contact Us form to ask for a copy of your medical records that can be seen on the exchange.
     
  3. You can also request a list of the people who have used the exchange to view your medical records. Both are available free of charge. This will not affect the care you receive from your providers.
     
  4. If you think someone has seen your records that should not have, you can call VITL to tell them. VITL has a policy to address this. This will not affect the care you receive from your providers.
     
  5. In an emergency, a health care provider may use the exchange to find medical information about you from other providers. This may happen even if you have not given your consent. This would happen only if you are badly hurt or very sick, and unable to give your consent. When you are better, your health care provider must tell you that they looked at your medical records on the exchange. You can then decide if it is OK for them to keep seeing and using your information from other providers on the exchange.