HIPAA and your electronic communications

Checking your weather app on your phone for today’s forecast before you leave the house.
Tweeting your response to a news article.
Reading your e-mail on the light rail during your commute.
Paying for your coffee with your electronic wallet.
Liking your friend’s Instagram post.

Likely one or all of these activities describes part of your day. Electronic devices are ingrained in our daily habits and communication on them is second nature to most of us. We may rarely stop to think about the consequences of using them when corresponding with patients or using patients’ protected health information (PHI). However, if you are a healthcare provider, there are things that you must be aware of when using your device via text, e-mail, or social media.

Type of Network: Know what type of wireless or cellular network you are on when texting or e-mailing. PHI is vulnerable to being intercepted via unsecured networks such as the public WiFi at a local coffee shop or hotel. It is important to think about HIPAA security and privacy concerns whenever communicating with patients or other providers.

Size of Device: One area of risk when texting and e-mailing using a handheld device such as an iPhone, tablet or Android device is their size. They are generally small and can be easily stolen, thereby allowing PHI to be accessible to the thief. The device passcodes and biometric identifiers (such as touch ID on iPhones) may help to deter access but do not provide secure protection of the information contained in the memory of the device.

Internet: The internet can be a great way to advertise and/or educate your patients; however, it is vitally important to be sure the person managing this area of your practice understands the professional obligations pertaining to HIPAA. Think carefully before posting on the internet. Do not assume an online forum is private or secure. Be aware that information posted on the internet may remain there permanently, even if you delete your comment or post.

How can you ensure a secure electronic communication? There are methods available to assist with data security when transmitting PHI electronically such as encryption or subscription to a secure messaging service. For more information on securing your digital information, HealthIT.gov is an excellent resource that offers training materials and guidance on this topic.

“Sweet relief” for chronic pain?

The importance of diet on overall health has been documented in many areas including heart disease, diabetes, dementia, and skin disorders. What possible impact could diet have on chronic pain? This daily wellness tip from the Cleveland Clinic highlights the connection between sugar and simple carbohydrate consumption – like honey, corn syrup, white rice, and wheat flour – and chronic pain. Dr. Brenda Powell, an integrative medicine specialist and fellowship director at Cleveland Clinic’s Center for Integrative & Lifestyle Medicine, noted that these foods all stimulate increased insulin levels which, in turn, causes pain-producing inflammatory markers. The Clinic’s recommendation? An anti-inflammatory diet that can assist in controlling chronic pain caused by these inflammatory markers. What should it include? Dr. Powell encourages lots of fruits and vegetables with an ideal meal plate template that includes two-thirds fruits and vegetables and one-third protein, grains, and nourishing fats. While there are sugars in fruit and some vegetables, there is a balance of fiber that allows them to be broken down more slowly without an inflammatory reaction.

If you are treating patients with chronic pain conditions, talking with them about an anti-inflammatory diet may be appropriate.

The “wonder drug”?

What if there was a magical “wonder drug” that could improve your patient’s (and your) health in a number of ways? What if it treated a multitude of conditions including musculoskeletal diseases, hypertension, diabetes, Parkinson’s disease, and depression? What if it was free, easy to access, and didn’t require a prescription?

Would you make sure everyone knew about it? Would you discuss it openly with your patients?

Great news – it exists! However, it’s not a pill, powder, or injection. It’s simply… exercise.

A recent column by Aaron E. Carroll in The New York Times noted that the outcomes achieved with the recommended 150 minutes/week of moderate physical activity for health-related conditions can’t be claimed by any other single intervention. While it is not a “miracle cure” for all ailments, the authors of a editorial in the BMJ call it “the best buy for public health”; it has been linked to improved health in many areas including the ones mentioned above. Mr. Carroll also notes that “Moderate intensity is probably much less than you think”. A brisk walk, a leisurely bicycle ride, or even vacuuming floors will qualify.

A systematic review and meta-analysis of physical activity promotion, published in 2012, showed that provider advocacy and recommendation of activity in a primary care setting works. If you are not already doing so, why not add a question to your intake form about how much moderate physical activity your patients are getting? Make time to discuss the benefits of just 30 minutes a day of physical activity with your patients and offer suggestions for incorporating physical activity into daily routines.

Will it cure every disease? No. Can it have an beneficial impact on you and your patients? Yes, definitely. Why not try and recommend the “wonder drug” of moderate physical activity today?

More best practices on informed consent

The topic of informed consent has been discussed in the medical community for many years, yet there still exist problems with the informed consent process that many patients face. A recent article in JAMA noted that “… informed consent documents are often signed minutes before the start of a procedure, a time when patients are most vulnerable and least likely to ask questions…”

CHP recommends the use of the PARQ format for obtaining informed consent. Informed consent forms come in many sizes and content formats, but, for all providers, the basic rule is to include:

  • P = Procedures explained
  • A = Alternatives given and providers may choose to explain what may happen with no treatment rendered
  • R = Risks explained
  • Q = Questions from the patient

The PARQ format is designed to be used BEFORE the patient signs the informed consent document and includes both appropriate time for verbal discussion and proper documentation. (See our best practices blog post on PARQ here and documenting PARQ here.) The use of PARQ protects both the patient and the provider.

A recent trend in informed consent documents among multiple professions has been the addition of indemnification language. A sample of indemnification language seen in recent forms is below:

“The patient will hold the provider, all its agents, employees, family and corporation harmless from any and all claims, demands damages and causes of action present or arising in the future from any injuries or harm received during treatment, even in cases of negligence by the provider or its’ employees. I understand this release of liability and assumption of risk and fully accept this agreement, affirming with my signature.”

While indemnification language may seem like a smart provision for protections, providers are advised to check with their malpractice companies before using it. A chiropractic malpractice insurance carrier we consulted with advises against using this type of language in consent forms; University of Western States does not use indemnification language in its curriculum and advises against using it in practice. Local law firms also warn of the potential fallout if a case were to come before a judge or jury. Further, a provider may not indemnify against negligence when coming before a licensing board.

If you are currently using indemnification language on any of your forms, you are encouraged to consult with your legal counsel.

Meta-analysis shows tai chi lowers blood pressure as well as prescription medication

Researchers from the University of Connecticut presented their findings on the blood pressure-lowering effects of tai chi at the American College of Sports Medicine 2016 Annual Meeting. Their meta-analysis of 28 studies on tai chi practiced by adults with a median age of 62 years, showed that tai chi can lower blood pressure as effectively as drugs or aerobic exercise. This may be good news to elderly patients who are more adapted to low intensity exercise. On average, subjects practiced tai chi for 61 minutes twice a week for 20.6 weeks. Systolic pressure was lowered 6 mm Hg and diastolic was lowered 3mm Hg. The researchers noted that with greater frequency of tai chi practice, the blood pressure was lowered even more.

If you treat elderly patients who are open to adding low-intensity exercise to their daily routine, tai chi may be an appropriate recommendation, especially if they have high blood pressure.

Disposing of prescription drugs in Oregon, Washington

If you or your patients are like most Americans, you probably have at least one or two unused prescription medications sitting in your bathroom cabinet. Prior to 2014, consumers wanting to dispose of these drugs legally had to give them to a law enforcement agency. But, that was often difficult and most people either flushed the drugs, resulting in waterway contamination, or threw them out in the garbage with the potential for theft or abuse by drug-seekers.

In 2014, the US Drug Enforcement Agency greatly expanded the types of locations that can accept unwanted medications on a routine basis to include drug manufacturers, distributors, narcotics treatment programs, retails pharmacies, and hospitals. By late 2015, multiple location in Oregon and Washington have modified their DEA registration to offer authorized collection locations. To find a DEA authorized collection location near you, visit https://www.deadiversion.usdoj.gov/pubdispsearch/spring/main?execution=e1s1 and enter your ZIP code or a city/state combo to search by.

For more information on disposing of unwanted medicates in Oregon, visit https://public.health.oregon.gov/HealthyEnvironments/DrinkingWater/SourceWater/Pages/takeback.aspx

For more information on disposing of unwanted medications in Washington, visit http://www.atg.wa.gov/prescription-drug-disposal

To salt or not to salt?

Is the age-old advice of “too much salt is bad for everyone” correct? Aaron E. Carroll, writing for The Upshot column in The New York Times, covered a new meta-analysis study that looked at salt consumption and how it is connected to heart attacks, strokes, death and blood pressure. He noted that the idea that people with high blood pressure should avoid excessive salt holds true, but this does not translate to people who don’t have high blood pressure. However, that’s not the whole story as the study demonstrated that the outcomes of people with high blood pressure who used too little salt (less than 3 grams) was actually worse than a using a moderate amount (4-5 grams) or higher levels (more than 7 grams). Lastly, even those without high blood pressure who used less than 3 grams of salt per day also demonstrated an increased risk.

So, as Mr. Carroll writes, take dietary advice about salt consumption “with a grain of you know what”.

Can acupuncture help menopause symptoms?

Menopause is a natural biologic process which can trigger physical symptoms including hot flashes, night sweats, sleep problems, and mood changes. It occurs generally in the 40’s or 50’s with the average age in US women being 51. Treatments, especially for the “vasomotor” symptoms which include hot flashes and night sweats, include medications and lifestyle modification such as dressing in layers, drinking a cold glass of water, avoid spicy foods and hot beverages.

A recent study conducted by researchers at Wake Forest and Duke medical schools, highlighted by the National Center for Complementary and Integrative Health, shows that acupuncture practicing in a clinical setting may offer significant and persistent benefit on these vasomotor symptoms. In addition, a number of other quality of life measures were improved such as sleep quality, memory symptoms, and anxiety were improved.

If you have patients experiencing menopause symptoms, recommending acupuncture treatments may prove beneficial for their quality of life.

Online communications – do you know the rules?

Most health care providers have become accustomed to working in an environment where protected health information (PHI) is appropriately handled on a day-to-day basis. Knowing when to require patient signatures prior to releasing records and finding private areas to have conversations with and about patients now seems to be second nature and follows common sense rules. However, one area that may be more challenging to providers and patients are electronic communications – including texting, emailing, and using social media. While these methods might provide an easy way of communicating with patients directly – especially when responding to reviews on Yelp or Facebook – there are security concerns pertaining to HIPAA privacy that outweigh any perceived benefits. ProPublica recently published an article about providers responding to negative reviews online – it outlines the realities faced by healthcare providers when trying to defend themselves online and is a good reminder for all providers that a patients’ protected health information must not be disclosed by the provider in any public forum.