JCAHO, AHA clash on performance data
Debate rages over how quality data is being used
Performance measures may be getting glowing reviews from researchers and are an integral part of the Joint Commission on Accreditation of Healthcare Organization (JCAHO)’s new survey process, but a recent advisory from the American Hospital Association (AHA) has criticized JCAHO’s intentions. The advisory claimed, among other things, that JCAHO "plans to become a purveyor of performance data analysis for a variety of purposes."
The AHA charges that JCAHO plans to seek patient-level data for purposes unrelated to accreditation. In response, JCAHO insists that patient-level data are being used only to improve the accuracy and completeness of the data collection and data aggregation processes and that no protected health information would ever be released to third parties. In addition, JCAHO adds that patient-level data would be de-identified before it was ever used for research or other purposes not related to accreditation.
In a prepared statement, JCAHO responded that it is "not an information company and intends to remain focused on its mission to continuously improve the quality and safety of health care. Using and analyzing data is a critically important element of a credible and continuous accreditation process."
In addition, JCAHO recently announced that it would continue to use data analyses and reporting to measure and encourage quality improvement in accredited health care organizations but has decided not to sell performance measurement data analyses to private third party payers.
JCAHO says it is committed to the creation of a single collection system for hospital performance data, for a single reliable data source to support JCAHO’s own Quality Check web site and the Centers for Medicare & Medicaid Services and Hospital Quality Alliance’s Hospital Compare web site, provided JCAHO is allowed unfettered access and the data quality could be assured.
Although both web sites report hospital performance data, the Quality Check web site reports additional accreditation-related performance information.
Here are assertions made by AHA and JCAHO’s responses:
• AHA accuses JCAHO of making patient privacy an "afterthought." To this, JCAHO responded that its current uses of aggregate performance data are not in violation of requirements under the Health Insurance Portability and Accountability Act (HIPAA) since these protect individual privacy, not institutional privacy.
JCAHO says it welcomes guidance from the Department of Health and Human Services (HHS) Office for Civil Rights (OCR) on patient privacy concerns raised by the AHA and will not move forward with its quest for the patient-level data in question until the relevant HIPAA issues are resolved.
According to JCAHO, access to patient-level performance data is needed to support its ongoing accreditation-related measurement activities, and it plans to work in collaboration with AHA to resolve this issue. But JCAHO insists that it has never breached the confidentiality of any protected health information (PHI).
The AHA claims that hospitals are at risk for civil and criminal penalties if JCAHO’s uses of patient information are found to be out of compliance with HIPAA requirements. JCAHO denies this. "The Joint Commission feels it is on solid legal ground under the HIPAA privacy rule with its past and current uses of PHI for accreditation-related purposes," says Mark Forstneger, spokesperson for JCAHO.
He adds that the previous disclosure, to which the AHA objects, involved only de-identified aggregate data that will not subject hospitals to any civil or criminal penalties. Forstneger notes that JCAHO recently met with OCR representatives, who affirmed that once PHI appropriately received for health care operations under a business associate agreement has been de-identified, it is no longer protected by the privacy rule and can be disclosed to a third party.
"I agree with JCAHO," says Kathleen A. Catalano, RN, JD, director of regulatory compliance services for Dallas, TX-based PHNS. "If the information is de-identified, it means that all of the 18 enumerated identifiers have been removed."
According to HIPAA, an expert opinion is needed stating that a statistically small risk exists that the released information could be used by others to identify the subject of the information. "If JCAHO does this, there should be no problem. I doubt anyone could identify a patient after all of this information is removed," says Catalano. "JCAHO is also saying that they will be in compliance with HIPAA requirements."
If information is de-identified, no authorization is needed to use the information, she adds.
Some hospital risk managers do have problems with JCAHO using data for purposes unrelated to accreditation, fearing possible liability under HIPAA. "It was really inappropriate for the JCAHO to do what they did. If hospitals hadn’t raised the issue, then I think we could have faced some exposure," says Sue Dill, RN, MSN, JD, director of hospital risk management at OHIC Insurance Company, based in Columbus, OH, and former vice president of legal services at Memorial Hospital of Union County in Marysville, OH. "Shame on the JCAHO, and I can’t believe they didn’t think this would upset the hospitals."
[For more information, contact:
Kathleen A. Catalano, RN, JD, Director of Regulatory Compliance Services, PHNS Inc., One Lincoln Centre, 5400 LBJ Freeway, Suite 200, Dallas, TX 75240. Telephone: (214) 257-7112. Fax: (214) 257-7042. E-mail: [email protected].
Sue Dill, RN, MSN, JD, Director, Hospital Risk Management, OHIC Insurance Company, 155 East Broad Street, Columbus, OH 43215-3614. Telephone: (614) 221-7777. E-mail: [email protected].]
Performance measures may be getting glowing reviews from researchers and are an integral part of the Joint Commission on Accreditation of Healthcare Organization (JCAHO)s new survey process, but a recent advisory from the American Hospital Association (AHA) has criticized JCAHOs intentions.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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