Health Information Technologies and Processes

Race and Ethnicity Collection

  • 1.  Race and Ethnicity Collection

    Posted 10-30-2019 09:45

    Hello,

     

    Recently, Epic and reception staff have been having a lot of discussion about collecting race and ethnicity, primarily regarding patients who have "Patient declined to answer" as their response for their race and ethnicity. Overall, there is a concern that these patients have not truly declined, rather clinical staff were not comfortable asking the question, so they just entered in "Patient declined to answer."

     

    As such, there is a push to re-ask patients who have "Patient declined to answer" as their race and ethnicity, but as it stands within Epic today, we don't have a great way to track the patients who declined the second time, and clearly we do not want to be alienating that population by continuing to ask for their race and ethnicity when they do not want to disclose it.

     

    So, one suggestion that was given was to clear out the race and ethnicity fields in Epic for any patient who has "Patient declined to answer" selected, so that there is a higher comfort level in knowing that they were truly asked when the fields are eventually repopulated.

     

    My question is … Is there any kind of legal implication by removing that data from the patient's chart?

     

    Note: As the system functions today, when the race and ethnicity fields are edited, on the back end there is a stamp on the patient record of "Race Modified" with a date and time, but it doesn't actually track previous value to current value, and we don't have the ability to make a note of why those fields were changed.

     

    There is an audit trail report that could be run after the fields are cleared, and then saved somewhere outside of Epic for future reference if needed. Technically, that report could be re-run within Epic, but Epic only stores audited items for one year, so if we decided to clear out those fields on 1/1/20, the audit trail report for that particular update would only work until 1/1/21.

    Thanks!



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    Sarah Dietz
    HIM & Privacy Manager
    GHC-SCW
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  • 2.  RE: Race and Ethnicity Collection

    Posted 12-13-2019 10:27
    Hello Sarah,

    I am the NYHIMA Communications Director.  Although I am not an attorney, I don't think there would be any legal implication to remove the fields that state "patient declined" and trying to get the information updated.  The audit shows the filed was updated which shouldn't be an issue maybe it was listed incorrectly or the patient wanted it removed from their record. I have my staff ask "is there a race or ethnicity you would like to have on file" and if they say no we put declined or unknown.

    I think as long as you have documentation for what your doing and why you are doing it you should be fine.

    Tennille Schmitt, RHIT
    NYHIMA Communications Director

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    Tennille Schmitt
    Medical Records Supervisor
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