Reporting Requirements and Procedures

Reporting Requirements and Procedures 1. By virtue of authority vested in it by the Mississippi Code Annotated Sections 41-63-4 or as otherwise amended, the Mississippi Department of Health does hereby adopt and promulgate the following regulations and standards for the Healthcare Data Registry System. 2. Purpose -The Mississippi State Department of Health (MSDH), acting as the state’s public health authority, is required to design and establish a registry program concerning the condition and treatment of persons seeking medical care in the state of Mississippi (“Healthcare Data Registry System”). MSDH must collect, analyze and disseminate these health care data in order to improve the quality and efficiency of medical care. 3. Reporting Responsibility-Each of the following licensed health care facilities in the state of Mississippi shall be required to report the specified health care data described in these rules and regulations: A. Hospital Facilities – See Rule 1.19.2; B. Ambulatory Surgical Facilities – See Rule 1.19.3 [Reserved]; C. Outpatient Diagnostic Imaging Centers – See Rule 1.19.4 [Reserved]; 4. Reporting Contact-In order to facilitate communication and problem solving, each reporting facility must designate a person as contact and advise the Department from time to time of any changes to such contact information. Contact information shall include the office name, telephone number, job title and name of the person assigned this responsibility to the MSDH. 5. Penalties for Not Reporting- A. The MSDH is authorized to assess penalties as provided by statute pursuant to Mississippi Code Annotated § 41-63-4 Paragraph (12) which states, “A person or organization who fails to supply data required under this section is liable for a civil penalty of Five Cents (5¢) for each record for each day the submission is delinquent. A submission is delinquent if the department does not receive it within thirty (30) days after the date the submission was due. If the department receives the submission in incomplete form, the department shall notify the provider and allow fifteen (15) additional days to correct the error. The notice shall provide the provider an additional fifteen (15) days to submit the data before the imposition of any civil penalty. The maximum civil penalty for a delinquent submission is Ten Dollars ($10.00) for each record. The department shall issue an assessment of the civil penalty to the provider. The provider has a right to an informal conference with the department, if the provider requests the conference within thirty (30) days of receipt of the assessment. After the informal conference or, if no conference is requested, after the time for requesting the informal conference has expired, the department may proceed to collect the penalty. In its request for an informal conference, the provider may request the department to waive the penalty. The department may waive the penalty in cases of an act of God or other acts beyond the control of the provider. Waiver of the penalty is in the sole discretion of the department;” and B. Failure of any health care facility or other person or entity covered by the “Mississippi Health Care Certification of Need Law of 1979”, Mississippi Code Annotated § 41-7-171 through § 41-7-209, to report any requested information, data or otherwise failure to report under these provisions, shall be in violation of the “Mississippi Health Care Certification of Need Law of 1979” and subject to violations provided in Mississippi Code Annotated § 41-7-209. 6. Confidentiality-Information maintained in the Mississippi Healthcare Data Registry System shall be confidential and shall not be distributed or released except with the permission of MSDH in accordance with its established policies and procedures. Violation of confidentiality requirements may be subject to severe civil and/or criminal penalties. A. The release of identifiable patient health information may be made by MSDH only to the facility that initially reported the identifiable information, upon the written request of such facility. Any request by any other party for the release of identifiable information shall be reviewed by the MSDH Data Use Council (described below), and the Data Use Council may approve such request only for the purpose of public health assessment or research under such guidelines and stipulations as may be necessary to maintain confidentiality requirements. B. Prior to the dissemination or release of any data analysis or statistical reports concerning registry information, including any release to MSDH divisions or programs, the Data Use Council may review the methods and procedures deemed necessary to maintain the privacy and confidentiality of patient records, including the system security requirements. C. The MSDH shall be required to regularly monitor the physical security of the registry, to train personnel concerning the system’s confidentiality standards, to limit access to the registry information solely to authorized personnel, and to implement password and encryption protections in the system. 7. Protected Health Information-The disclosure of protected health information by a reporting facility pursuant to these rules and regulations shall be recognized as a disclosure to a public health authority as required by law, pursuant to the Health Insurance Portability and Accountability Act and the Privacy Rules promulgated there under at 45 CFR Sections 164.512(a) and (b). 8. Data Use Council-The State Health Officer will create a Data Use Council consisting of not less than five individuals to recommend policies and procedures regarding the release of any registry data to MSDH divisions and programs, to the public, to researchers and to industry. Appointments to the Council shall be made at the sole discretion of the State Health Officer for such terms as may be established by the policies and procedures of the MSDH. MSDH divisions and programs may, with the consent of the Data Use Council, use patient abstract data to assist in fulfilling its public health mission. These data will not be re-released in any form by the program without the prior authorization of the Data Use Council. Authorization for subsequent release shall be considered only if the proposed release does not identify a patient. 9. Temporary Waiver of Reporting Requirement-With respect to any licensed health care facility otherwise required to report data or other information to the MSDH pursuant to these rules and regulations, the MSDH shall be authorized to temporarily waive reporting requirements due to system requirements of MSDH or the reporting facility, or in the case of irregularities or errors involving data delivery. Any waiver of the reporting requirements must be made in writing by the MSDH and notice of the termination of any waiver shall be provided to the applicable reporting facility, at which time these Regulations shall become applicable to such facility. 10. Charges and Fees for Access to Data-Subject to the confidentiality requirements of these Regulations, the MSDH may develop reports and data analyses based upon registry data which may be released to the public. The reports may be published or disseminated for a reasonable charge, or without charge at the discretion of MSDH as outlined in the policies and procedures established by the Healthcare Data Registry System. At the time of the promulgation of these Regulations, the MSDH shall refrain from assessing any charges to reporting facilities for the collection of health care data. Nothing shall prohibit the State Board of Health from authorizing, at any future date in accordance with its statutory authority, the assessment of reasonable charges for the collection of such data, or the reporting of specified health care data to the MSDH for purposes of the registry. 11. Persons receiving encounter-level data must complete an application and submit the signed data use agreement according to policies and procedures of the Hospital Discharge Registry System. Encounter level datasets available include Inpatient, Outpatient, and Emergency Department The following provides the cost to purchase one or many datasets by calendar year: A. State Inpatient Database: $1,740 per year of data (students $300) B. State Emergency Department Database: $1,740 per year of data (students $300) C. Ad Hoc Data Request - Customized data requests are priced according to policies and procedures established by the Healthcare Data Registry System and are primarily on the time required to analyze the request write the query; and the time required to access, merge, validate and prepare the information for delivery. D. Hospitals requesting data – The MSDH will not charge hospitals for data requests when the data they are requesting originated from their facility. All other hospital requests will follow the Ad Hoc Data Request or dataset file request fee schedule. E. Waiver Grants awarded to students – The MSDH may award grants to students actively involved in a school setting (High School, Undergraduate or Graduate). The grants will be in the form of a waiver for agreeing to allow the MSDH to publish their findings and methodology if the MSDH Data Use Council deems the information appropriate. Data restrictions will apply. Should the student request more than three datasets, the Ad Hoc Data Request will apply.