The testimony I am giving this morning is presented in behalf of the American Academy of Nurse Practitioners, the largest full service nurse practitioner organization for all nurse practitioner specialties representing over 75,000 of the nation’s 82,000 nurse practitioners.
Nurse practitioners are advanced practice nurses who provide primary care and specialty services to individuals and families according to their specialty. They diagnose and treat acute episodic illnesses, such as infections and injuries, and chronic diseases, such as hypertension and diabetes. In their practice, they take medical histories, conduct appropriate physical examinations, order, perform and interpret diagnostic and laboratory tests, making diagnoses, prescribe treatments including medication and refer patients for needed specialty services. They admit and cover patients in hospitals and long term care settings. Their services include, but are not limited to examining patients, ordering, conducting, supervising and interpreting diagnostic and laboratory tests and prescription of pharmacologic agents and nonpharmacologic therapies. They practice autonomously and in collaboration with health care professionals and other individuals to diagnose, treat and manage the patient’s health problems.(American Academy of Nurse Practitioners, 2002)
Nurse practitioners have a minimum of six years preparation with additional professional nursing experience. Entry level preparation for advanced practice nurse practitioners is a master’s degree. Didactic and clinical courses prepare nurses with specialized knowledge anc clinical competency to practice in primary care, acute care and long term care. Specialty areas for nurse practitioners include family, adult, gerontologic, pediatric, women’s health, acute care and psychiatric/mental health care. They are licensed and regulated by the State Boards of Nursing in the states in which they practice.(American Academy of Nurse Practitioners)
Nurse practitioners practice in a variety of settings including free standing primary care clinics, physician practices, HMOs, nurse managed centers, hospital outpatient and inpatient settings, long term care settings, schools, occupational health settings, public health departments, the Veterans Administration and other federal facilities as well as military. Over 30% work with vulnerable populations, among them, the elderly, the homeless, indigent groups and the chronically ill.
The autonomous nature of the nurse practitioner’s advanced clinical practice requires accountability for health care outcomes. Ensuring the highest quality of care requires certification, periodic peer review, clinical outcome evaluations, a code for ethical practice, evidence of continuing professional development and maintenance of clinical skills. Nurse practitioners are committed to seeking and sharing knowledge that promotes quality health care and improves clinical outcomes. Within the discipline’s standards of practice the maintenance of confidentiality of patient records and the responsibility of each nurse practitioner to be a patient advocate is clearly stated.
At the outset, let us assure you that patient advocacy, including protection of patient privacy has always been a very high priority to nurse practitioners. Steps have always been taken within our practices to protect patient confidentiality and to prevent exploitation through the inappropriate dissemination of confidential information about our patients.
Advanced practice nurse practitioners find themselves in a unique position in the implementation of rules protecting patient rights through the advocacy of patient privacy protections. On one hand, they may be functioning in their own clinics, where they are responsible for the implementation of the patient privacy regulations in that setting. On the other, they may be functioning in settings that require them to be knowledgeable about the issues surrounding these regulations, but do not necessarily control the business and practice interactions of the entities with which they contract or with whom they are employed.
Small practices or practices and clinics with limited income are concerned about their inability to implement the perceived requirements of these rules, because of the cost associated with such implementation. One example given was the cost of building new “fire walls” to protect computer based records and processes used in electronic billing ( which is now being required by Medicare). These practices and clinics often serve our most vulnerable and most isolated populations. The concern is : what will happen to patients if the cost for implementing privacy rules is so excessive that these practices and clinics can no longer operate?
Currently there is a sparsity of free or low cost consultation or guidance available to small practices or those with limited incomes. The cost charged by consultants who sell their “how to” information is prohibitive to many small practices or practices and clinics serving low income populations. Guidance systems need to be made available to them as well. Questions arise regarding the exploitative nature of “consultants” who charge heavy fees to help people learn how to implement the new rules.
In addition to the concern that costs will close practices and clinics who are providing a valuable service to patients who might not otherwise be served. There is concern that it will be increasingly difficult for health care providers and other entities to exchange information in order to help patients. There is concern that referrals to specialists will not be responded to, hence information about the patient being seen by the specialist will not get back to the original provider, interfering with continuity of care. Fears have also been raised regarding what happens to a provider who releases patient information to a specialist, if the specialist subsequently releases this information to another entity without obtaining the proper consents. Will they be held liable if proper procedures were not followed by the specialist?
In settings where sliding fee schedules are used, there is concern regarding the kinds of consent forms that will have to be used simply to determine eligibility of a patient to be billed in a certain way. In settings providing care to vulnerable populations, there is concern regarding the kinds of restrictions that will be placed on clinics as they determine eligibility for care in their setting?
There continues to be concern that simply trying to track patients epidemiologically, or to simply conduct an evaluation on how well a practice or a community is meeting the Healthy People 2010 standards for health promotion, will be seriously compromised by the requirements for de-identify patient information in order to study patient care results.
Clinics and practices often receive third party assistance with printing news letters, health promotion tips or guides for care, that could not be shared with patients without such subsidization. Concerns about loss of assistance in this area continue to be expressed.
In summary, while the language of the statute may, on the surface, be reasonable enough. The potential for implementation and enforcement overkill could, in fact, while protecting patient privacy, severely compromise patient care.
Question 1 regarding outreach, education and technical support. Outreach, educational and technical support services from the federal government are needed to help to implement this law and its regulation in an uncomplicated and clear manner. These services should not be economically prohibitive so that small practices and clinics will not be unduly hindered when implementing the rules. Currently, what appears to be available is high priced, and at times appears to be feeding the “overkill frenzy” that appears to be emanating from these rules. Currently the rumor mill is having a very negative impact on practices. Everyone has heard something, but little can be documented. Harnessing this will facilitate the logical implementation of the patient privacy rules.
Questions 2. Regarding areas in need of guidance. Currently there seems to be a great deal of misinformation being circulated through hearsay that can be very damaging to the logical implementation of these regulations. The concerns regarding cost, payment, the disruption of continuity of care and the dissolution of quality of care through over regulation need to be addressed. Particular attention needs to be placed on the impact of these regulations on the individual practitioner who is working directly with patients on a daily basis. Rules to prevent improper corporate activity should not be implemented in a way that clinicians such as nurse practitioners and physicians are no longer able to provide high quality care to their patients in both private and public settings.
Question 3 regarding Best Practices. While best practices have been found to be an excellent way to guide implementation, caution should be taken to not set limits in implementation through rigid use of “best practices” that may be applicable only in unique and narrow situations.
Question 4 regarding available resources for HIPPA compliance. The availability or resources for the individual practitioner appears limited and costly at this time. Our organization is very willing to work with the advisory group and CMS in the implementation and dissemination of usable resources for this purpose.
Question 5 regarding privacy rule mandates. Where approaches are being made, groups are getting together to discuss and share ideas and plans for preparing for the implementation of these rules in an efficient, logical and cost effective manner. Unfortunately, not everyone has access to this kind of resource; hence the need for other kinds of guidances and resources. As an organization, we are attempting to discover where the problems exist, so that we can facilitate increased knowledge and guidance regarding the issues surrounding the implementation of these rules.
Questions 6, 7 and 8 regarding private public partnerships;integrating federal and state mandates and accuracy and quality of information and service. Some of the concerns expressed earlier reflect concern regarding the integration of these regulations with other federal and state requirements. There is a great deal of concern that the accuracy of information being disseminated is lacking, and that improved resources for the small provider and the provider working with vulnerable populations in particular need to be protected and assisted so that the valuable work that they do does not get undone. We would emphasize that nurse practitioners because of their position as primary providers and as patient advocates and guardians of patient rights need to be included in the policy making activities surrounding the implementation of these rules.
In summary, nurse practitioners have a variety of concerns regarding the implementation of the patient privacy rules, both in their own clinics and practices and in the practices, clinics, institutions and agencies that they serve. Because they are in so many settings, issues that focus on implementation are varied. Also because they are in these settings and play a pivotal role in the care provided there, they can be a valuable resource for the implementation of these rules. To date, this resource has been underutilized. We are here to offer our help in whatever way we can.
While nurse practitioners have multiple concerns regarding the implementation of these rules, they also have a great deal of knowledge regarding the concerns of clinicians and the realities of implementing the rules in the settings where they practice. We would suggest that you include them as a resource in your deliberations. The American Academy of Nurse Practitioners is willing to provide more information and to be of assistance to you in your activities regarding the issues at hand. We thank you for the opportunity to speak today and look forward to further dialogue with you in the future.