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Introduction: Patient centered family sensitive care, Temecula Valley Hospital presenting our series of informative podcasts. It's TVH Health Chat with Melanie Cole.

Melanie Cole: Welcome to TVH Health Chat with Temecula Valley Hospital. I'm Melanie Cole and today we're discussing how you can get your medical records so that you can be your own best health advocate. Joining me is Carrie Pedersen. She's the System Director and Privacy Officer in Health Information Management at Temecula Valley Hospital. Carrie, it's a pleasure to have you with us and what a great topic for people that really want to advocate on their own behalf and know what's going on with their medical records. Tell us a little bit first, how many staff are located in the medical records department at Temecula Valley Hospital?

Carrie Pedersen: So as far as the number of staff, we're also known as health information management, as you had stated, we have in a typical HIM setting, we have comprised many teams which include coding, clinical documentation, integrity, documentation analysts, physician liaison, and then we have the release of information members. And today, since we're talking about obtaining medical record information, Temecula Valley Hospital, HIM utilizes MRO as our vendor for release of information. And currently on site, we have about six of those members.

Host: Well thank you for telling us about that. So how can people access their health records online? Tell us a little bit about how that works.

Carrie Pedersen: So health records online is actually known as the patient portal, and that's really the best way to try to manage and we encourage patients to engage in their healthcare. So when the patient is registered at our hospital, they're asked to provide an email address for portal access. And if that wasn't given at the time of registration and the patient can call the HIM department and that can be set up or reset the access.

Host: Okay. So if people want to do that, tell us what can they see? What will they be seeing? What kinds of records can be viewed and even can they even see imaging studies?

Carrie Pedersen: It is limited, but it is the information that's supplied that helps with healthcare decisions. So the patient portal contains allergies, immunizations, problems, procedure history, and mini summary of care documents. So actual images, those imaging studies are not viewed. A lot of the providers in their offices who are privileged with our hospitals, have access to those images, or the patient can request an image on a DVD and that can be sent to their provider, or they can take that with them.

Host: Well, I think one of the things patients always want to know is when can they expect to see their information, if they've had an MRI and they're waiting for the report or an ultrasound, and they're waiting, how long do those usually take?

Carrie Pedersen: So the information will show in the portal. As soon as it's documented in the electronic record, typically labs are displayed 24 hours in the record, which will show in the portal after they're resulted. And the radiology results will display 14 days after they are resulted. For requests outside of the patient portal. We have other means online. If you go to the hospital's website and you go online to request the records, anything for continued care can be requested without a cost to the patient. And we strive to have those requests done within five days. We also have other available information. So during this COVID pandemic, we have also devised a way if you go online to the hospital's website and request COVID results, if that result is resulted, we, you know, I've made arrangements with my vendor to get those results to that requester in one to two hours. Because a lot of people are waiting and saying, you know, I need to have that result. I need to get back to work or for whatever reason. And we want to make sure that we are providing the information as timely as possible because we know how critical the information can be.

Host: Well, it certainly can. And you mentioned one that there's no fee for something particular, but is there a fee to use health records online in general?

Carrie Pedersen: So health records online, again, the portal is not no fee to the patient. We want to get them to be able to access the information and the patient or their legal representative can also go through the website under the patient and visitors, medical records section. There's sometimes can be a little confusion where health records online is the portal with limited information, but information used for continued care. And if there's anything outside of that information that they need for continued care, it's recommended they go online and they just kind of follow the prompts through this online wizard that just kind of asks them for information, gets their authorization or the patient's legal representative. And I do want to kind of elaborate a little bit on who is the patient's legal representative, because if that information isn't provided online, it would delay the information being sent. And those could be anywhere from a healthcare power of attorney, a court appointed legal guardian. You could have unemancipated minors. The parent could ask for the child, anyone who has that legal authority to make those healthcare decisions. And if we have a deceased patient, the executor administrator of the estate can have that information as well, but they just need to have that provided to us so we can then move quickly on getting the information to them.

Host: That's great information. So how does someone go about requesting medical records? If the information that they seek isn't available on health records online or their patient portal, and when you're telling us that, Carrie tell us what's the quickest response time when someone has submitted their medical record request through the medical correspondence system, how long does that take?

Carrie Pedersen: Okay. So the first thing I do recommend is patient portal, get in there, manage the information, you know yourself, so you can then download it. You can manage it, you can save it, you can send it to your provider. If you don't have the access to the portal, it didn't happen. Or you've lost the invitation. You can call the HIM department and we can get you that invite sent that out to you. Online requests, go to the hospital website. You can call the HIM department, speak to a representative. They can walk you through that. You know, during this time of the COVID pandemic, we know everyone is trying to avoid going out and visiting physical addresses. But if that's something that you need to do and you feel comfortable with that this release of information department, the centralized areas away from any of the hospitals. And we have people there when you request the records that if you have anything for pertinent, let's say you want an imaging disc. You want anything for continued care that wasn't within the portal. You can get that within 30 minutes and best practices to call ahead. If you request something online, we try to get the turnaround time within three to five days for the patients we have that either mailed to the patient, they can come physically pick it up, or we can have it sent to a third party payer or another provider, you know, at the patient's request.

Host: So I think one of the main questions people have when we're doing all these electronic medical records, Carrie, is are they secure? Is health records online, secure? And how does someone know that they're safely kept? And as we switch over and everything is completely electronic. Tell us a little bit about privacy.

Carrie Pedersen: Well, privacy is a big issue and we want to make sure everyone understands that we adhere to the HIPAA security rule requirements. We are very diligent in ensuring that, and we have audits in place that we make sure that we are looking at everything all the time, making sure that everything is secure, and no one can get access to records unless they have the legal authority to do so. And you know, we do have treatment payment, operational things where the information, you know, is disseminated for those purposes, but anything outside of that, you have to have a legal authorization in order to have access to those records.

Host: That's such important information for listeners to hear. So as we wrap up, if someone has a question about their medical records, who can they call? Is there a way to reach you? What should they do? Tell us a little bit the process.

Carrie Pedersen: Well, I think people need to understand that the information contained in the medical record is something that the HIM department can't assist with because we are not clinical. And it is outside of our scope to have any interpretation of the record. We can assist in getting the copies of the record for, you know, the patient or the legal representative. I think the best thing is, is who documented the information, calling your provider, trying to find out, you know, what the information needs, any questions that they have. If there's information within a record, and people need to know that if it is incorrect information and, you know, for example, it states that you came in for, let's say a right ankle contusion, and it was on the left. You know, we want to make sure the records are correct and that you have you know, the ability to contact my department. And, you know, we could go through a formal amendment process to get that information corrected. We work with the providers who've done the documentation, present it to them, have them review the information. So that's another possibility, but the best way, if there's a question about the medical record is to obtain copies and then go to your provider, the provider of care.

Host: Do you have any final thoughts you'd like to share with the listeners about medical records online and being their own best healthcare advocate, knowing what's in their medical records so that they can ask the right questions, visit the proper doctors and know what's going on with their health.

Carrie Pedersen: I think it's important for everyone to utilize the online, the portal, you know, when you're discharged from the hospital, eating out, you're not feeling that great. You know, you've just gone through something you don't really want to go here and they're trying to get your records. And that's sort of my whole intent to try to get people to, you know, go online, go into their portal, be their own advocate, to be able to manage the information. And it's something where we want to be able to help the patient. I mean, we're all patients, our family members are patients, and that's one of the things it's like, Oh, you know, now I need to see a specialist. I have to gather all this information. And if you can do it online with minimal effort, that's really the intent of trying to get people to go in, manage the information, obtain the information without having to physically run around because let's face it. There's a lot more things that you, you know, you need to do and make the appointments and get it ready for that next step. If a next step is needed.

Host: Thank you so much, Carrie, for joining us today and sharing that really important information on medical records. Thank you again. And to learn how you can access your medical records, please visit TemeculaValleyhospital.com/patientvisitors/medicalrecords. And if you have questions or would like additional information, please call (951) 696-6013 and the staff will be happy to assist you. That concludes this episode of TVH Health Chat with Temecula Valley Hospital. Please remember to subscribe, rate, and review this podcast and all the other Temecula Valley Hospital podcasts. Physicians are independent practitioners who are not employees or agents of Temecula Valley Hospital. The hospital shall not be liable for actions or treatments provided by physicians. This is Melanie Cole.