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Screening Consolidated Clinical Document Architecture (CCDA) Documents for Sensitive Data Using a Rule-Based Decision

Beatriz H Rocha1, Deepika Pabbathi, Molly Schaeffer

  • 1Beatriz H. Rocha, MD, PhD, Brigham and Women's Hospital, General Medicine, 1620 Tremont Street, Boston, MA 02120, USA, Email: bhscrocha@icloud.com, Scopus Author ID: 7005976021.

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PubMed
Summary
This summary is machine-generated.

Hospitals can now meet "meaningful use" requirements by using a rule-based system to automatically screen patient transition of care documents for sensitive data, ensuring legal compliance.

Keywords:
Clinical decision supportcontinuity of patient carehealth information exchangemeaningful use

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Area of Science:

  • Health Informatics
  • Clinical Decision Support Systems
  • Healthcare Compliance

Background:

  • The Centers for Medicare & Medicaid Services' Stage 2 final rule mandates electronic visit summaries at transitions of care for "meaningful use" incentive payments.
  • Massachusetts and Federal laws restrict transmitting sensitive data without explicit patient consent for each transmission.

Purpose of the Study:

  • To implement and evaluate a rule-based decision support system for screening transition of care documents for sensitive data.
  • To ensure hospitals could achieve "meaningful use" while adhering to data privacy regulations.

Main Methods:

  • A rule-based system was developed to identify sensitive data in transition of care documents.
  • Document transmission was paused for flagged documents pending patient consent.
  • The system's accuracy was evaluated through two review periods, assessing true-positive rates and missed/unnecessarily withheld documents.

Main Results:

  • The rule-based screening system has been operational for 18 months.
  • Initial evaluation identified 3% of documents as sensitive (44% true-positive rate).
  • Post-enhancement, 4.5% of documents were flagged with a 98.4% true-positive rate.

Conclusions:

  • Automated screening of transition of care documents for sensitive data using production rules is feasible.
  • The decision support system facilitated "meaningful use" compliance and adherence to state/federal privacy laws.