Health Center Case Examples in Coding and Documenting Social Risks: Introduction

Privacy and Data Sharing Considerations | HITEQ Learning Collaborative

This health center learning collaborative series presented health center case examples that explore the privacy and data sharing considerations of EHR documentation of sensitive patient information, such as social history and social risk, and encouraged participants to discuss the implications for health centers and their patients. 

Providers encounter an increasing scope of potentially sensitive social history information as screenings for intimate partner violence, sexual and substance use history, and social risks become more common. Simultaneously, health centers face more pressure to openly share patient records with patients, patients’ other providers, and patient proxies like parents. Many of these decisions require decision-making by the clinician within the encounter, leaving clinicians feeling like they must have legal and technical expertise to apply in the context of each encounter. This session provided an overview of regulatory considerations including information blocking, the open notes movement, and common considerations and challenges that present when coding and documenting patient information in electronic medical records and aiming to ensure privacy, accuracy, and sensitivity.