Medical Records and the Law

Utilization Review and Quality Assurance 205practitioner states that the released information could harm the patient,the QIO must disclose the material to the patient’s representativerather than directly to the patient. 482 If the patient is mentally, physically,or legally unable to designate a representative, the QIO mustdisclose the information to a person responsible for the patient as determinedby the QIO in accordance with the regulations. 483 The QIOmust disclose patient information directly to the patient unless knowledgecould be harmful. 484Utilization Review and Quality AssuranceIn addition to their uses in medical research, patients’ records play acritical role in each healthcare organization’s effort to improve thequality of healthcare services and to increase the efficiency with whichthe services are provided. Patients’ records are a primary source of datafor such utilization review and other quality assurance activities.Healthcare providers and health law practitioners must be aware of thestatutes, regulations, and judicial opinions in their jurisdictions that affectthe ability to use medical records for these purposes.Two types of review processes occur in hospitals.The first type is thefederal QIO system, part of the Medicare program governed by federalstatute and regulation, 485 which is discussed more fully above.The secondtype of review is hospital utilization review and quality assurance.These two review programs are conducted by hospital staff membersand consist of in-house monitoring of both the quality and cost of providingservices. The basic requirements for these review programs areset forth in the standards of accreditation adopted by the Joint Commissionand in various state laws.Quality assurance and utilization review programs also are an importantaspect of managed health care. State laws usually condition issuanceof an HMO or MCO certificate of authority on the submissionand approval of a quality assurance program. Statutes and regulationsmandating quality assurance activities vary in terms of level of detail. 48648242 C.F.R. §§ 480.132(a)(2) and (c)(2).48342 C.F.R. § 480.132(c)(3).48442 C.F.R. § 480.132(c)(1).485See, generally, 42 C.F.R. §§ 480.101 through 480.143.486See, e.g., Idaho Code § 41-3905(6)(a); Md. Code Ann., Health-Gen., §§ 19-705.1(d),(e), and (f ).