In the NPRM estimate, inspection and copying were a major cost. Based on data and information from the public comments and further fact-finding, however, the Department has re-estimated these policies and found them to be much less expensive.
The public comments demonstrate that copying of records is wide-spread today. Records are routinely copied, in whole or in part, as part of treatment or when patients change providers. In addition, copying occurs as part of legal proceedings. The amount of inspection and copying of medical records that occurs for these purposes is not expected to change measurably as a result of the final regulation.
The final regulation establishes the right of individuals to access, that is to inspect and obtain a copy of, protected health information about them in designated record sets. Although this is an important right, the Department does not expect it to result in dramatic increases in requests from individuals. The Georgetown report on state privacy laws indicates that 33 states currently give patients some right to access medical information. The most common right of access granted by state law is the right to inspect personal information held by physicians and hospitals. In the process of developing estimates for the cost of providing access, we assumed that most providers currently have procedures for allowing patients to inspect and obtain a copy of individually identifiable health information about themselves. The economic impact of requiring entities to allow individuals to access their records should be relatively small. One public commenter addressed this issue and provided specific data which supports this conclusion.
Few studies address the cost of providing medical records to patients. The most recent was a study in 1998 by the Tennessee Comptroller of the Treasury. It found an average cost of $9.96 per request, with an average of 31 pages per request. The cost per page of providing copies was $0.32 per page. This study was performed on hospitals only. The cost per request may be lower for other types of providers, since those seeking hospital records are more likely to have more complicated records than those in a primary care or other types of offices. An earlier report showed much higher costs than the Tennessee study. In 1992, Rose Dunn published a report based on her experience as a manager of medical records. She estimated a 10-page request would cost $5.32 in labor costs only, equaling labor cost per page of $0.53. However, this estimate appears to reflect costs before computerization. The expected time spent per search was 30.6 minutes; 85 percent of this time could be significantly reduced with computerization (this includes time taken for file retrieval, photocopying, and re-filing; file retrieval is the only time cost that would remain under computerization).
In estimating the cost of copying records, the Department relied on the public comment from a medical records outsourcing industry representative, which submitted specific volume and cost data from a major firm that provides extensive medical record copying services. According to these data, 900 million pages of medical records are copied each year in the U.S., the average medical record is 31 pages, and copying costs are $0.50 per page. In addition, the commenter noted that only 10 percent of all requests are made directly from patients, and of those, the majority are for purposes of continuing care (transfer to another provider), not for purposes of individual inspection. The Department assumed that 25 percent of direct patient requests to copy medical records are for purposes of inspecting their accuracy (i.e., 2.5 percent of all copy requests) or 850,000 in 2003 if the current practice remained unchanged.
To estimate the marginal increase in copying that might result from the regulation, the Department assumed that as patients gained more awareness of their right to inspect and copy their records, more requests will occur. As a result, the Department assumed a ten percent increase in the number of requests to inspect and copy medical records over the current baseline, which would amount to a little over 85,000 additional requests in 2003 at a cost of $1.3 million. Allowing for a 5.3 percent increase in records based on the increase in ambulatory care visits, the highest growth rate among health service sectors (the National Ambulatory Medical Care Survey, 1998), the total cost for the ten-year period would be $16.8 million.
The final rule allows a provider to deny an individual the right to inspect or obtain a copy of protected health information in a designated record set under certain circumstances, and it provides, in certain circumstances, that the patient can request the denial to be reviewed by another licensed health care professional. The initial provider can choose a licensed health care professional to render the second review.
The Department assumes denials and subsequent requests for reviews will be extremely rare. The Department estimates there are about 932,000 annual requests for inspections (i.e., base plus new requests resulting from the regulation), or approximately 11 million over the ten-year period. If one-tenth of one percent of these requests were to result in a denial in accordance with the rule, the result would be 11,890 cases. Not all these cases would be appealed. If 25 percent were appealed, the result would be 2,972 cases. If a second provider were to spend 15 minutes reviewing the case, the cost would be $6,000 in the first year and $86,360 over ten years.