DHS 120.26(2)(2) Contents. The hospital quality indicators report shall present variations in the delivery of inpatient care at individual hospitals without identifying the individual hospitals. The purpose of the report is to promote improvements in the overall quality of hospital care by providing an analysis of the variations in care delivery across the state. Where appropriate, national comparisons serve as improvement benchmarks. Each report shall include all the following information: DHS 120.26(2)(a)(a) A description of the report’s data and the limitations in interpreting the data. DHS 120.26(2)(c)(c) A discussion of how to interpret the analysis of the variations in care delivery across the state. DHS 120.26(2)(d)(d) A graphical presentation of the performance of hospitals relative to the quality indicators selected for presentation in the report. DHS 120.26(2)(e)(e) A discussion of how a hospital may obtain from the department hospital-specific information resulting from application of the nationally recognized quality indicators. DHS 120.26(3)(a)(a) The department shall distribute a paper copy of the report at no charge to the governor, the legislature and a board-approved list of individuals and agencies. The department shall make the paper version of the report available for purchase by others. The department shall make available from the department’s website an electronic version of the report at no charge. DHS 120.26(3)(b)(b) The department may not release the identity of the individual hospitals in the report. Individual hospitals may request information from the department that allows the hospital to assess the hospital’s standing relative to a group of hospitals with comparable patient volumes or state or national benchmarks. DHS 120.26(4)(4) Suggested uses of report. Some suggestions for using the report are as follows: DHS 120.26(4)(a)(a) By legislators and policymakers to examine the variation in indicators of hospital quality for various diagnoses and procedures and, in turn, whether the variation suggests the need for improvements in the quality of the health care delivery system. DHS 120.26(4)(b)(b) In conjunction with other available information, by commercial and public health care purchasers to determine the extent of variation in indicators of hospital quality. Contracts between health care purchasers and health plans and providers may address concerns arising from the reported indicators of quality. DHS 120.26(4)(c)(c) As a resource document for persons wishing to conduct research or seek information on hospital quality indicators. DHS 120.26(4)(d)(d) As a resource for consumers interested in learning about the expected outcomes of hospital care associated with a specific diagnostic category or a procedure. DHS 120.26(4)(e)(e) As a resource for individual hospitals that want to assess the need for quality improvement projects. DHS 120.26 HistoryHistory: Cr. Register, December, 2000, No. 540, eff. 1-1-01. DHS 120.29(1)(1) Public use data files based on information submitted by health care providers other than hospitals or ambulatory surgery centers may not permit the identification of specific patients, employers or health care providers. The department shall protect identification of patients, employers and health care providers by all necessary means, including all of the following: DHS 120.29(1)(c)(c) The specification of counties as to residence rather than zip codes. DHS 120.29(1)(e)(e) Not releasing information concerning a patient’s race or ethnicity, or dates of admission, discharge, procedures or visits. DHS 120.29(1)(f)(f) Masking sensitive diagnoses and procedures by use of larger diagnostic and procedure categories. DHS 120.29(2)(g)(g) The name and address of the facility in which the patient’s services were rendered. DHS 120.29(2)(i)(i) Information that contains the name of the health care provider who is an individual, if the independent review board first reviews and approves the release or if the department promulgates rules that specify the circumstances under which the independent review board need not review and approve the release. DHS 120.29(2)(j)(j) Calendar quarters of service during which the patient visit or procedure occurred, except if the department determines the number of data records included in the public use file is too small to enable protection of patient confidentiality. DHS 120.29(2)(k)(k) Information, other than patient-identifiable data, as defined in s. 153.50 (1) (b), Stats., as approved by the independent review board. DHS 120.29(3)(a)(a) Public use data files based on information submitted by hospitals and ambulatory surgery centers may not permit the identification of specific patients or employers. DHS 120.29(3)(b)(b) The department shall protect the identification of patients and employers by all necessary means, including all of the following: DHS 120.29(3)(b)3.3. Not releasing information concerning a patient’s race or ethnicity, or dates of admission, discharge, procedures or visits. DHS 120.29(3)(c)(c) The department shall suppress or mask zip code information in the public use data file when the number of persons having a given zip code is insufficient to mask their identity. DHS 120.29 HistoryHistory: Cr. Register, December, 2000, No. 540, eff. 1-1-01. DHS 120.30DHS 120.30 Patient data elements considered patient-identifiable. DHS 120.30(1)(1) Nonrelease of patient-identifiable data. The department may not release or provide access to patient-identifiable data, except as provided in s. 153.50 (4), Stats. The department shall protect the identity of a patient by all necessary means, including the use of calculated, masked or aggregated variables. DHS 120.30(2)(2) Procedures governing release of patient-identifiable data. DHS 120.30(2)(a)(a) Persons authorized and desiring to access patient-identifiable data under s. 153.50 (4), Stats., shall submit to the department a request for the release of the data in writing and shall include all of the following: DHS 120.30(2)(a)3.3. For a person who is authorized under s. 153.50 (4), Stats., to receive or have access to patient-identifiable data, evidence, in writing, that indicates the authorization. DHS 120.30(2)(a)4.4. For an entity that is authorized under s. 153.50 (4), Stats., to receive or have access to patient-identifiable data, evidence, in writing, of all of the following: DHS 120.30(2)(a)4.a.a. The federal or state statutory requirement to obtain the patient-identifiable data. DHS 120.30(2)(a)4.b.b. Any federal or state statutory requirement to uphold the patient confidentiality provisions of this chapter or patient confidentiality provisions that are more restrictive than those of this chapter; or, if the latter evidence is inapplicable, an agreement, in writing, to uphold the patient confidentiality provisions of this chapter. DHS 120.30(2)(a)4.c.c. An entity specified under s. 153.50 (4), Stats., having access to data elements considered patient-identifiable may not rerelease these data elements. DHS 120.30 NoteNote: Requests should be sent to the following address: Bureau of Health Information and Policy, P. O. Box 26599, Madison, Wisconsin 53701-2659, or deliver the communications to Room 372, 1 W. Wilson Street, Madison, Wisconsin.
DHS 120.30(2)(b)(b) Upon receiving a request for patient-identifiable data under par. (a), the department shall, as soon as practicable, either comply with the request or notify the requester, in writing, of all of the following: DHS 120.30(3)(3) Access to patient-identifiable data. In accordance with s. 153.50, Stats., only the following persons or entities may have access to patient-identifiable data maintained by the department: DHS 120.30(3)(a)(a) A health care provider or the agent of a health care provider to ensure the accuracy of the information in the department database. DHS 120.30(3)(b)(b) An agent of the department responsible for collecting and maintaining data under this chapter and who is responsible for the patient-identifiable data in the department in order to safely store the data and ensure the accuracy of the information in the department’s database. DHS 120.30(3)(c)2.2. Eliminating the need to maintain duplicative databases where the requesting department agent has statutory authority to collect patient-identifiable data as defined in s. 153.50 (1) (b), Stats. DHS 120.30(3)(d)(d) Other entities that have a signed, notarized written agreement with the department, in accordance with the following conditions: DHS 120.30(3)(d)1.1. The entity has a statutory requirement for obtaining patient-identifiable data for any of the following: DHS 120.30(3)(d)2.2. The department may review and approve specific requests by the entity for patient-identifiable data to fulfill the entity’s statutory requirement. The entity’s request shall include all of the following: DHS 120.30(3)(d)2.a.a. Written statutory evidence that the entity is entitled to have access to patient-identifiable data. DHS 120.30(3)(d)2.b.b. Written statutory evidence requiring the entity to uphold the patient confidentiality provisions specified in this section or stricter patient confidentiality provisions than those specified in this section. If these statutory requirements do not exist, the department shall require the entity to sign and notarize a written data use agreement to uphold the patient confidentiality provisions in this section. DHS 120.30 NoteNote: Examples of other entities include the U.S. Centers for Disease Control and cancer registries in other states.
DHS 120.30(3)(e)(e) Of information submitted by health care providers that are not hospitals or ambulatory surgery centers, patient-identifiable data that contain a patient’s date of birth may be released to an entity specified under s. 153.50 (4) (a), Stats., upon request and a demonstrated need for the date of birth. DHS 120.30(3)(f)(f) Notwithstanding sub. (2) and pars. (a) to (e), no employer may request the release of or access to patient-identifiable data of an employee of the employer. DHS 120.30(3)(g)(g) An entity specified under s. 153.50 (4), Stats., having access to data elements considered patient-identifiable may not rerelease these data elements. DHS 120.30(4)(a)(a) For information submitted by hospitals and ambulatory surgery centers, all of the following data elements from the uniform patient billing form that identify a patient shall be considered confidential, except as stated in sub. (3): DHS 120.30(4)(a)4.4. Patient’s employment status and occurrence and place of an auto or other accident. DHS 120.30(4)(a)9.9. Date of patient’s first symptom of current illness, injury or pregnancy.
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Chs. DHS 110-199; Health
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