UW Health Operations Council Approved 6/15/2010 ‐
II. Requests for financial information that are internal to an entity (i.e. the UWHC Direc
Radiology requesting UWHC financial information for UWHC radiology services)
III. Information produced to support cross‐entity planning, business development, and
management efforts of discrete business units and initiatives, where the appropriate
cross‐entity leadership has jointly agreed in advance to share information
UW Health Information Sharing Policy
Requesting information from the
Health Decision Support, ITS Reporting Team
Quality Improvement & Finance Departments
Note: This policy also applies to information and analytic resources in academic or operational
departments that are accessing and distributing information from UW Health data stores sourced from
ealth Link H
The intent of this policy is provide guidelines for appropriate and informed sharing of
information within UW Health, and to ensure compliance with legal and regulatory standards in
illing information requests. The intended audience includes both requestors of information as f
well as staff in departments that serve the information and analytic needs of UW Health.
This policy applies to the UW Health entities of UWHC, UWMF, UWSMPH, and UHC. This policy
pplies primarily to information retrieved from the Clarity data warehouse, Health Link, and a
other data stores that receive information from these sources.
This policy will provide guidance for handling of specific types of requests as categorized below.
Sharing information with parties outside of the UW Health entities is not covered by this policy.
Generally, proprietary UW Health information is for internal consumption only. Any decision to
hare UW Health information with outside parties is a management decision to be made by the s
appropriate UW Health senior leadership on a case by case basis.
While the UW Health Decision Support, ITS, Quality, Business Planning and Analysis and Finance
departments will take an interest in the intended audience for each information request to
insure both a quality end product and integrity in the use of analytic products, the final
responsibility for appropriate use and sharing of information lies with the requestor/recipient of
he information or analysis. This policy is not a substitute for requestor responsibility to use t
information in a responsible manner to the overall benefit of the UW Health enterprise.
ategories of information requests NOT governed by this policy (can be requested and filled
ith u ents):
o t application of policy and procedure requirem
I. Market share and market assessment studies
UW Health Operations Council Approved 6/15/2010 ‐ 2 ‐
olicy and Procedure:
I. Patient specific information requests (not including research related requests, see #2)
Patient specific refers to requests that will include individual patient identifiers, such as name
and/or medical record number, in the output that is being requested. Patient specific
information requests may fall into two categories.
First are patient lists intended to be used to contact patients for marketing/public affairs or
clinic operations/patient care purposes. The requests include patient contact information
(address and/or telephone). These requests are to be made using the electronic data request
system (UWHC ITS online *self‐service function for report requests available on U‐connect or
email HEAT ticket request for UWMF). ITS will maintain a process for triaging and responding
to these requests that includes a review by the UW Health Marketing & Public Affairs Director
of appropriate usage by the requestor to meet HIPAA patient privacy requirements.
Second are requests for patient specific information that include patient name or medical
record number, but not patient contact information. These requests typically come from
clinical/operational programs that need to manage specific patient populations or support
operations. In these cases, the responding department will take steps to insure confidentiality
of patient information, including notating the report as “confidential” and “not for distribution”
and including a HIPAA notice statement. These requests may be received directly by staff in
the analytic and information departments of UW Health, or may be made using the electronic
data request system (ITS online *self‐service function for report requests available on U‐
connect or email HEAT ticket request).
The UW Health information and analytic departments will place the following HIPAA statement
on all reports/data communications that contain patient identifiable information.
This report/data is being provided for the purpose of UW Health business and operational
needs. This report/data must not be used for release outside of the UW Health. Reports/data
I V. Board certification/residency related data requests
V. Patient specific lists used in operations such as patient business services operations or
clinic daily operations
VI. Information delivered through structured reporting tools (ex. Infoview) that already have
security and limited data access incorporated
ate by this policy:
gories of information requests governed
I. Patient specific information requests
II. Research related information requests
Requests for cross‐entity financial information between UW Health entities
IV. Recurring UW Health wide programmatic and market studies that include financial
used for research purposes must have been approved through a UW sponsored IRB. If this
report is not subject to Records Retention Policy please dispose of in a locked and secure bin
* ITS Self Service is available on U‐connect on the UWHC Help Desk page. A Health Link
account or a UWHC account is required to submit a Heat Self Service report request. Staffs
wishing to use Heat Self Service that do not have either of these accounts may request an
account from the UWHC ITS department.
II. Research related requests for information
To insure compliance with documentation required for research related information requests,
all requests related to research must be made using the ITS self service function on Uconnect.
ITS will triage these requests and will ensure appropriate documentation in compliance with
III. Requests for cross‐entity financial information between UW Health entities and/or between
Requests for cross‐entity financial information including measures such as charges, net
revenue, expense, profitability, margins, etc. between the UW Health entities can only be made
the following positions:
UWHC CEO, Vice‐Presidents, & Directors
UWMF CEO, Vice‐Presidents, & Directors
UWSMPH Dean, Assoc Dean‐Admin, Assoc Dean‐F
WSMPH Department Chairpersons and DepartmU
UHC CEO, VP Regional Development, & Directors
Examples include a request by UWHC for professional billing and collections information
related to a newly recruited surgeon; a request by UWMF for information regarding
charges, net revenue, and expense related to a specific technology at UWHC; a request by a
UWSMPH department for information regarding UWHC financial outcomes for patients
cared for by their physicians; or a request by a UWSMPH department to see the financial
impact of patient referrals to another UWSMPH department.
These requests will only be accepted by the various information and data departments
UW Health Operations Council Approved 6/15/2010 ‐ 3 ‐
when originated by one of the leadership positions specified above.
Additionally, the requestor of this information is required to notify and receive approval
from the Chief Financial Officer of the entity for which information is being requested. In
the case of UWMF billing and collections information, this approval must be received from
both the UWMF CFO, and either the appropriate Chairperson, Division or Section Leader, or
Department Administrator. This notification and approval is to be documented in writing
and shared with the analyst that will be working on the request.
Requestors are required to communicate the reason for the cross‐entity financial request
when making the request and when making the appropriate notifications. Requests for
cross‐entity financial information require notification to and approval from the appropriate
CFO and/or medical school departmental leadership before any analytic work will be
started. This advance notice creates the opportunity for a dialogue between the UW Health
entities regarding the information request. In the event that the CFO is unavailable and a
request is time‐sensitive, the COO of the respective organization will serve as a back‐up for
CFO in this process.
University Health Care, as a jointly sponsored representative of UWHC, UWMF, and
UWSMPH, is granted the permission to request UW Health wide financial analysis from the
UHC Business Planning and Analysis Department for the purposes of managed care and
contracting, as well as regional development operations management and strategic
planning. University Health Care employed requestors are not required to make
notifications when requesting UWHC and UWMF financial information for these purposes.
UHC Business Planning and Development will provide the UWHC and UWMF CFOs with a
onthly report of new analytic projects involving UWHC and/or UWMF financial m
information that have been requested by UHC employees.
See the Cross Entity Financial Information Sharing Request process flow chart in the
IV. Recurring UW Health wide programmatic and market studies that include financial
University Health Care, as the UW Health entity that has historically had the ability and
appropriate access to create reports that include financial analysis for both UWHC and
UWMF, has a roster of recurring reports to measure UW Health wide program
perform hese reports include: ance. At the time of drafting of this policy, t
Outreach System Value
Regional Primary Care Clinics System
UW Health Market Reference Reports
These reports are distributed to the appropriate leadership within UW Health and are
widely accepted by UW Health leadership. These established reports require no
dditional notifications and will continue to be produced and distributed for as long as a
UW Health Operations Council Approved 6/15/2010 ‐ 4 ‐
customers deem them to be valuable.
Any new reports of this nature will initially need to follow the notification process
outlined in number three above. With the population of the Health Link Clarity data
repository, a wider group of analytic resources will have the technical ability to create
cross‐entity and UW Health wide reports. After initial development of a UW Health wide
financial report, if a decision is made to transition the report to be a recurring report, it
will fall into the category of the above list of reports and will not require notification with
Sr. Management Sponsors: UWHC CFO/UWMF CFO
Authors: UHC/UWHC Business Planning and Development Manager, UWMF Decision
Support Director, UWHC ITS Reporting Supervisor, UWMF CQI Associate Medical
irector, UWHC Sr. VP Information & Quality, UWSMPH Neurology/Neurosurgery D
Department Administrator, University Legal Counsel
eview/Approval Committee: UW Health Operations Council
UW Health Operations Council Approved 6/15/2010 ‐ 5 ‐