Neb. Admin. Code tit. 186 — Health Registries and Release of Information

Chapter 1 Cancer Registry

Neb. Admin. Code tit. 186, ch. 1 Cancer Registry {#sec-186-nac-1 omnilex-key=us-ne-regs-official--title-186--186 NAC 1}

001. SCOPE AND AUTHORITY . These regulations implement the laws governing the establishment and maintenance of a registry pursuant to Nebraska Revised Statutes (Neb. Rev. Stat.) §§ 81-642 to 81-650 and §§ 81-663 to 81-675.

002. DEFINITIONS . Definitions set out in Neb. Rev. Stat. §§ 81-653 to 81-662, § 81-663 to 81-675, and the following apply to this chapter.

002.01 HEALTH PRACTITIONER. An individual who practices medicine and surgery, osteopathic medicine and surgery, or dentistry within the State of Nebraska.

002.02 INITIAL DIAGNOSIS. The recognition of cancer in a patient by a health practitioner, medical examiner, facility, or coroner.

003. DATA REQUIREMENTS . For each medical record of cancer the data required to be provided to the Department pursuant to Neb. Rev. Stat, § 81-646 must include all of the information set out in statute and additional information as set out in Attachment 1 which is incorporated herein by this reference.

004. HOSPITAL AND HEALTH PRACTITIONER REPORTING REQUIREMENTS . The reporting requirements for hospitals and health practitioners within the State of Nebraska are set out below:

(A) Each hospital and health practitioner shall produce and make available the data specified in this chapter to the Department; (B) Data must be submitted on disk or in encrypted electronic form in a manner acceptable to the Department; (C) Data must be submitted on an ongoing monthly basis, within six months from the date of initial diagnosis; and (D) Supplemental and follow-up data on previously reported cases must be reported in the next reporting period following receipt of the data.

005. CONFIDENTIALITY AND RELEASE OF INFORMATION . All data obtained from medical records of individual patients is confidential and may only be released as provided in Neb. Rev. Stats. §§ 81-647, §§ 81-663 to 81-675 and Title 185 Nebraska Administrative Code.

History

• Effective 2020-09-15

Chapter 2 Brain Injury Registry

Neb. Admin. Code tit. 186, ch. 2 Brain Injury Registry {#sec-186-nac-2 omnilex-key=us-ne-regs-official--title-186--186 NAC 2}

001. SCOPE AND AUTHORITY . These regulations are authorized by and implement the Brain Injury Registry Act, Nebraska Revised Statutes (Neb. Rev. Stat.) §§ 81-653 to 81-662 and §§ 81-663 to 81-675.

002. DEFINITIONS . Definitions set out in Neb. Rev. Stat. §§ 81-653 to 81-662, §§ 81-663 to 81-675 and the following apply to this chapter.

002.01 DISPOSITION UPON DISCHARGE. The destination of the patient following dismissal such as type of facility, service or home.

003. DATA REQUIREMENTS . The data that must be provided to the Department from medical records or made available through medical records for abstracting by the Department is set out in Neb. Rev. Stat. § 81-657 and must include the final diagnosis or classification of the injury according to the International Classification of Disease, Tenth Revision, Clinical Modification Coding System of the World Health Organization (ICD-10-CM), and available for viewing at the Nebraska Department of Health and Human Services, Division of Public Health, Office of Health Statistics, 301 Centennial Mall South, Lincoln, Nebraska 68509-5026.

003.01 REPORTING BY NEBRASKA HOSPITAL ASSOCIATION OR SUCCEEDING ASSOCIATION IN LIEU OF PHYSICIANS OR PSYCHOLOGIST. If the Nebraska Hospital Association or a succeeding entity provides a report containing the required information to the Department, a hospital, rehabilitation center located in a hospital, physician or psychologist is not required to make the report to the Department. Hospitals, rehabilitation centers located in a hospital, physicians and psychologists remain obligated to report when such reports are not made by Nebraska Hospital Association or do not contain all of the required information.

003.02 REPORTING BY HEALTHCARE FACILITIES IN LIEU OF PHYSICIANS OR PSYCHOLOGIST. If a hospital or rehabilitation center located in a hospital provides a report containing the required information to the Department, the physician or psychologist is not required to make the report to the department. Physicians and psychologists remain obligated to report when such reports are not made by a hospital or rehabilitation center located in a hospital or do not contain all of the required information.

004. AVAILABILITY OF MEDICAL RECORDS . Each hospital, rehabilitation center located in a hospital, physician, and psychologist required to report must make available medical records which document the diagnosis and treatment received by individuals with head and brain injury. Such medical records must be made available to the Department or its authorized representative.

005. CONFIDENTIALITY AND RELEASE OF INFORMATION . All data and information obtained from records of individuals with brain or head injury are classified as Class I, Class II, or Class IV. Data can only be released as provided by statute and Title 186 of the Nebraska Administrative Code (NAC). Any de-identified data asked for by and furnished to a researcher may not be intentionally re-identified in any manner. Should a recipient of de-identified information unintentionally or accidentally be able to identify any individual, the recipient must not use that information in any way. The recipient must notify the Department of the means of accidental re-identification in order for the Department to consider additional procedures to safeguard against breaches in confidentiality.

History

• Effective 2022-06-26

Chapter 3 External Cause of Injury Registry

Neb. Admin. Code tit. 186, ch. 3 External Cause of Injury Registry {#sec-186-nac-3 omnilex-key=us-ne-regs-official--title-186--186 NAC 3}

001. SCOPE AND AUTHORITY . These regulations set forth procedures for reporting requirements for Nebraska hospitals for data concerning external causes of injury, poisoning and adverse effects, and provide procedures and standards for governing access to registry data pursuant to Nebraska Revised Statutes (Neb. Rev. Stat.) §§ 71-2078 to 71-2082 and Neb. Rev. Stat. §§ 81-677 to 81-680.

002. DEFINITIONS . The definitions in Neb. Rev. Stat. § 71-2079 and the following apply to this chapter.

002.01 DEPARTMENT. The Nebraska Department of Health and Human Services.

002.02 DIAGNOSIS CODES. The codes for diseases and health-related conditions determined in accordance with Volumes I and II of the International Classification of Diseases, 10th Revision, Clinical Modification ("ICD-10-CM"), incorporated herein by reference and available for viewing at the Nebraska Department of Health and Human Services, Division of Public Health, 301 Centennial Mall South, 3rd floor, Lincoln, Nebraska, 68509.

002.03 EXTERNAL CAUSE OF MORBIDITY CODES. The codes for external causes of injury, poisoning, or adverse effects, to be entered on the hospital uniform billing form pursuant to Neb. Rev. Stat. § 71-2080, which are determined in accordance with the Supplementary Classification of External Causes of Injury and Poisoning of the International Classification of Diseases, 10th Revision, Clinical modification ("ICD-10-CM"), incorporated herein by reference and available for viewing at the Nebraska Department of Health and Human Services, Division of Public Health, 301 Centennial Mall South, 3rd floor, Lincoln, Nebraska, 68509.

002.04 PROCEDURE CODES. The codes for procedures in medicine, determined in accordance with Volume III of the International Classification of Diseases, 10th Revision, Clinical Modification ("ICD-10-CM"), incorporated herein by reference and available for viewing at the Nebraska Department of Health and Human Services, Division of Public Health, 301 Centennial Mall South, 3rd floor, Lincoln, Nebraska, 68509.

003. DATA REQUIREMENTS . Data are to be abstracted for each patient discharged from a hospital, receiving outpatient services, or released from observation, for whom an external cause of injury code is recorded. The data to be abstracted from medical records or made available through medical records for abstracting are those specified in Neb. Rev. Stat. § 71-2081 and must include the identification of the hospital reporting.

004. HOSPITAL REPORTING REQUIREMENTS . Each hospital within the state must assign an external cause of morbidity code to each patient discharged, receiving outpatient services, or released from observation, for whom an external cause of morbidity code is appropriate. The hospital must submit data to the Department on a quarterly basis. The data may be submitted to the Department via an agreement between the Department and the Nebraska Hospital Association or any other entity that has such data collection agreement. This submission may be in electronic or written format.

005. AVAILABILITY OF MEDICAL RECORDS . Each hospital must make available to the Department or its authorized representative, upon presentation of proper identification, medical records which document the diagnosis and treatment of individuals for whom an external cause of morbidity code was appropriate for the purpose of recording specific data required by Neb. Rev. Stat. §§ 71-2078 to 71-2082 and this chapter. These records must be made available on the hospital premises during normal working hours.

006. CONFIDENTIALITY AND RELEASE OF INFORMATION . All data provided to the Department pursuant to Neb. Rev. Stat. §§ 71-2078 to 71-2082 and this chapter, is confidential and will be released pursuant to Neb. Rev. Stat. §§ 71-2081 and 81-667. All data provided to the Department is classified as Class I and Class II data.

History

• Effective 2020-09-19

Chapter 4 Parkinson’s Disease Registry

Neb. Admin. Code tit. 186, ch. 4 Parkinson’s Disease Registry {#sec-186-nac-4 omnilex-key=us-ne-regs-official--title-186--186 NAC 4}

001. SCOPE AND AUTHORITY . These regulations implement the establishment and maintenance of a registry pursuant to Nebraska Revised Statutes (Neb. Rev. Stats.) §§ 81-697 to 81-6,110 and 81-663 to 81-675.

002. DEFINITIONS . Definitions set out in Neb. Rev. Stat. §§ 81-697 to 81-6,110 and 81-663 to 81-875 apply to this chapter.

003. PHYSICIAN REPORTING REQUIREMENTS . Reports filed by physicians shall include the information identified in Neb. Rev. Stat. § 81-6,102 and the following:

(A) Race;

(B) Education level;

(C) Occupation;

(D) Dementia/cognitive impairment (Y/N);

(E) Bradykinesia diagnosis, if any;

(F) Gait difficulty diagnosis, if any; and

(G) All Parkinson’s disease-related procedures provided.

003.01 REPORTING IN LIEU OF PHYSICIANS. If a licensed healthcare facility or the Nebraska Health Information Initiative, or its successor, submits the required information to the Department, the physician is not required to make the report to the Department. Physicians remain obligated to report when such report is not made by either a licensed healthcare facility or the Nebraska Health Information Initiative, or its successor, or a report does not contain all of the required information.

004. INDIVIDUAL REPORTING . An individual may file a report as provided in Neb. Rev. Stat. § 81-6,102 with the information set out in 186 Nebraska Administrative Code (NAC) 4-003 and the name of the treating physician.

005. PHARMACIST REPORTING REQUIREMENTS . Reports filed by pharmacist shall include the information identified in Neb. Rev. Stat. § 81-6,103. The report for the months of January through June must be filed on or before the following July 31st, and the report for the months of July through December must be filed on or before January 31st of the following year.

006. AVAILABILITY OF MEDICAL RECORDS . For purposes of validation of reports made by individuals each physician must make available medical records that document the diagnosis of individuals with Parkinson’s disease or related movement disorders. Each pharmacist must make available patient drug profiles that document the prescribing of the reportable drugs. Such medical records or patient drug profiles must be made available to the Department or its authorized representative in the offices of such physician or pharmacist.

007. CONFIDENTIALITY AND RELEASE OF INFORMATION . Data can only be released as provided by statute and Title 186 NAC. Any de-identified data asked for by and furnished to a researcher may not be intentionally re-identified in any manner. Should a recipient of de-identified information unintentionally or accidentally be able to identify any individual they must not use that information in any way. The recipient must also notify the Department of the means of accidental re-identification in order for the Department to consider additional procedures to safeguard against breaches in confidentiality.

History

• Effective 2021-07-04

Chapter 5 Release of Medical Records and Health Information

Neb. Admin. Code tit. 186, ch. 5 Release of Medical Records and Health Information {#sec-186-nac-5 omnilex-key=us-ne-regs-official--title-186--186 NAC 5}

001. SCOPE AND AUTHORITY . This regulation governs the release of medical records and health information Neb. Rev. Stat. §§ 81-663 to 81-675 which are contained in the registries that record certain medical conditions occurring in this state, as prescribed by law. These registries include the Birth Defects Registry established in Neb. Rev. Stat. §§ 71-645 to 71-648, the Cancer Registry established in Neb. Rev. Stat. §§ 81-642 to 81-650, the Brain Injury Registry established in Neb. Rev. Stat. §§ 81-653 to 81-661 and the Parkinson’s Disease Registry established in Neb. Rev. Stat. §§ 81-697 to 81-6,110.

002. DEFINITIONS . The definitions set in Neb. Rev. Stat.§§ 81-642 to 81-650, 81-653 to 81-675, 81-697 to 81-6,110 and the following definitions apply to this chapter.

002.01 CERTAIN DISEASES OR INJURIES. Certain diseases or injuries are cancers, birth defects, head and brain injuries and Parkinson’s disease or related movement disorders.

002.02 PERMISSION. Permission is the written consent or written authorization for contact obtained by the approved researcher from such patient or patient’s family.

003. CONFIDENTIALITY AND RELEASE OF INFORMATION . The data released must not be used in a manner to identify the individual and a data processing fee for the request will apply.

003.01 PROHIBITED RE-IDENTIFICATION. Any de-identified data (other than Class III data) furnished to a researcher may not be intentionally re-identified in any manner. Should a recipient of de-identified information unintentionally or accidentally be able to identify any individual they must not use that information in any way. The recipient must also notify the Department of the means of accidental re-identification in order for the Department to consider additional procedures to safeguard against breaches in confidentiality.

003.02 DATA PROCESSING FEE. The cost of data retrieved and data processing must be paid by the researchers, private or public entities, or individuals requesting data from a certain disease or injury registry.

004. APPROVED RESEARCHER . The Department may approve individuals or entities who submit written application to obtain access to case-specific data or case-specific and patient-identifying data to assist in their research for the prevention, cure and control of certain diseases and injuries. These individuals or entities must show that the applicant is a qualified researcher, that the data requested will be used for bona fide scientific or medical research for prevention, cure, or control of certain diseases and injuries, and that the applicant will maintain the confidentiality and security of the data obtained. The application must contain the information required by Neb. Rev. Stat. § 81-666 and the following information:

(A) The applicant’s name and address;

(B) The name of the entity, if any, which the applicant represents and its address, and a brief description of the entity; and

(C) The name and address of the principal investigator, if different from the applicant.

History

• Effective 2020-04-19

Chapter 6 Outpatient Surgical Procedures Data

Neb. Admin. Code tit. 186, ch. 6 Outpatient Surgical Procedures Data {#sec-186-nac-6 omnilex-key=us-ne-regs-official--title-186--186 NAC 6}

001. SCOPE AND AUTHORITY . The regulations set the procedures for reporting by hospitals and ambulatory surgical centers pursuant to Nebraska Revised Statutes (Neb. Rev. Stat.) §§ 81-6,111 to 81-6,119.

002. DEFINITIONS . Definitions set out in Neb. Rev. Stat. §§ 81-6,111 to 81-5,119 apply to this chapter.

003. DATA REQUIREMENTS . Every hospital or ambulatory surgical center licensed under the Health Care Facility Licensure Act must report outpatient surgical and related information to the Department as required by Neb. Rev. Stat. § 81-6,114.

003.01 DATA FORMAT. The information must be submitted in an electronic format that meets the requirements of Attachment 1.

004. CONFIDENTIALITY AND RELEASE OF INFORMATION . All information reported pursuant to this chapter is subject to the confidentiality requirements set out in Neb. Rev. Stat. §§ 81-6,115 through 81-6,117.

005. FAILURE TO REPORT . A late fee of $50 per day, to a maximum of $1000 may be imposed for failure to report.

ATTACHMENT 1

Nebraska Hospitals and Ambulatory Surgery Centers Data Dictionary. This precise format is necessary. Please follow the instructions for preparing the data.

History

• Effective 2020-09-15