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(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.
(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.
(4) Suggested uses of report. Some suggestions for using the report are as follows:
(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.
(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.
(c) As a resource document for persons wishing to conduct research or seek information on hospital quality indicators.
(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.
(e) As a resource for individual hospitals that want to assess the need for quality improvement projects.
History: Cr. Register, December, 2000, No. 540, eff. 1-1-01.
Subchapter V — Data Dissemination
DHS 120.29 Public use files.
(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:
(a) The deletion of patient identifiers.
(b) The use of calculated variables and aggregated variables.
(c) The specification of counties as to residence rather than zip codes.
(d) The use of 5-year categories for age rather than exact age.
(e) Not releasing information concerning a patient’s race or ethnicity, or dates of admission, discharge, procedures or visits.
(f) Masking sensitive diagnoses and procedures by use of larger diagnostic and procedure categories.
(2) Public use data files under s. 153.45 (1) (b) 2., Stats., may include only the following:
(a) The patient’s county of residence.
(b) The payment source, by type.
(c) The patient’s age category, by 5-year intervals.
(d) The patient’s procedure code.
(e) The patient’s diagnostic code.
(f) Charges assessed with respect to the procedure code.
(g) The name and address of the facility in which the patient’s services were rendered.
(h) The patient’s gender.
(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.
(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.
(k) Information, other than patient-identifiable data, as defined in s. 153.50 (1) (b), Stats., as approved by the independent review board.
(3) 
(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.
(b) The department shall protect the identification of patients and employers by all necessary means, including all of the following:
1. The deletion of patient identifiers.
2. The use of calculated variables and aggregated variables.
3. Not releasing information concerning a patient’s race or ethnicity, or dates of admission, discharge, procedures or visits.
(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.
History: Cr. Register, December, 2000, No. 540, eff. 1-1-01.
DHS 120.30 Patient data elements considered patient-identifiable.
(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.
(2) Procedures governing release of patient-identifiable data.
(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:
1. The requester’s name and address.
2. The reason for the request.
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.
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:
a. The federal or state statutory requirement to obtain the patient-identifiable data.
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.
c. An entity specified under s. 153.50 (4), Stats., having access to data elements considered patient-identifiable may not rerelease these data elements.
Note: 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.
(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:
1. That the department is denying the request in whole or in part.
2. The reason for the denial.
3. For a person who believes that he or she is authorized under s. 153.50 (4), Stats., the procedures for appealing the denial under s. 19.37 (1), Stats.
(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:
(a) A health care provider or the agent of a health care provider to ensure the accuracy of the information in the department database.
(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.
(c) The department for any of the following purposes:
1. Epidemiological investigation purposes specified in writing.
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.
(d) Other entities that have a signed, notarized written agreement with the department, in accordance with the following conditions:
1. The entity has a statutory requirement for obtaining patient-identifiable data for any of the following:
a. Epidemiological investigation purposes.
b. Eliminating the need to maintain duplicative databases, under s. 153.50 (4) (a), Stats.
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:
a. Written statutory evidence that the entity is entitled to have access to patient-identifiable data.
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.
Note: Examples of other entities include the U.S. Centers for Disease Control and cancer registries in other states.
(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.
(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.
(g) An entity specified under s. 153.50 (4), Stats., having access to data elements considered patient-identifiable may not rerelease these data elements.
(4) Data elements considered patient-identifiable.
(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):
1. Patient medical record or chart number.
2. Patient control or account number.
3. Patient date of birth.
4. Patient’s employment status and occurrence and place of an auto or other accident.
5. Patient’s school name, if applicable.
6. Patient’s race.
7. Patient’s ethnicity.
8. Patient’s city of residence.
9. Date of patient’s first symptom of current illness, injury or pregnancy.
10. Dates of services provided to patient.
11. Hospitalization dates related to current services provided to patient.
12. Dates patient is unable to work in current occupation.
13. Date of patient admission.
14. Date of patient discharge.
15. Date of patient’s principal procedure.
16. Encrypted case identifier.
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Published under s. 35.93, Stats. Updated on the first day of each month. Entire code is always current. The Register date on each page is the date the chapter was last published.