IN THE CASE OF: BOARD DATE: 23 September 2023 DOCKET NUMBER: AR20220010310 APPLICANT REQUESTS: amendment of the medical information contained in her AHLTA (Armed Forces Health Longitudinal Technology Application), the military's electronic health record, documented by two Primary Care Provider, on 28 January 2020 and on 13 April 2021. APPLICANT'S SUPPORTING DOCUMENT(S) CONSIDERED BY THE BOARD: * DD Form 149 (Application for Correction of Military Record) * Email regarding redaction of medical record * Headquarters, Army Medical Department Activity (MEDDAC) Response * AHLTA Medical records, March-April 2021 * Counsel Statement FACTS: 1. The applicant states she has requested MEDDAC change the erroneous entries in her record and was denied. Her medical records are in material error, and she requests redaction or removal of the adverse information. She adds: a. She visited Aviation Medicine Clinic on Fort Campbell and saw provider NH on 1/27/20. She was experiencing pain in her left knee. The pain presented during her Basic Combat training in May of 2017. When she arrived at Fort Campbell, she began physical therapy which was helping. In May of 2018, she re-injured her knee playing football during physical training. She told the provider how she was injured in a statement made 1/27/2020, but the next day the same provider made a change in her records. He wrote "Patient reinjured the left knee over the holiday leave and has had pain and instability since." Mr. did not see her or speak with her on January 28, 2020. b. Additionally, she is requesting a redaction or amendment to the records regarding an encounter on 4/13/21 with medical provider at Health Clinic. There was a note that said "SM states she only has a month till ETS and she would still be interested in getting MEB (medical evaluation board) due to financial issues". This statement was made without seeing her through an appointment, neither in person or virtual. No provider mentioned that she is pursuing MEB due to financial reasons. The MEB discussion came about after Major recommended she do so. She had to have an explanation for her medical situation and had nothing to do with "financial issues." Since she never spoke to anyone on April 13, 2021, she would like that note removed from her medical records. The recommendation of Major for follow up with her PCM (primary care manager) recorded on March 19, 2021. 2. The applicant enlisted in the Regular Army on 8 May 2017, and she holds military occupational specialty 92A, Automated Logistical Specialist. b. She was issued a DD Form 214 (Certificate of Release or Discharge from Active Duty) on 7 May 2021 due to completion of her required active service. This DD Form 214 was revoked. She had extended her Regular Army enlistment by 12 months on 16 April 2021. c. She enlisted or reenlisted on 9 June 2021 for 3 years and 7 months and followed that with a 7-month extension on 23 March 2023. 3. On 17 August 2021, by letter to Patient Administration Division, Blancfield Army Community Hospital, Fort Campbell, KY , she requested an amendment of her medical record documentation. 4. On 5 October 2021, by letter, a Privacy Official at Headquarters, U.S. Army MEDDAC informed the applicant that the Blanchfield Army Community Hospital, Patient Administration Division and Privacy Office, have reviewed her request for an amendment. She requested an amendment of the medical information contained in her AHLTA medical record, documented by your Primary Care Provider, 1LT MPE, on 13 Apr 2021. After a review of her medical records, her request has been denied because your Provider has confirmed that the information is accurate and that the events actually happened as recorded. She submitted a letter of disagreement with this decision to their office, stating why she believes her records are inaccurate or erroneous, and this letter will be filed in her medical record. Because her request has been denied, she also have the right to appeal this determination to the Headquarters, United States Army Medical Command. If she decides to appeal at this time, her appeal must be submitted within 60 days of the date of this letter. In her appeal, she must state the basis for her disagreement with the denial and the justification for your amendment request. 5. On 26 March 2022, by letter to the Commander, U.S. Army Medical Command, Access and Amendment Refusal Authority and Initial Denial Authority, Fort Sam Houston, the applicant’ counsel stated: a. This is an appeal to the denial of removing adverse information from her record. She specifically appeals the finding that "After a review of your medical records, your request has been denied because your Provider has confirmed that the information is accurate and that the events actually happened as recorded." She specifically requests that her appeal be granted, and the information is removed or amended. b. The applicant made a timely request to amend her medical records. She states, "I visited Aviation Medicine Clinic on Fort Campbell and saw provider on 1/27/20. She was experiencing pain in her left knee. The pain presented during her Basic Combat training in May of 2017. When she arrived at Fort Campbell, she began physical therapy which was helping. In May of 2018, she re-injured her knee playing football during PT. She told the provider how she was injured in a statement made 1/27/2020, but the next day the same provider made a change in her records. He wrote, "Patient reinjured the left knee over the holiday leave and has had pain and instability since." Mr. did not see [Applicant] or speak with her on January 28, 2020. c. Additionally, [Applicant] is requesting a redaction or amendment to the records regarding an encounter on 4/ 13/21 with medical provider at Health Clinic. There was a note that said, "SM states she only has a month till ETS and she would still be interested in getting MEB due to financial issues". This statement was made without seeing [Applicant] through an appointment, neither in person nor virtual. No provider mentioned that she is pursuing MEB due to financial reasons. The MEB discussion came about after Major recommended she do so. [Applicant] had to have an explanation for her medical situation and had nothing to do with "financial issues". Since she never spoke to anyone on April 13, 2021 she would like that note removed from her medical records. The recommendation of Major is for follow-up with her PCM recorded on March 19, 2021. d. In accordance with AR 40-66. Medical Record Administration and Healthcare Documentation, accurate medical records which properly document the encounters between patient and physician are required. A patient that believes these records are in error may appeal for an amendment to the records when they are in error. The applicant has specifically challenged the legitimacy of the medical records related to her. She believes the records are in material error and do not accurately reflect the events that transpired. It is critical for medical records to be accurate, and she has a duty to ensure that these records properly reflect what happened during her medical visits. 6. A staff member of the Case Management Decision contacted the applicant’s counsel multiple times in an effort to obtain the response he received from Medical Command at Fort Sam Houston; however, counsel failed to provide such response. ? BOARD DISCUSSION: 1. After reviewing the application, all supporting documents, and the evidence found within the military record, the Board found that relief was not warranted. The Board carefully considered the applicant's record of service, documents submitted in support of the petition and executed a comprehensive and standard review based on law, policy and regulation. Upon review of the applicant’s petition and available military records, the Board determined there is insufficient evidence to support amendment of the applicant’s medical information contained in her AHLTA health records. The Board agreed the applicant provided no supporting documentation to contradict her claims for the meeting dates she identifies as to not seeing medical professional on those dates. Furthermore, the Board found without proper evidence the Board is unable to assess that an error has occurred. Therefore, the Board denied relief. 2. This Board is not an investigative body. The Board members determined that the burden of proof rest with the applicant; however, she did not provide any supporting documentation and her service record has insufficient evidence to support the applicant’s contentions for amendment of the medical information contained in her AHLTA (Armed Forces Health Longitudinal Technology Application), the military's electronic health record, documented by two Primary Care Provider, on 28 January 2020 and on 13 April 2021. BOARD VOTE: Mbr 1 Mbr 2 Mbr 3 : : : GRANT FULL RELIEF : : : GRANT PARTIAL RELIEF : : : GRANT FORMAL HEARING :X :X :X DENY APPLICATION ? BOARD DETERMINATION/RECOMMENDATION: The evidence presented does not demonstrate the existence of a probable error or injustice. Therefore, the Board determined the overall merits of this case are insufficient as a basis for correction of the records of the individual concerned. I certify that herein is recorded the true and complete record of the proceedings of the Army Board for Correction of Military Records in this case. REFERENCES: 1. Army Regulation 40–66, Medical Services, Medical Record Administration and Healthcare Documentation prescribes policies for preparing and using medical reports and records. a. Chapter 2 explains Department of the Army policies and procedures governing the release of PHI (protected health information) pertaining to individual patients. The HIPAA governs the use and disclosure of PHI that is under the control of the military treatment facility/dental treatment facility (MTF/DTF). Once the information is disclosed within the Federal government, it is then protected by the provisions of the Privacy Act of 1974 (AR 340-21). DA policy mandates that the confidentiality of PHI of both living and deceased individuals will be ensured to the fullest extent possible. PHI will be disclosed only if authorized by law and regulation b. Individuals may file a complaint when they believe that PHI relating to them has been used or disclosed improperly; that an employee has improperly handled the information; that they have wrongfully been denied access to or opportunity to amend the information; or that the entity’s notice does not accurately reflect its information practices. All such complaints must be in writing. c. Amendment to medical records. (1) Under HIPAA, individuals have the right to request an amendment or correction to their PHI. MTFs/DTFs will have procedures in place to address this issue. (2) MTFs/DTFs may deny any individual’s request for amendment, if they determine that the PHI that is subject to the request— (a) Was not created by the covered entity, unless the individual provides a reasonable basis to believe that the originator of PHI is no longer available to act on the requested amendment; (b) Would not be available for inspection under DOD 6025.18–R, chapter 11; or (c) Is accurate and complete. (3) If the MTF/DTF denies the requested amendment, in whole or in part, they will provide the individual with a timely, written denial, written in plain language, that will contain—(a) The basis for the denial; (b) A statement of the individual’s right to submit a written statement disagreeing with the denial; (c) A description of how the individual may file such a statement; (d) A description of how the individual may complain to the MTF/DTF, to include the name, title, and telephone number of the contact person or office designated to receive such complaints; (e) A description of how the individual may file a complaint with the HHS;(f) A statement that, if the individual does not submit a statement of disagreement, he or she may request that the MTF/DTF provide his or her request for amendment and the denial with any future disclosures of the PHI that is the subject of the amendment. (4) Medical records will be amended according to AR 340–21, paragraph 2–10. //NOTHING FOLLOWS// ABCMR Record of Proceedings (cont) AR20220010310 1 ARMY BOARD FOR CORRECTION OF MILITARY RECORDS RECORD OF PROCEEDINGS 1