Overview
UMMH did not provide evidence that it had reported all 74 births in our sample to the Department of Public Health (DPH). Specifically, UMMH could not provide birth logbook entries for 66 (89%) out of 74 births in our sample. This is important because UMMH’s birth registrar told us that they use birth logbook entries to ensure that all birthing patients on a particular day have been sent the appropriate forms to fill out for DPH. Additionally, UMMH could not provide evidence that all 74 births in our sample were reported to DPH within 10 days or that all 74 births were accounted for during UMass Memorial Medical Center’s and HealthAlliance Clinton Hospital’s annual reconciliations with DPH.
According to the Centers for Disease Control and Prevention, birth tracking is important because birth outcomes may vary across different geographic regions due to access to care. The birth data that DPH collects from hospitals, such as UMMH hospitals, can be used by stakeholders, such as medical scholars and public health professionals, to understand population trends, identify health disparities, and inform policy decisions. As such, it is important that the data UMMH provides to DPH be complete, accurate, and timely.
Authoritative Guidance
Section 305.020 of Title 105 of the Code of Massachusetts Regulations (CMR) states,
The physician, certified nurse midwife, administrator or other person in charge of a hospital or birthing facility, or any other person responsible for recording and/or reporting a birth pursuant to [Chapter 46 of the Massachusetts General Laws], shall report to the Registrar within ten days of the birth of the child all confidential birth information that the Commissioner deems necessary for administrative, statistical or research purposes pursuant to [Section 24B of Chapter 111 of the Massachusetts General Laws].
Additionally, 105 CMR 130.370(F) states,
At the expiration of the retention period specified in [Section 70 of Chapter 1111 of the Massachusetts General Laws], which begins after the discharge or the final treatment of the patient to whom a retained medical record relates, a hospital may destroy the medical record. The manner of destruction must ensure the confidentiality of patient information. At least 30 days prior to the proposed date of destruction of a medical record(s), a hospital shall provide written notification to the Department, generally indicating the type of records to be destroyed and the dates of service which exceed the applicable retention period, in a manner specified by the Department, of the hospital’s intent to destroy medical record(s) that exceed the 20 year retention period.
Reasons for Issue
UMMH, through its counsel, stated that it disposed of some of the birth logbooks used in its birth reporting process. Additionally, UMMH’s counsel stated that UMMH no longer had access to any of the information it sent to DPH.
Recommendations
- UMMH should ensure that it reports all births occurring in its hospitals to DPH within 10 days and maintain documentation to show this.
- UMMH should document the birth reconciliation process that it performs annually with DPH and maintain documentation of this process.
Auditee’s Response
The Auditee respectfully disagrees with Finding 2. UMMH produced extensive information regarding MassHealth member births, including those 74 births described as “Sample 1” during the audit process. On June 14, 2024, UMMH produced a report of all MassHealth births within the UMMH network of hospitals during the audit period. On August 2, 2024, UMMH produced birth logbook entries for 8 of the 9 patients listed in Sample 1 from HealthAlliance-Clinton Hospital. (One patient was not documented in the birth log because there was a fetal demise.) Furthermore, on August 24, 2024, UMMH produced documentation of all services that were billed to MassHealth for these 74 patients on the date of delivery and date of birth.
The draft report states that UMMH “could not account for when or if it had reported births occurring in his hospitals to the Department of Public Health” and “no longer has access to any information it sent to DPH.” This is not accurate. As evidenced by the extensive records provided to [the Office of the State Auditor (OSA)], UMMH maintains robust electronic medical records of all births at its hospitals. As to the reporting process, UMMH employees interviewed by OSA confirmed the process by which UMMH reports births to DPH and the process by which UMMH reconciles the births reported by UMMH with the records maintained by DPH. UMMH provided OSA with the relevant policies related to birth reporting, as well as documentation of its reconciliation with DPH for 2023. For the reconciliations performed in the years prior to 2023, UMMH confirmed it no longer had copies, as those reconciliations were sent to DPH via encrypted messages, per DPH’s request, that have since been cleared from UMMH’s system, as is best practice when transferring documentation with significant Personal Health Information (“PHI”). See [Section 164.308(a)(5)(i) of Title 45 of the Code of Federal Regulations]. Similarly, because the submission of birth records to DPH occurs via a secure DPH electronic portal, records regarding those submissions were not available to UMMH. To the extent OSA had any concerns on this issue, DPH would maintain records of its own secure portals, not UMMH, and could provide confirmation of such submissions.
As OSA is aware from interviews it conducted of UMMH employees, UMMH maternity wards maintain a physical birth logbook as a backup for newborn birth records that is kept in the maternity ward for easy access during patient admissions. Those paper logs are routinely disposed of in [Health Insurance Portability and Accountability Act (HIPAA)]-compliant shredding bins in the ordinary course of business and the electronic medical records remain the official medical records maintained by UMMH recording every birth. While UMMH produced to OSA the paper birth logbooks that were still available at the time of the audit, it did not have a complete set of paper logbooks for the multi-year period requested by OSA due to the HIPAA-compliant procedures outlined above. But in all cases, UMMH appropriately maintained birth records through its secure electronic medical records system.
Response from EOHHS-MassHealth
EOHHS agrees that UMMH must document births and report them to DPH within 10 days, in accordance with DPH regulations at 105 CMR 305. The [Office of the State Auditor (OSA)] report indicates that UMMH “reported a total of 15,784 births to DPH between January 1, 2020, through December 31, 2022.” EOHHS notes that, notwithstanding the OSA’s finding, from the data included in the OSA’s report, it appears that UMMH is reporting births occurring in its hospitals to DPH. The OSA notes that “UMMH could not provide evidence that all 74 births in [its] sample were reported to DPH within 10 days.” However, it is not clear from the OSA report what percentage of the sample could not be verified as being reported within 10 days.
EOHHS does not have sufficient information to comment on whether UMMH has existing internal controls sufficient to ensure compliance with birth reporting requirements. As a general matter, EOHHS agrees that UMMH should have internal controls in place to ensure that births are reported to DPH within 10 days, in accordance with the regulation.
Auditor’s Reply
In its response, UMMH states that it disagrees with Finding 2 because it provided us with (1) a report of all MassHealth births during the audit period; (2) birth logbooks for 8 out of 74, or 9%, of the MassHealth patients in our sample; (3) documentation of the services billed to MassHealth for the 74 sampled patients; and (4) policies related to its birth reporting and reconciliation process. However, none of the information provided by UMMH could be used to verify that births for the 74 sampled patients were reported to DPH. UMMH does not mention that we also requested copies of birth registration forms signed by the UMMH birth registrar for all 74 sampled patients, along with the annual birth reconciliation that UMMH performs with DPH in order to verify that these births were reported to DPH within 10 days. However, as indicated in its response, UMMH stated it no longer had copies of any annual birth reconciliations with DPH prior to 2023. Additionally, UMMH refused to provide us with copies of birth registration forms for all 74 sampled MassHealth patients. Furthermore, if UMMH maintained electronic copies of the logbooks that it disposed of, then those should have been provided to us pursuant to our request. However, in lieu of providing electronic copies of the outstanding birth logbooks, UMMH told us it was “unable to produce any additional logs in response to this request.”
In its response, EOHHS states, “it is not clear from the [Office of the State Auditor] report what percentage of the sample could not be verified as being reported within 10 days.” To be clear, we did not receive sufficient evidence from UMMH to be able to verify that any of the births for the 74 sampled patients were reported to DPH within the required 10-day period. Our inability to report the number of births was due to UMMH’s failure to maintain accurate records. This does not in any way undermine the findings of our audit. On the contrary, it reinforces them. We urge UMMH to implement our recommendations above.
| Date published: | November 4, 2025 |
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