Hospital Issues Guidelines Regarding Disclosures to Avert Threats to Health or Safety

Hospital Issues Guidelines Regarding Disclosures to Avert Threats to Health or Safety
Covered Entity: General Hospital
Issue: Safeguards; Impermissible Uses and Disclosures; Disclosures to Avert a Serious Threat to Health or Safety

After treating a patient injured in a rather unusual sporting accident, the hospital released to the local media, without the patient’s authorization, copies of the patient’s skull x-ray as well as a description of the complainant’s medical condition. The local newspaper then featured on its front page the individual’s x-ray and an article that included the date of the accident, the location of the accident, the patient’s gender, a description of patient’s medical condition, and numerous quotes from the hospital about such unusual sporting accidents.  The hospital asserted that the disclosures were made to avert a serious threat to health or safety; however, OCR’s investigation indicated that the disclosures did not meet the Privacy Rule’s standard for such actions.  The investigation also indicated that the disclosures did not meet the Rule’s de-identification standard and therefore were not permissible without the individual’s authorization. Among other corrective actions to resolve the specific issues in the case, OCR required the hospital to develop and implement a policy regarding disclosures related to serious threats to health and safety, and to train all members of the hospital staff on the new policy.



What is a covered entity’s obligation under the Breach Notification Rule if it transmits an individual’s PHI to a third party designated by the individual in an access request, and the entity discovers the information was breached in transit? This guidance remains in effect only to the extent that it is consistent with the court’s order in Ciox Health, LLC v. Azar, No. 18-cv-0040 (D.D.C. January 23, 2020), which may be found at https://ecf.dcd.uscourts.gov/cgi-bin/show_public_doc?2018cv0040-51. More information about the order is available at https://www.hhs.gov/hipaa/court-order-right-of-access/index.html. Any provision within this guidance that has been vacated by the Ciox Health decision is rescinded. ...read more



Can a covered entity use existing aspects of the HIPAA Privacy Rule to give individuals the right to decide whether sensitive information about them may be disclosed to or through a health information organization (HIO)? Yes. To the extent a covered entity is using a process either to obtain consent or act on an individual’s right to request restrictions under the Privacy Rule as a method for effectuating individual choice, policies can be developed for obtaining consent or honoring restrictions on a granular level, based on the type of information involved. For example, specific consent and restriction policies could ...read more



Large Provider Revises Patient Contact Process to Reflect Requests for Confidential Communications Covered Entity: General Hospital Issue: Impermissible Disclosure; Confidential Communications A patient alleged that a general hospital disclosed protected health information when a hospital staff person left a message on the patient’s home phone answering machine, thereby failing to accommodate the patient’s request that communications of PHI be made only through her mobile or work phones.  In response, the hospital instituted a number of actions to achieve compliance with the Privacy Rule.  To resolve this matter to the satisfaction of OCR, the hospital: retrained an entire Department with ...read more



Health Plan Corrects Impermissible Disclosure of PHI through Training, Mitigation, and Sanctions Covered Entity: Health Plans Issue: Impermissible Uses and Disclosures An employee of a major health insurer impermissibly disclosed the protected health information of one of its members without following the insurer's authorization and verification procedures. Among other corrective actions to resolve the specific issues in the case, OCR required the health insurer to train its staff on the applicable policies and procedures and to mitigate the harm to the individual. In addition, the employee who made the disclosure was counseled and given a written warning. ...read more

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