Hospital Revises Email Distribution as a Result of a Disclosure to Persons Without a "Need to Know"
Hospital Revises Email Distribution as a Result of a Disclosure to Persons Without a "Need to Know"
Covered Entity: General Hospital
Issue: Impermissible Use and Disclosure
A complainant, who was both a patient and an employee of the
hospital, alleged that her protected health information (PHI) was
impermissibly disclosed to her supervisor. OCR’s investigation revealed
that: the hospital distributed an Operating Room (OR) schedule to
employees via email; the hospital’s OR schedule contained information
about the complainant’s upcoming surgery. While the Privacy Rule may
permit the disclosure of an OR schedule containing PHI, in this case, a
hospital employee shared the OR scheduled with the complainant’s
supervisor, who was not part of the employee's treatment team, and did
not need the information for payment, health care operations, or other
permissible purposes. The hospital disciplined and retrained the
employee who made the impermissible disclosure. Additionally, in order
to prevent similar incidents, the hospital undertook a complete review
of the distribution of the OR schedule. As a result of this review, the
hospital revised the distribution of the OR schedule, limiting it to
those who have “a need to know.”
| Physician Revises Faxing Procedures to Safeguard PHI Covered Entity: Health Care Provider Issue: Safeguards A doctor's office disclosed a patient's HIV status when the office mistakenly faxed medical records to the patient's place of employment instead of to the patient's new health care provider. The employee responsible for the disclosure received a written disciplinary warning, and both the employee and the physician apologized to the patient. To resolve this matter, OCR also required the practice to revise the office's fax cover page to underscore a confidential communication for the intended recipient. The office informed all its employees of the ...read more |
| Mental Health Center Provides Access and Revises Policies and Procedures Covered Entity: Mental Health Center Issue: Access, Restrictions The complainant alleged that a mental health center (the "Center") refused to provide her with a copy of her medical record, including psychotherapy notes. OCR’s investigation revealed that the Center provided the complainant with an opportunity to review her medical record, including the psychotherapy notes, with her therapist, but the Center did not provide her with a copy of her records. The Privacy Rule requires covered entities to provide individuals with access to their medical records; however, the Privacy Rule exempts ...read more |
| SCOPE OF CRIMINAL ENFORCEMENT UNDER 42 U.S.C. § 1320d-6 Covered entities and those persons rendered accountable by general principles of corporate criminal liability may be prosecuted directly under 42 U.S.C. § 1320d-6, and the knowingly element of the offense set forth in that provision requires only proof of knowledge of the facts that constitute the offense. MEMORANDUM OPINION FOR THE GENERAL COUNSEL DEPARTMENT OF HEALTH AND HUMAN SERVICES AND THE SENIOR COUNSEL TO THE DEPUTY ATTORNEY GENERAL You have asked jointly for our opinion concerning the scope of 42 U.S.C. § 1320d-6 (2000), the criminal enforcement provision of the ...read more |
| Hospital Implements New Minimum Necessary Polices for Telephone Messages Covered Entity: General Hospital Issue: Minimum Necessary; Confidential Communications A hospital employee did not observe minimum necessary requirements when she left a telephone message with the daughter of a patient that detailed both her medical condition and treatment plan. An OCR investigation also indicated that the confidential communications requirements were not followed, as the employee left the message at the patient’s home telephone number, despite the patient’s instructions to contact her through her work number. To resolve the issues in this case, the hospital developed and implemented several new procedures. ...read more |
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