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.”
| May a covered entity use or disclose protected health information for litigation? Answer: A covered entity may use or disclose protected health information as permitted or required by the Privacy Rule, see 45 CFR 164.502(a) (PDF); and, subject to certain conditions the Rule typically permits uses and disclosures for litigation, whether for judicial or administrative proceedings, under particular provisions for judicial and administrative proceedings set forth at 45 CFR 164.512(e) (GPO), or as part of the covered entity’s health care operations, 45 CFR 164.506(a) (PDF). Depending on the context, a covered entity’s use or disclosure of protected health information in ...read more |
| Enforcement Actions Ensure Patients Receive Timely Access to their Records, at a Reasonable Cost Today, the U.S. Department of Health and Human Services (HHS) Office for Civil Rights (OCR) announced the resolution of three investigations concerning potential violations of the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule's patient right of access provision. These cases are part of a collective effort, bringing the total 41 cases, to drive compliance on right of access under the law. “These three right of access actions send an important message to dental practices of all sizes that are covered by the HIPAA ...read more |
| If a CSP stores only encrypted ePHI and does not have a decryption key, is it a HIPAA business associate? Answer: Yes, because the CSP receives and maintains (e.g., to process and/or store) electronic protected health information (ePHI) for a covered entity or another business associate. Lacking an encryption key for the encrypted data it receives and maintains does not exempt a CSP from business associate status and associated obligations under the HIPAA Rules. An entity that maintains ePHI on behalf of a covered entity (or another business associate) is a business associate, even if the entity cannot actually ...read more |
| HMO Revises Process to Obtain Valid Authorizations Covered Entity: Health Plans / HMOs Issue: Impermissible Uses and Disclosures; Authorizations A complaint alleged that an HMO impermissibly disclosed a member’s PHI, when it sent her entire medical record to a disability insurance company without her authorization. An OCR investigation indicated that the form the HMO relied on to make the disclosure was not a valid authorization under the Privacy Rule. Among other corrective actions to resolve the specific issues in the case, the HMO created a new HIPAA-compliant authorization form and implemented a new policy that directs staff to obtain patient signatures ...read more |
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