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.”



When does the Privacy Rule allow covered entities to disclose protected health information to law enforcement officials? Answer: The Privacy Rule is balanced to protect an individual’s privacy while allowing important law enforcement functions to continue. The Rule permits covered entities to disclose protected health information (PHI) to law enforcement officials, without the individual’s written authorization, under specific circumstances summarized below. For a complete understanding of the conditions and requirements for these disclosures, please review the exact regulatory text at the citations provided. Disclosures for law enforcement purposes are permitted as follows: To comply with a court order or ...read more



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



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 ...read more



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

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