Private Practice Revises Policies and Procedures Addressing Activities Preparatory to Research

Private Practice Revises Policies and Procedures Addressing Activities Preparatory to Research
Covered Entity: Private Practice
Issue: Impermissible Disclosure-Research

A private practice physician who was the principal investigator of a clinical research study disclosed a list of patients and diagnostic codes to a contract research organization to telephone patients for recruitment purposes.  The disclosure was not consistent with documents approved by the Institutional Review Board (IRB). The private practice maintained that the disclosure to the contract research organization was permissible as a review preparatory to research.  Activities considered “preparatory to research” include: preparing a research protocol; developing a research hypothesis; and identifying prospective research participants.  Contacting individuals to participate in a research study is a use or disclosure of protected health information (PHI) for recruitment, as it is part of the research and is not an activity preparatory to research.  To remedy this situation, the private practice revised its policies and procedures regarding the disclosure of PHI and trained all physicians and staff members on the new policies and procedures.  Under the revised policies and procedures, the practice may use and disclose PHI for research purposes, including recruitment, only if a valid authorization is obtained from each individual or if the covered entity obtains documentation that an alteration to or a waiver of the authorization requirement has been approved by an IRB or a Privacy Board.



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



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 dispose of protected health information in dumpsters accessible by the public? For example, depending on the circumstances, proper disposal methods may include (but are not limited to): Shredding or otherwise destroying PHI in paper records so that the PHI is rendered essentially unreadable, indecipherable, and otherwise cannot be reconstructed prior to it being placed in a dumpster or other trash receptacle.Maintaining PHI for disposal in a secure area and using a disposal vendor as a business associate to pick up and shred or otherwise destroy the PHI.In justifiable cases, based on the size and the ...read more



Pharmacy Chain Enters into Business Associate Agreement with Law Firm Covered Entity: Pharmacy Chain Issue: Impermissible Uses and Disclosures; Business Associates A complaint alleged that a law firm working on behalf of a pharmacy chain in an administrative proceeding impermissibly disclosed the PHI of a customer of the pharmacy chain.  OCR investigated the allegation and found no evidence that the law firm had impermissibly disclosed the customer’s PHI.  However, the investigation revealed that the pharmacy chain and the law firm had not entered into a Business Associate Agreement, as required by the Privacy Rule to ensure that PHI is ...read more

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