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.”
| 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 Any provision within this guidance that has been vacated by the Ciox Health decision is rescinded.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 refuse to disclose ePHI to an app chosen by an individual because of concerns about how the app will use or disclose the ePHI it receives? No. The HIPAA Privacy Rule generally prohibits a covered entity from refusing to disclose ePHI to a third-party app designated by the individual if the ePHI is readily producible in the form and format used by the app. See 45 CFR 164.524(a)(1), (c)(2)(ii), (c)(3)(ii). The HIPAA Rules do not impose any restrictions on how an individual or the individual’s designee, such as an app, may use the health information ...read more |
| Entity Rescinds Improper Charges for Medical Record Copies to Reflect Reasonable, Cost-Based Fees Covered Entity: Private Practice Issue: Access A patient alleged that a covered entity failed to provide him access to his medical records. After OCR notified the entity of the allegation, the entity released the complainant’s medical records but also billed him $100.00 for a “records review fee” as well as an administrative fee. The Privacy Rule permits the imposition of a reasonable cost-based fee that includes only the cost of copying and postage and preparing an explanation or summary if agreed to by the individual. To ...read more |
| 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; ...read more |
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