Train your employees. Staff should be able to protect the privacy of patients in the performance of their work. Train them to recognize the difference between random disclosures and data breaches. Well-trained employees not only protect patients` privacy, but also protect their business from litigation. For example, random disclosure may occur when an employee of a business partner visits a treatment facility and sees a patient in the waiting room. While the provider does not need to know the identity of patients in the facility, they have a compliant BAA and visit the facility to perform the work described in the BAA. Their exposure to PSR is secondary to the compliant work they perform. The confidentiality rule does not require the elimination of all accidental exposures. This is simply not practical.
In August 2002, specific changes were made to the rule to clarify that accidental disclosures do not violate the Privacy Rule if you have policies in place that adequately protect and restrict the use and disclosure of protected health information (PSR). (Note 45 CFR 164.502(a)(1)(iii)) If accidental exposure is a by-product of an underlying use or disclosure that violates the confidentiality rule, accidental exposure is also a violation. Health care providers communicate regularly with other employees and patients to facilitate patient treatment. Because this disclosure is so commonplace and mundane, there is a risk of random disclosure of protected information (PSR). According to the HIPAA Privacy Rule, covered companies must have adequate administrative, technical, and physical safeguards in place that limit accidental disclosure. However, disclosure that is expressly the result of a lack of reasonable safeguards or the failure to apply the required minimum standard is not permitted under the HIPAA Privacy Rule. HHS defines random disclosure as follows: In summary, random disclosure is allowed if it is unavoidable and occurs during compliant activity. If it is the result of something that violates the confidentiality rule, this is not allowed and will be considered a violation of compliance.
For example, a hospital visitor may listen to a provider`s confidential conversation with another provider about caring for a patient they are both treating. In such cases, the primary use or disclosure of PSR is communication between suppliers. Such communication is permitted under the HIPAA Privacy Rule because it relates to patient care. A secondary or random disclosure was made by chance to the hospital visitor who was listening to the conversation. Assuming this random disclosure is inherently limited and could not reasonably have been avoided, the HIPAA Privacy Rule allows it. “Accidental use or disclosure is a secondary use or disclosure that cannot reasonably be prevented, is of a limited nature and results from any other use or disclosure permitted under the rule. However, accidental use or disclosure is not permitted if it is a by-product of an underlying use or disclosure that violates the confidentiality policy. In the Kentucky case, the nurse sued the hospital for discharge, claiming the disclosure was accidental.
But has it sufficiently protected the patient`s privacy? The nurse did not lower her voice or take any other protective measures, although others were present, so it was not accidental. For example, if a hospital grants an employee unfettered and unnecessary access to patient data, this would be a failure to enforce the required minimum standard. If that employee had subsequently disclosed this information because of this lack of security, it would be an unlawful disclosure that could have been avoided by the requirements outlined in the Confidentiality Rule. In summary, if your organization is actively involved in HIPAA compliance and has the right policies and procedures in place, you probably don`t have to worry about random risks. Take the time to document them and turn them into “learning moments” for the workforce. This improves your processes, compliance and security. On the other hand, if you don`t take HIPAA compliance seriously, accidental exposure can result in a significant audit and fines if reported by an unhappy patient or employee. Suppose a patient registers at the reception. Although there is a partition, the patient hears a name and date of birth while the employee speaks quietly on the phone. This is a random disclosure and not a violation of HIPAA, as appropriate safeguards have been put in place: a score and the employee speaking quietly. The reality-based HIPAA privacy rule does not require that any risk of accidental disclosure be eliminated in order to meet its standards. Instead, the privacy policy allows for random disclosure of protected health information, provided the company has the following: If you have any questions about random disclosures or HIPAA, please contact us at: compliance@thirdrock.com The HIPAA Privacy Rule is not intended to impede patient care and therefore does not require that all risks of such random disclosures be eliminated in order to maintain compliance.
Instead, the HIPAA Privacy Rule allows certain random disclosures of protected health information (PHI) if a covered entity complies with all other elements of compliance, including necessary safeguards and policies and procedures that reflect the minimum standard required for privacy. General provisions. The confidentiality rule allows for certain random uses and disclosures that occur as a by-product of any other permitted or required use or disclosure, provided that the covered entity has put in place appropriate safeguards and, where applicable, implemented the required minimum standard of primary use or disclosure. See 45 CFR 164.502(a)(1)(iii). Accidental use or disclosure is a secondary use or disclosure that cannot reasonably be prevented, is limited in nature and is the result of any other use or disclosure authorized by the Rule. However, accidental use or disclosure is not permitted if it is a by-product of an underlying use or disclosure that violates the confidentiality policy. An example of disclosure that is not random could be a treatment facility that performs diagnostic activities in the waiting room, where other people can hear the conversation between the doctor and the patient. Unless there are unusual restrictions due to the physical facility or the budget of the facility, the practice should be able to avoid sharing patient information with others in the waiting room.
You can imagine that if it was a mass accident where all the treatment rooms were full and patients needed immediate triage, diagnosis in the waiting room might not have been reasonably avoided. .