Privacy Guidelines of Administrative Simplification

The Privacy Rule provides the first comprehensive Federal protection for the privacy of health information and is carefully balanced to provide strong privacy protections that do not interfere with patient access to, or the quality of, healthcare delivery.

By the compliance date of April 14, 2003 covered entities (Health Plans, Healthcare Clearinghouses, and Healthcare Providers) must implement standards to protect and guard against the misuse of individually identifiable health information. Failure to timely implement these standards may, under certain circumstances, trigger the imposition of civil or criminal penalties.

Incidental Uses and Disclosures (45CFR 164.502(a))

An incidental use of disclosure is a secondary use of disclosure that cannot be reasonably be prevented, is limited in nature, and that occurs as a result of another use or disclosure that is permitted by the Rule. An incidental use or disclosure is NOT permitted if it is a by-product of an underlying use or disclosure which violates the Privacy Rule.

Minimum Necessary (45CFR 164.502(b), 164.514(d))

The essence of this rule is the conveyance of patient information, in whatever form that conveyance may take (documented, verbal, data transfer, etc.) with the minimum amount of data necessary to meet the current treatment needs of the patient. The Privacy Rule requires covered entities to take reasonable steps to limit the use or disclosure of protected health information to the minimum necessary to accomplish the intended purpose.

Personal Representatives (45CFR 164.502(g))

Under the Privacy Rule, a person authorized to act on behalf of the individual in making health care related decisions is the individual’s personal representative. Covered entities are required to treat an individual’s personal representative as the individual with respect to uses and disclosures of the individual’s protected health information. The personal representative has the ability to act for the individual, exercise the individual’s rights, and may also authorize disclosures of the individual’s protected health information.

Business Associates (45CFR 164.502(e), 164.504(e), 164.532(d) and (e))

By law, the HIPAA Privacy Rule applies only to covered entities. However, most healthcare providers do not carry out all of their activities and functions by themselves. Often the use of services provided by a variety of other persons and businesses are required. The Privacy Rule allows covered providers to disclose protected health information to these “business associates” if the providers obtain satisfactory assurances that the business associate will use the information only for the purposes for which it was engaged by the covered entity, will safeguard the information from misuse, will help the covered entity comply with some of the covered entity’s duties under the Privacy Rule, and help the covered entity carry out its healthcare functions.

• A member of the covered entity’s workforce is NOT a business associate.
• An independent medical transcriptionist that provides transcription services to a physician IS a business associate.
• A software vendor only becomes a “Business Associate” when it is required that a company representative view patient data in relation to providing services in the installation or maintenance of computer software. If the viewing of patient data can be avoided in this regard, a software vendor is not considered a business associate.

*These are excerpts from Privacy Rule guidelines created by the U.S. Dept. of Health and Human Services Office of Civil Rights. For comprehensive text, visit the Office of Civil Rights on the web.