Under HIPAA, a disclosure accounting process is mandated for Protected Health Info. This means covered entities must keep track of each time PHI is disclosed.
A disclosure accounting process is required to identify who received the PHI, what PHI was disclosed, and why it was disclosed.
Covered entities must document each disclosure, including the date, name of the recipient, and a brief description of the PHI disclosed.
HIPAA Basics
The HIPAA Privacy Rule protects individual health information while allowing necessary access to health information, promoting high-quality healthcare, and protecting the public's health.
A covered entity must disclose protected health information in only two situations: to individuals or their personal representatives when they request access to or an accounting of disclosures of their protected health information, and to the Department of Health and Human Services when it's undertaking a compliance investigation, review, or enforcement action.
Disclosure accounting is not financial, but rather keeping records of particular disclosures made for purposes other than Treatment, Payment, or Healthcare Operations (TPO).
Every disclosure made for purposes other than Treatment, Payment, or Healthcare Operations must be included in the log, except for exceptions where patients have asked for it themselves.
The log must include access to delivery of or transmission to parties that do not have authorization to have access to those records.
If a patient has given written authorization to share their information, you do not have to log that in the accounting log because you will keep that written authorization in the patient's file.
HIPAA Privacy Rule
The HIPAA Privacy Rule is a set of standards that protects an individual's protected health information (PHI).
Covered entities, which include individuals and organizations, must follow these standards to ensure the proper use and disclosure of PHI.
The Privacy Rule allows necessary access to health information while protecting the individual's privacy.
A covered entity must disclose PHI in only two situations: to the individual or their personal representative when they request access to their PHI, or to the Department of Health and Human Services (HHS) for a compliance investigation or enforcement action.
The Privacy Rule also contains standards for individuals' rights to understand and control how their health information is used, promoting high-quality healthcare and protecting the public's health.
Accounting
An accounting of disclosures is required under HIPAA if you disclose patient records for certain purposes, such as selling them or for scientific research. It's also necessary if the client has consented to have their information included in a marketing story or if their information has been disclosed for other marketing purposes.
You need to account for the following categories in your log: court orders, subpoenas, state reporting, indoor emergencies, public healthcare activities, prevention of disease, public health investigations, victims of abuse, neglect or domestic violence, health oversight activities, decedents, research purposes, and specialized government functions.
A huge part of your normal HIPAA routine should not be accounting for disclosures, but you need to be aware of it because patients have the right to request it. They have the right to request it for up to 6 years prior to the request.
You should not make disclosure outside of the TPO part of your practice, and when it does happen, you know exactly what to do for those disclosures. If you don't have an AOD log, it should be part of your HIPAA Policies and Procedures Manual which is a requirement under HIPAA.
Here are the required categories to be accounted for by law in an accounting of disclosures:
- court orders
- subpoenas
- state reporting
- indoor emergencies
- public healthcare activities
- prevention of disease
- public health investigations
- victims of abuse, neglect or domestic violence
- health oversight activities
- decedents
- research purposes
- specialized government functions
- workman's compensation
- and even accidental disclosures
Permitted Use and Disclosure
Under HIPAA, a covered entity can use and disclose protected health information (PHI) without an individual's authorization in certain situations.
These situations include disclosure to the individual if the information is required for access or accounting of disclosures, treatment, payment, and healthcare operations.
The law also permits use and disclosure of PHI for opportunity to agree or object to the disclosure, incident to an otherwise permitted use and disclosure, and limited dataset for research, public health, or healthcare operations.
A covered entity must disclose PHI to the Department of Health and Human Services (HHS) when it is undertaking a compliance investigation, review, or enforcement action.
Here are the 12 national priority purposes for public interest and benefit activities that permit use and disclosure of PHI without an individual's authorization or permission:
- When required by law
- Public health activities
- Victims of abuse or neglect or domestic violence
- Health oversight activities
- Judicial and administrative proceedings
- Law enforcement
- Functions concerning deceased persons
- Cadaveric organ, eye, or tissue donation
- Research, under certain conditions
- To prevent or lessen a serious threat to health or safety
- Essential government functions
- Workers' compensation
A covered entity is permitted, but not required, to use and disclose PHI for the following purposes or situations: treatment, payment, and healthcare operations, limited dataset for research, public health, or healthcare operations, and public interest and benefit activities.
A use or disclosure of PHI that occurs as a result of, or as "incident to", an otherwise permitted use or disclosure is permitted as long as the covered entity has adopted reasonable safeguards and the information being shared was limited to the "minimum necessary."
Security and Confidentiality
Under HIPAA, a disclosure accounting is required to ensure the confidentiality, integrity, and availability of all e-PHI.
To comply with the HIPAA Security Rule, covered entities must detect and safeguard against anticipated threats to the security of the information. This includes protecting against anticipated impermissible uses or disclosures that are not allowed by the rule.
Covered entities must also certify compliance by their workforce. This means that all employees and staff must be aware of and adhere to the HIPAA Security Rule standards.
Here are the four main requirements for covered entities to ensure the security and confidentiality of e-PHI:
- Ensure the confidentiality, integrity, and availability of all e-PHI
- Detect and safeguard against anticipated threats to the security of the information
- Protect against anticipated impermissible uses or disclosures that are not allowed by the rule
- Certify compliance by their workforce
The HHS Office for Civil Rights enforces HIPAA rules, and all complaints should be reported to that office. HIPAA violations may result in civil monetary or criminal penalties.
Ohrp vs Hipaa
HIPAA requires a disclosure accounting to individuals who request access to their protected health information.
Under HIPAA, a covered entity must disclose protected health information in two situations.
A covered entity must disclose protected health information to individuals specifically when they request access to their protected health information.
The Department of Health and Human Services (HHS) is also entitled to protected health information when it is undertaking a compliance investigation, review, or enforcement action.
Covered entities are required to provide a disclosure accounting to individuals who request access to their protected health information.
Sources
- https://www.cdc.gov/phlp/php/resources/health-insurance-portability-and-accountability-act-of-1996-hipaa.html
- https://www.law.cornell.edu/cfr/text/45/164.528
- https://compliancy-group.com/use-and-disclosure-of-phi/
- https://academics.prismahealth.org/research-and-innovation/research-development/resources/data-use-under-hipaa
- https://www.functionallawyer.com/blog/5
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