fie #437451] 11-? DR DEPARTMENT OF HEALTH HUMAN SERVICES OFFICE OF THE SECRETARY voice - (212) 254-3313, (soc) 3ss1o1s Of?ce for Civil Rights, Region II TDD (212) 254-2355. {8010) Jacob Javits Federal Buikling (FAX) - {212) 264-3039 26 Federal Plaza, Suite 3312 New York, NY 10278 Ms. Andrea Wilson, RHIA, CIPP, CIPPIG VHA Privacy Implementation Coordinator Information Access and Privacy Of?ce -10P20?l Department of Veterans Affairs - Veterans Health Administration 810 Vermont Avenue, NW. Washington. DC 20420 MR 2 6 2013 OCR Transaction Number: 12-146325 Dear Ms. Wilson: On July 24, 2012. the US. Department of Health and Human Services (HHS), Of?ce for Civil Rights (OCR), Region II received a complaint aliegihg that the Veterans Administration, the covered entity, has violated the Federal Standards for Privacy of Individually Identi?able Health information 45 OER. Pa 1 0 and 164, SubparlsA and E, the Privacy . - a - ifically, ibiieitmimi {the complainant) alleges that on July 9, 2012(the Doctor) at the Veterans Administration Hospital in Ponce, Puerto Rico, disclosed the complainant's protected health information when the Doctor had a conversation with the compiainant regarding his health condition in a loud tone of voice, which was overheard by other patients. This allegation could re?ect a violation of 45 C.F.R. 164.502(a) and OCR enforces the Privacy. Security, and Breach Notification Rules, and also enforces Federal civil rights laws which prohibit discrimination in the delivery of health and human services because of race, color, national origin, disability, age. and under certain circumstances, sex and religion. 'The Privacy Rule permits certain incidental uses and disclosures of protected health information that occur as a by-product of another permissible or required use or disclosure of PHI, as long as the covered entity has applied reasonable safeguards and implemented the minimum necessary standard, where applicable, with respect to the primary use or disclosure. See 45 C.F.R. For example, the Privacy Rule permits covered health care providers to share PHI for treatment purposes without patient authorization as long as they use reasonable safeguards when doing so. These safeguards may vary depending on the mode of communication used. For example, when discussing patient health information orally with another provider in proximity of others, a doctor may be able to reasonably safeguard the information by lowering hisiher voice. In this matter, the complainant alleges the incidental use or disclosure of PHI was not permissible, either because reasonable safeguards were not in place to prevent the use Page 2 Ms. Wilson, VHA Privacy Imptementation Coordinator or disclosure and/or because the minimum necessary standard was not implemented when it should have been. Pursuant to its authority under 45 CPR. 160.304(a) and OCR has determined to resolve this matter informally through the provision of technical assistance to the Veterans Administration. To that end, OCR has enclosed material explaining the Privacy Rule provisions related to Incidental Uses and Disclosures, Reasonable Safeguards, and the Minimum Necessary requirement. You are encouraged to review these materials closely and to share them with your staff as part of the Health Insurance Portability and Accountability Act (HIPAA) training you provide to your workforce. You are also encouraged to assess and determine whether there may have been an incident of noncompliance as alleged by the complainant in this matter, and, if so, to take the steps necessary to ensure such noncompliance does not occur in the future. Please contact OCR if you need further information regarding the allegations in this matter. Should OCR receive a similar allegation of noncompliance against the Veterans Administration in the future, OCR may initiate a formal investigation of that matter. Based on the foregoing, OCR is closing this case without further action, effective the date of this letter. determination as stated in this letter applies only to the allegations in this complaint that were reviewed by OCR. Under the Freedom of lnforrnation Act, we may be required to release this letter and other information about this case upon request by the public. In the event OCR receives such a request, we will make every effort, as permitted by law, to protect information that identifies individuals or that, if released, could constitute a clearly unwarranted invasion of personal privacy. If you have any questions regarding this matter, please contact Cheylisia Edwards, Investigator, at (212) 2644148 (Voice) or (212) 264-2355 (TDD). Sincerely, MK a: inda C. Coion Regional Manager Enclosures: Incidental Disclosures Reasonable Safeguards Minimum Necessary