FAX (til 565-3309, Office for Civil Rights, Region I JFK Federal Building, Room 1375 Government Center Boston, MA 02203-00112 I yew?, 1r 3 DEPARTMENT QE 351mg SERVICE QFFIQE QE Voice 565-1340, (800) 368-1019, TDD (617] 565- 1343, SEP 1 0 2013 {blt?libltilicl OCR Transaction Number: 13-160004 6i) DearIEClli On May 8, 2013, the U.S. Department of Health and Human Services (HHS), Of?ce for Civil Rights (OCR), Region I received your complaint alleging that Eisenhower Army Medical Center, the covered entity, has violated the Federal Standards for Privacy of Individually Identi?able Health Information (45 C.F.R. Parts 160 and 164, Subparts A and E, the Privacy Rule). Speci?cally, you allege that your protected health information was impermissiny disclosed when your records were comingled with that of another patient with a similar name. This allegation could re?ect a violation of 45 C.F.R. ?164.502(a) Thank you for bringing this matter to attention. Your complaint is an integral part of enforcement efforts. OCR enforces the Privacy, Security, and Breach Noti?cation Rules, and also 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. A covered entity must maintain reasonable and appropriate administrative, technical, and physical safeguards to prevent intentional or unintentional use or disclosure of PHI in violation of the Privacy Rule and to limit its incidental use and disclosure pursuant to otherwise permitted or required use or disclosure. 45 C.F.R. For example, such safeguards might include shredding documents containing protected health information before discarding them, securing medical records with lock and key or pass code, and limiting access to keys or pass codes. We have carefully reviewed your complaint against Eisenhower Army Medical Center and have determined to resolve this matter informally through the provision of technical assistance to Eisenhower Army Medical Center. Should OCR receive a similar allegation of noncompliance against Eisenhower Army Medical Center in the future, OCR may initiate a formal investigation of that matter. For your informational purposes, OCR has enclosed material regarding the Privacy Rule provisions related to Safeguards. 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 lnfonnation 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 identi?es individuals or that, if released, could constitute a clearly unwarranted invasion of personal privacy. If you have any questions regarding this matter, please contact Phil Levvis, Investigator, at (617) 565-1355 (Voice) or (617) 565-1343 (TDD). Sincerely, Regional Manager SW I 5' TMENT LTH om i a Voice (517} 565-1340, (soc) ass-1019, 111mm) 565- 1343, (see) FAX (617} 565-3309, Of?ce for Civil Rights, Region I . Federal Building, Room 1375 Government Center mannerisms-coo: {bramva I SEP 1 a 2013 Director, Privacy and Civil Liberties Of?ce TRICARE Man ement Activity Skyline 5, Suite 5111 Leesburg 1 Falls Church VA 22041 Re: 13-160004 Dear On May 8, 2013, the U.S. Department of Health and Human Services (HHS), Of?ce for Civil Rights (OCR), Region I received a complaint alleging that Eisenhower Army Medical Center, the covered entity, has violated the Federal Standards for Privacy of Individually Identi?able Health Information (45 C.F.R Parts 160 and 164, Subparts A and E, the Privacy Rule). Speci?cally, the complaint alleges that complainant?s protected health information was impermissihly disclosed when her records were comingled with that of another patient with a similar name. This allegation could re?ect a violation of 45 CPR. ?164.502(a) ?164.530(c) OCR enforces the Privacy, Security, and Breach Noti?cation Rules, and also 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. In this matter, the complainant alleges that the covered entity does not employ reasonable safeguards to prevent impermissible disclosures of protected health information (PHI). A covered entity must maintain reasonable and appropriate administrative, technical, and physical safeguards to prevent intentional or unintentional use or disclosure of PHI in violation of the Privacy Rule and to limit its incidental use and disclosure pursuant to otherwise permitted or required use or disclosure. 45 C.F.R. Pursuant to its authority under 45 C.F.R. 160.3 04(a) and OCR has determined to resolve this matter informally through the provision of teohnical assistance to Eisenhower Army Medical Center. To that end, OCR has enclosed material explaining the Privacy Rule provisions related to Reasonable Safeguards. 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 mayr have been any 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. In addition, OCR encourages you to review the facts of this individual?s complaint and provide the individual the appropriate written response swiftly if necessary to comply with the requirements of the Privacy Rule. Should OCR receive a similar allegation of noncompliance against Eisenhower Army Medical Center in the future, OCR may initiate a formal investigation of that matter. In addition, please note that, after a period of six months has passed, OCR may initiate and conduct a compliance review of Eisenhower Army Medical Center related to your compliance with the Privacy Rulc?s provisions related to Reasonable Safeguards. 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 Information 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 identi?es individuals or that, if released, could constitute a clearly unwarranted invasion of personal privacy. If you have any questions regarding this matter, please contact Phil Lewis, Investigator, at (617) 565-1355 (Voice) or (617) 565-1343 (TDD). Sincerely, Peter Chan Regional Manager Enclosure: Reasonable Safeguards