stmh?h 11' 5 i a QEFICE 0F SECBETARY Of?ce for Civil Rights, Region 2.33 N. Michigan Ave, Suite 240 Chicago, IL 6060] DEPARTMENT OF HEALTH HUMAN SERVICES Voice - (512} 555-4355 Top - {312) 3535553 (FAX) - {312) 555-155? 0W mild August 7, 2013 Privacy of?cer Marsh?eld Clinic 1000 North Oak Avenue Marshfield, WI 54449 Re: OCR Transaction Number: 11-13132? Dear {bileiibimlci On August 25, 2011, the US. Department of Health and Human Services (HHS), Of?ce for Civil Rights (OCR), received a complaint alleging that Marsh?eld Clinic, the covered entity, has violated the Federal Standards for Privacy of Individually Identi?able Health Information andfor the Security Standards for the Protection of Electronic Protected Health Information (45 C.F.R. Parts 160 and 164, Subparts A, C, and E, the Privacy and Security Rules). Speci?cally, the complainant alleges that, on February 11, 2011, the complainant was informed by Clinic that one of its employees impermissiny accessed her protected health information (PHI). This allegation could reflect a violation of 45 C.F.R. 164.502(a) and OCR enforces the Privacy, Security, and Breach Notification 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. OCR is pleased that, Marsh?eld Clinic has taken the following steps toward coming into compliance with the Privacy Rule: met with complainant to mitigate this matter, and dismissed the involved employee for the impermissible access. Please note that, after a period of six months has passed, OCR may initiate and conduct a compliance review of Marsh?eld Clinic related to your compliance with Reasonable Safeguards. Based on the foregoing, OCR is closing this case without further action, effective the date of this letter. OCR's determination as stated in this letter applies only to the allegations in this complaint that were reviewed by OCR. Page 2 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, couid constitute a clearly unwarranted invasion of personal privacy. If you have any questions regarding this matter, please contact Alyce Hilden, Investigator, at (312) 353-9638 (Voice) or (312) Sincerely, Aim/4 este H. Davis Regional Manager DEPARTMENT OF HEALTH 8: HUMAN SERVICES OFFICE OF THE SECRETARY Voice - {312) 336-2359 Of?ce for Civil?Rights, Region TDD - {312) 3536693 233 N. Michigan Ave, Suite 240 (FAX) - {312) 336-1807 Chicago, IL 60601 August 7, 2013 Re: OCR Transaction Number: 11-131327 Dear {bii?ilbi?'ilCi On August 25, 2011, the US. Department of Health and Human Services (HHS), Of?ce for Civil Rights (OCR), received your complaint alleging that Marshfield Clinic, the covered entity, has violated the Federal Standards for Privacy of Individually Identi?able Health Information andfor the Security Standards for the Protection of Electronic Protected Health Information (45 C.F.R. Parts 160 and 164, Subparts A, C, and E, the Privacy and Security Rules}. Speci?cally, you allege that, on February 11, 2011, Marsh?eld Clinic informed you that one of its employees impermissiny accessed your protected health information (PHI). This allegation could re?ect a violation of 4S C.F.R. 164.502(a) and Thank you for bringing this matter to OCR's 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. We are pleased to inform you that your complaint in this matter has been resolved. Speci?cally, met with you to mitigate this matter, and dismissed the involved employee for the impermissible access of your PHI. For your informational purposes, OCR has enclosed material regarding the Privacy Rule provisions related to Reasonable Safeguards. Based on the foregoing, OCR is closing this case without further action, effective the date of this letter. Page 2 Under the Freedom of Information Act, we may be required to release this ietter 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 Alyce Hilden, Investigator, at (312) 353?9638 (Voice) or (312) Sincerely, damn Celeste H. Davis Regional Manager Enclosure: Reasonable Safeguards Page 3 Reasonable Safeguards 45 C.F.R. 164.530 A covered entity must have in place appropriate administrative, technical, and physical safeguards that protect against uses and disclosures not permitted by the Privacy Rule, as well as that limit incidental uses or disclosures. See 45 C.F.R. ?164.530 It is not expected that a covered entity's safeguards guarantee the privacy of protected health information from any and all potential risks. Reasonable safeguards will vary from covered entity to covered entity depending on factors, such as the size of the covered entity and the nature of its business. In implementing reasonable safeguards, covered entities should anaiyze their own needs and circumstances, such as the nature of the protected health information it holds, and assess the potential risks to patientsr privacy. Covered entities should also take into account the potentiai effects on patient care and may consider other Issues, such as the ?nancial and administrative burden of implementing particular safeguards. Many health care providers and professionals have long made it a practice to ensure reasonable safeguards for individuals' health information - for instance: 0 By speaking quietly when discussing a patient's condition with family members in a waiting room or other public area By avoiding using patients? names in pubiic hallways and elevators, and posting signs to remind employees to protect patient con?dentiality; - By isolating or locking file cabinets or records rooms: or By providing additional security, such as passwords, on computers maintaining personal information. Protection of patient con?dentiality is an important practice for many health care and health information management professionals; covered entities can build upon those codes of conduct to develop the reasonable safeguards required by the Privacy Rule.