slum an a, f?m?e 4? August 6, 2013 OFFICE OF THE SECRETARY for Civil Rights, Region 2.33 N. Michigan Ave, Suite 240 Chicago, IL 6060] DEPARTMENT OF HEALTH HUMAN SERVICES voice - (312} 336-2359 TDD (312) 353-5693 (FAX) - {312) 333-133? (bii?iinTiiCi Privacy Of?cer Mars ie - mm 1000 North Oak Avenue Marshfield, WI 54449 Re: OCR Transaction Number: 12-13626-4- Dear {bii?iibiifiici On December 12, 2011, the US. Department of Health and Human Services (HHS), Of?ce for Civil Rights (OCR), received a complaint alleging that Marshfield Clinic, the covered entity, has violated the Federal Standards for Privacy of Individually Identifiable 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, between July 1 and September 15, 2011, lof Marshfield Clinic at the Mosinee Center, impermissiny accessed the complainant?s protected health information without a need to do so. This allegation could re?ect a violation of 4S 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: investigated the complainant's allegations, ran an audit report of the complainant's medical record, and sent the complainant letters dated November 18 and 21, 2011, documenting the results of Marsh?eld Clinic?s investigation. 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. 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 Page 2 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?9683 (Voice) or (312) Sincerely, a; Celeste H. Davis Regional Manager omen. ?le in. DEPARTMENT OF HEALTH HUMAN SERVICES Voice - (312) 836-2359 TDD - (312) 353-5693 (FAX) - (312) 883-180? mm 233 N. Michigan Ave, Suite 240 Chicago, IL 60601 August 6, 2013 Re: OCR Transaction Number: 12-136264 Dear (blisnbiin On December 2, 2011, the U.S. Department of Health and Human Services (HHS), Office for Civil Rights (OCR), received your complaint alleging that Marshfield Clinic, the covered entity, has violated the Federal Standards for Privacy of Individually Identifiable Health Information andjor 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 Securi Rules). Specifically, you allege that, between July 1 and September 15, 2011, {bile}. Marshfield Clinic at the Mosinee Center, impermissibly accessed your protected health information without a need to do so. This allegation could reflect a violation of 45 C.F.R. 164.502(a) and Thank you for bringing this matter to attention. Your complaint is an integral part of OCR's 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. Specifically, on November 18 and 21, 2011, Marsh?eld Clinic sent you letters documenting the results of its investigation, ran an audit report of your medical record, and advise you that it found that only accessed your records in February 2011, for services he provided to you on February 1, 2011. 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. 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 OFFICE OF SECRETARY Office for Civil Rights, Region Page 2 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, Celeste H. Davis Regional Manager Enclosure: Reasonable Safeguards 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 analyze their own needs and circumstances, such as the nature of the protected health information it holds, and assess the potential risks to patients' privacy. Covered entities should also take into account the potential effects on patient care and may consider other issues, such as the financial 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: 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 public hallways and elevators, and posting signs to remind employees to protect patient confidentiality By isolating or locking file cabinets or records rooms; or a 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.