??m?mth DEPARTMENT OF HEALTH HUMAN SERVICES OFFICE OF THE SECRETARY Voice - {312) 836-2359 Of?ce for Civil Rights, Region 3 TOO - (312] 353-5693 2.33 .N. Michigan Ave. Suite 240 ?is (FAX) - (312) 335-130? Chicago, IL 6060! in, ?were February 28, 2014 {bii?iibimlci Re: OCR Transaction Number: 13-1673?5 {bil?iibim'ici Dear On August 2013, the U.S. Department of Health and Human Services (HHS), Of?ce for Civil Rights (OCR), received your complaint alleging that Marshfield Clinic (Marshfield), 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). Specifically, you allege that your protected health information (PHI), as maintained by Marshfield, was impermissiny used by a Marshfield employee. This allegation could reflect a violation of 45 C.F.R. 164.502(a) and Thank you for bringing this matter to OCR's 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. In general, the Privacy Rule requires that a covered entity or business associate may not use or disclose PHI, except as permitted or required by the Rule. 45 C.F.R. In addition, 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 are pleased to inform you that your complaint in this matter has been resolved. As part of its investigation, OCR has provided Marshfield with guidance to comply with the 45 C.F.R. 164.502(a) and Speci?cally, Marshfield took the following corrective actions: 1) counseled the individual staff member on the Code of Business Ethics and Conduct, Employee Conduct, and Patient Information Con?dentiality policies; 2) required staff member to complete HIPAAIHITECH refresher training; 3) reviewed the above mentioned policies with entire medical transcription department staff; 4) sanctioned individual staff member in accordance Marshfield?s progressive disciplinary policy; and reported incident to OCR. Page 2 For your informational purposes, OCR has enclosed material regarding the Privacy Rule provisions related to 45 C.F.R. 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 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 Wandah Hardy, Investigator, at (312) 353-9374 (Voice) or (312) 353-5693 (TDD). Sincerely, LWL 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 wili 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 ?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: a By speaking quietly when discussing a patient?s condition withlfamiiy members in a waiting room or other public area; 0 By avoiding using patients? names in public hallways and elevators, and posting signs to remind employees to protect patient confidentiality; By isolating or locking ?le cabinets or records rooms; or By providing additional security, such as passwords, on computers maintaining parsonal information. Protection of patient confidentiality 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. fwciiw DEPARTMENT OF HEALTH HUMAN SERVICES OFFICE OF THE SECRETARY iv'oioe - (312) 336-2359 Of?ce for Civil Rights, Region i Too - (312} 353-5693 233 N. Michigan Ave. Suite 240 (FAX) - (312} 885-1807 Chicago, IL 6060] mm February 28, 2014 Privacy Of?cer Marsh?elcl Clinic 1000 North Oak Ave. Marshfield, WI Re: OCR Transaction Number: 13-1673?5 {bli?libliili?ll Dear On August 27, 2013, the U.S. 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 Identi?able Health Information andfor the Security Standards for the Protection of Electronic Protected Health Information (45 CPR. Part - I . I - 4, Subparts A, C, and E, the Privacy and Security Rules). Speci?cally, the complainant, alleges that her protected health information (PHI), as maintained by Marsh?eld, was impermissiny used by a Marshfield employee. 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 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 general, the Privacy Ruie requires that a covered entity or business associate may not use or disclose PHI, except as permitted or required by the Rule. 45 C.F.R. In addition, 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. OCR is pleased that, in response to our investigation, Marshfield has taken the following steps toward coming into compliance with 45 C.F.R. Speci?cally, Marsh?eld took the following corrective actions: 1) counseled the individual staff member on the Code of Business Ethics and Conduct, Employee Conduct, and Patient Information Con?dentiality policies 2) required staff member to complete refresher training; 3) reviewed the above mentioned policies with entire medical transcription department staff: 4) sanctioned individual staff member in accordance Marsh?eld?s progressive disciplinary policy; and reported incident to OCR. Please note that, after a period of six months has passed, OCR may initiate and conduct a compliance review of Marsh?eld related to your compliance with 45 C.F.R. Page 2 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 ietter 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 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 Wandah Hardy, Investigator, at (312) 353-9?74 (Voice) or (312) 353?5693 (TDD). Sincerely, .. . .. are. 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 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 ,1 By avoiding using patients? names in public hallways and elevators, and posting signs to remind employees to protect patient con?dentiality; By isoiating or locking file cabinets or records rooms; or By providing additional security, such as passwords, on computers maintaining personai 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.