Health Information Management

HIPAA Q&A: You've got questions. We've got answers!

HIM-HIPAA Insider, April 27, 2015

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Submit your HIPAA questions to Editor Jaclyn Fitzgerald at and we will work with our experts to provide you with the information you need.

Q: We have an integrated healthcare system at our facility for the inpatient and outpatient departments and ED. Each clinic has its own electronic tracking system from the time of check-in until they are finished. We also have a tracking board for the testing center here that can be viewed by all providers and nursing staff. Is this more than the minimum necessary standard allows, and would it be considered a HIPAA violation if they are able to view all patients and not just their own?
A: If the tracking system and the tracking board are used for treatment purposes, it would not represent a violation of minimum necessary because the minimum necessary standard does not apply if the purpose of accessing the data is for treatment.
It's wise to assess whether patients can see the tracking board and computer screens that display patient data. Exposure of one patient's PHI to another patient may be considered a breach of unsecure PHI. Position screens and other devices that display patient information in a way that minimizes exposure of PHI to patients and visitors. Also, you can use privacy screens as long as the monitor or device is angled in such a way that unauthorized persons cannot see the screen.
If the patient can stand directly behind a healthcare provider and see the PHI, a privacy screen will likely not be effective. It's not always possible to position computers in a way that prevents patients from seeing the screen because of the physical configuration. For that reason, exposure of limited PHI can be chalked up to an incidental disclosure of PHI. For example, if the physical configuration of the nurses' station is such that all computer monitors face the front of the station and users sit with their backs to patients or visitors who walk up to the nurses' station, privacy screens would not prevent patients and visitors from viewing other patients' data displayed on the monitors.
Editor’s note: Chris Apgar, CISSP, president of Apgar & Associates, LLC, in Portland, Oregon, answered this question for HCPro’s Briefings on HIPAA newsletter. This information does not constitute legal advice. Consult legal counsel for answers to specific privacy and security questions.


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