OF MICHIGAN HEALTH SYSTEM
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1 1 PHI - Protected Health Information UNIVERSITY OF MICHIGAN HEALTH SYSTEM Updated 09/23/2013
2 2 Q: Is PHI the same as the medical record? A: No. protects more than the official medical record. Lots of other information besides the official medical record is considered PHI (e.g., billing records, etc.) For example, the fact that a person is a patient here at UMHS is considered PHI. Thus, it would be a violation to tell a friend or family member that a mutual friend or neighbor was admitted to UMHS, unless the patient gave authorization to do so.
3 3 Q: What if I m accidentally overheard discussing a patient s PHI record? A: This is usually considered an incidental disclosure. It is not a violation as long as you take reasonable precautions and discuss the protected health information for a legitimate purpose. The privacy rule is not meant to prevent health care team members from communicating with each other and their patients during the course of treatment. These "incidental disclosures" are allowed under.
4 4 Q: If I overhear patient care information in the elevator or in the hallway, how should I handle it? A: There are signs in the elevators stating that patient information should not be discussed. Point to the sign and remind the speakers of the policy. If the conversation clearly violates policies or regulations, report it to the UMHS Compliance Office, and if possible, obtain the name(s) of the speakers so education can be provided.
5 5 General Access Q: I work in the hospital and don't need to access PHI for my job, but every now and then a patient s family member asks me about a patient. What should I do? A: Explain that you do not have access to that information, and refer the individual to the patient s health care provider.
6 6 Category 1 Disclosures Patient Authorization NOT Required Q: What should I do if a government agency or law enforcement person requests information about a patient? A: If working with law enforcement is not part of your responsibility, contact your supervisor or the Health System Legal Office (HSLO) at or the attorney on call can be contacted through the hospital operator. Those who do work directly with law enforcement receive special training on the special rules about disclosing patient information to law enforcement authorites. The privacy rules are very specific in this area.
7 7 Category 2 Disclosures Patient Authorization Required Q: As part of my job, I have access to a patient s PHI. How do I know which family and friends can be told this information? A: Always ask the patient who can receive this information and document the patient s response in the medical record. The best way to do this is to have the patient complete the UMHS Family & Friends List Form - one for outpatient and one for each inpatient admission. Check with your supervisor. In cases where you cannot ask (e.g., patient is not present or is unconscious) and there is an no other documentation in the medical record, use your professional judgment.
8 8 Category 2 Disclosures Patient Authorization Required Q: When I am speaking to a patient, and friends or family members are in the treatment room, do I assume the patient has given me permission to speak of the PHI in front of these persons or do I need to ask them to leave? A: Do not assume it is okay to speak in from of the other people. Ask the patient if it okay to discuss their PHI in front of the person(s). If highly sensitive information needs to be discussed (HIV status for example), then ask the person(s) to leave the room before beginning any discussion about the highly sensitive information.
9 9 Q: If the patient is not conscious, to whom can we disclose the PHI? Category 2 Disclosures Patient Authorization Required A: You will have to decide this on a caseby-case basis. If you know the patient's preferences, as in you can tell my spouse, but not my sister, then document the request and follow it. Otherwise, use your professional judgment. Always use the Minimum Necessary standard: disclose only information that is directly relevant to the person's involvement with the patient's health care. Once a patient has regained consciousness, he or she will determine when and how we can share protected information.
10 10 Category 2 Disclosures Patient Authorization Required Q: Can someone else still pick up a patient's prescriptions, x-rays, or medical supplies? A: Yes, if in the care provider's professional judgment it is okay to give the prescription, x-rays or medical supplies to that individual.
11 11 Verification Requests for PHI by Phone Q: What if I get a phone call looking for information, and the caller says it s the patient? What should I do? A: If the request is made by phone, and the requester identifies him- or herself as the patient, you can ask him or her to provide personal information for verification, such as his or her UMHS medical record number, birth date, or address.
12 12 Verification Requests for PHI by Phone Q: What about requests to leave information on voice mail or an answering machine? A: If you are asked to phone or leave confidential information via voice mail, for example, you should verify with the patient or other approved individual that it is okay to leave messages this way. Make sure you confirm the number, and only leave the minimum necessary information. Your unit may have more restrictive policies, so check with your supervisor on what is appropriate.
13 13 Verification Requests for PHI by Phone Q: What if I m not supposed to leave a message? A: If you are asked not to leave voice messages, do not. This is especially important with patients who may not want to share PHI with family members, roommates, or co-workers. Also, at UMHS, encourage the patient to sign up for the patient portal (MyChart), which is a good way to communicate confidentially with the patient about upcoming appointment reminders, test results, etc.
14 Verification Requests for PHI by Phone Q: How much information is it OK to leave? A: Always leave the minimum possible amount of information. For example: This is the University of Michigan calling to remind you of your appointment on Wednesday, January 8. If you have questions or need to change your appointment, call XXX-XXXX. Notice: No information is included about where the appointment is or who the appointment is with. 14
15 15 Verification Requests for PHI by Q: What if a patient requests that I communicate with him or her via e- mail? A: If your unit has specific policies regarding requests, follow them. Otherwise, here are some things you can do
16 16 Verification Requests for PHI by 1.Make sure that patients understand that is not secure Requests by cont d. and there is a risk that a 3 rd party could obtain the information in the transmission. 2. At UMHS, Encourage the patient to sign up for and use the patient portal (MyChart) which is a secure way to communicate with providers. 3. Inform the patient to not use for time sensitive matters, as you may be out of the office or busy taking care of other patients. 4. Do not initiate with patients without first getting their permission, and only use the address they provide, unless they notify you of a change. -cont d. on next page
17 17 Verification Requests for PHI by Requests by cont d. 5. If you receive any request via , don t assume the sender is the person he or she claims to be, especially if the request is unexpected. If you have not previously verified an address with the patient, contact either the patient to verify the sender s identity and address, or contact the person making the request by another method for verification of the address. If in doubt, talk to your supervisor. In general, be careful about sending PHI in response to s because of the difficulty in identifying senders accurately. 6. Minimize the amount of information disclosed in an communication with a patient.
18 18 Verification Requests for PHI by Fax Q: What do I do if I receive a request for PHI by fax? A: Most often, faxed requests for PHI will come from other health care providers or payers, like billing agencies or insurance companies, although patients may occasionally ask to have information faxed to them. Check with your supervisor about your unit s procedures for sending PHI via fax. Note: violations easily occur through mis-dialing of fax numbers. Click here for more information to prevent this from happening.
19 19 Verification Requests for PHI by Pager Q: What if I receive a PHI on my pager? A: When communicating via pagers, send only the minimum amount of information necessary, and delete received messages once you no longer need them.
20 20 Staff Access Q: I have students and/or temporary staff people who will only be here a short time. They need computer access to do their work. Can I give them my password or log them in as me? A: No. It is against policy to allow any staff, including temporary staff, to use another employee's log in and/or password for computer access. If you allow someone to use your access, you will be held responsible for what they do. Your department's authorized signer can make the request for new accounts.
21 21 Security Q: What s the first thing to do to protect PHI on a laptop or other portable device such as a tablet? A: If a portable device is appropriately encrypted, and it is lost or stolen, the information on the device cannot be accessed without an encryption key (another password.) Encryption is the best and safest way to secure and protect PHI/ePHI. At UMHS, Contact Medical Center Information Technology (MCIT) for assistance with encryption.
22 Disposal Q: How do I dispose of PHI? A: Papers containing PHI either need to be shredded or disposed of in designated confidential recycling receptacles, such as the locked blue bins in many Health System facilities, and not in the regular trash. Thumb/flash drives, CD-ROMs, Computer hard drives and memory cards (e.g., on fax machines and copiers) must be physically destroyed or electronically shredded. Contact your IT Support for assistance. 22
23 23 Certificate and Credit IF YOU ARE associated with UMHS (the University of Michigan Health System) Please close this window and complete the remainder of the learning activity. IF YOU ARE associated with the University of Michigan (Non- UMHS) Click this link to download a printable PDF certificate.
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