Q: I work in a behavioral health hospital and am looking for guidance relating to disclosures as part of the Clozapine REMS Program. In order for a patient to fill a prescription for Clozapine at an outside pharmacy (not our on-site pharmacy), the pharmacy is required to have a copy of the patient's latest blood draw (absolute neutrophil count). Is the patient required to sign a release of information for us to be able to send the latest blood draw results, or is sharing the results with the outside pharmacy considered part of the process when the patient is registered in the Clozapine program?
In addition, if the latest lab results contain more information than what is required for the Clozapine prescription to be filled, should we edit the results to only include what is specifically needed by the pharmacy?
A: Releasing this information is considered treatment, so the patient's authorization is not needed. Editing the results report to release only the neutrophil count would be a good practice, if it is reasonable to do that. If not, it would be acceptable to release the complete results containing the neutrophil count, since the minimum necessary requirement does not apply to treatment disclosures.
Editor's note: This question was answered by Mary Brandt. Brandt is a healthcare consultant specializing in healthcare regulatory compliance and operations improvement. She is also an advisory board member for BOH. This information does not constitute legal advice. Consult legal counsel for answers to specific privacy and security questions. Email your HIPAA questions to Associate Editor Nicole Votta at nvotta@hcpro.com.
Submit your HIPAA questions to Associate Editor Nicole Votta at nvotta@hcpro.com and we will work with our experts to provide you with the information you need.
Q: Our front desk receptionist has asked the following question regarding residents who are admitted to our long-term care facility. If someone calls the front desk asking for information on a resident, such as "Is (resident) in your facility?" or "What is their room number?", would this information be considered PHI?
A: The answer is not straightforward when it comes to long-term care. It all depends on the care setting. If care is provided in an assisted living facility and the assisted living facility does not provide healthcare services, such as nursing care related to treatment or a clinic on-site, the information is not PHI. On the other hand, if the facility is a skilled nursing facility (SNF) and is providing what HIPAA defines as healthcare, it would be considered PHI. That doesn't mean the receptionist cannot share the information about whether a resident is at the facility or the resident's room number. Similar to a hospital, a long-term care facility could maintain a facilities directory. Unless the resident has specifically requested he or she not be included in the facility directory, you can share whether a resident is at the facility and where the resident is located in the facility. Providing more information would be prohibited. Review the long-term care regulations in the state in your state.
Editor’s note: Chris Apgar, CISSP, president of Apgar and Associates in Portland, Oregon, answered this question. This information does not constitute legal advice. Consult legal counsel for answers to specific privacy and security questions.
Q: When you refer to a laptop being encrypted for security reasons, is that the same as password protected? We have a number of employees with laptops who transport them from work to home and are concerned about a breach if a laptop is stolen.
Q: The company I work for has long debated what to do about medical records that are sent out on CDs. We concluded that since paper records could not be encrypted, we shouldn't have to worry about encrypting the CDs.
Q: Is it permissible to write down a patient's pending exams (e.g., MRI, ultrasound) on the patient boards located by the patient's bed in his or her room even if that patient has a roommate?
