Q: My facility no longer registers patients under aliases, but will allow them to opt out of the patient directory. However, opting out of the registry will not exclude our patients from the operating room (OR) list. At one time, the facility's CEO received the daily OR list with full patient names so he could visit board members, donors, or others whom he knows at our facility. HIM changed this practice so that patients' names would not be on the OR schedule provided to the CEO. The CEO took this matter to the hospital attorney, who said the names could be included because the use of PHI by the CEO to determine whether and when a patient visit is appropriate is permitted by HIPAA as it is part of healthcare operations. Is it a violation of HIPAA for the CEO to use PHI to track patients in this manner?
As the use of electronic health records (EHR) surges and organizations work toward meaningful use attestation, more in-depth monitoring of electronic patient records is becoming increasingly necessary.
The intent of quality and safety programs is to evaluate and monitor performance and to improve results. Organizations develop annual quality and safety plans with measurable objectives that departments adopt and include as integral aspects of their performance improvement plans.
Albert Einstein once said "The difference between stupidity and genius is that genius has its limits." To paraphrase Einstein, the difference between security and compliance is that compliance has its limits. With each high-profile breach that makes headlines, organizations likely question the link between compliance and security, wondering whether the two are one and the same.
