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FAQs: Protected health information (PHI)

FAQs: Protected health information (PHI)

Protected health information (PHI) refers to any information related to an individual's health, treatment, or payment for healthcare services that can be linked to that individual. Healthcare organizations must safeguard PHI to preserve patient privacy, prevent identity theft, and foster trust in the healthcare system. Organizations can ensure PHI's confidentiality, integrity, and availability by implementing robust security measures.

What qualifies as PHI?

Protected health information (PHI) encompasses a broad range of details linking an individual to their health status, history, or treatment. This includes:

  • Names: Full names, nicknames, or any variations
  • Addresses: Physical and email addresses
  • Phone numbers: All contact numbers, mobile or landline
  • Social security numbers: Sensitive information linking to identity and financial records
  • Dates: Birthdates, admission and discharge dates, appointment dates
  • Codes: Diagnostic, procedure, and billing codes
  • Geographic data: City, state, or region information

Read more: What are the 18 PHI identifiers?


What's the core regulation protecting PHI?

The primary safeguard for PHI is HIPAA. HIPAA establishes strict guidelines for the use, disclosure, and protection of PHI, ensuring the privacy and security of individuals' health information. HIPAA is a comprehensive legal framework with the PrivacySecurityBreach Notification, and Enforcement Rules. Additionally, various state and federal laws may complement HIPAA, reinforcing the commitment to patient privacy and data security. 


Why is safeguarding PHI required by HIPAA?

HIPAA's regulations protect personal information against unauthorized access, mitigating potential financial and reputational damages by preventing identity theft. Safeguarding PHI also reduces the risk of discrimination based on health information, promoting fairness in employment, insurance, and social contexts. Ultimately, HIPAA's emphasis on PHI protection is a cornerstone in building a reliable and patient-centric healthcare system.


What are the key steps I can take to secure PHI?

Securing PHI involves a comprehensive strategy. Implement physical safeguards like access controls and secure media handling to ensure confidentiality, integrity, and availability. Administrative measures include regular risk assessments and thorough employee training on PHI security. Technical safeguards involve electronic access controls, encryption, and audit trails to monitor system access. 

Read more: What are administrative, physical and technical safeguards?


What are my obligations for sharing PHI with partners?

Healthcare organizations must uphold HIPAA compliance and safeguard patient data when sharing PHI with external entities. Using business associate agreements (BAAs) is the first step in this process. These agreements legally bind business associates to adhere to HIPAA regulations, ensuring they implement safeguards to protect shared PHI. BAAs outline specific responsibilities, creating a framework for accountability and reinforcing the commitment to maintaining the privacy and security of patient information. 


What happens in the event of a PHI breach?

If PHI is breached, follow a structured response. Immediately initiate the established breach notification procedures and ensure that all affected individuals are informed according to legal requirements. Conduct a thorough investigation to determine the extent of the breach, identify vulnerabilities, and identify potential areas for improvement. At the same time, take swift corrective actions to mitigate immediate risks and implement preventative measures to prevent future incidents. 

Read more: How to respond to a data breach 


What rights do patients have regarding their PHI?

Patients' rights related to their PHI include the ability to access their health records, request corrections for inaccuracies, and ask for restrictions on the use and disclosure of their PHI. If their rights are violated, patients can file complaints to reinforce the importance of protecting their privacy.


How are patients notified of PHI breaches?

In case of a security breach involving unprotected PHI that could pose a significant danger, healthcare organizations must inform the impacted individuals. This notification process promotes accountability and transparency, ensuring that patients are promptly notified of any potential violations of their privacy. Complying with this responsibility helps strengthen the trust between patients and healthcare entities, providing individuals with the necessary information to take appropriate measures to safeguard themselves in the event of a PHI breach.


How can patients protect their own PHI?

Patients should be cautious when sharing health information, especially in online or unfamiliar settings. They must understand the privacy practices of healthcare providers and make sure they align with one's comfort level and security expectations. Patients should not hesitate to ask questions about how their PHI is handled and stored. Equally important, they should immediately report any suspected misuse or discrepancies to the relevant authorities. 


How does the minimum necessary rule apply to PHI use?

The minimum necessary rule requires covered entities to disclose only the smallest amount of PHI necessary for each authorized purpose. Healthcare entities should be precise and selective when accessing, disclosing, or using PHI, ensuring that information sharing is tailored to meet specific needs and avoiding unnecessary exposure. Adhering to this rule protects patient privacy and minimizes the risk of unauthorized access, leading to a more focused and secure use of PHI within healthcare practices.


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