Standards for Privacy of Individually Identifiable Health Information. Final Privacy Rule Preamble.. Section 164.514(d) - Minimum Necessary

12/28/2000

The proposed rule required a covered entity to make all reasonable efforts not to use or disclose more than the minimum amount of protected health information necessary to accomplish the intended purpose of the use or disclosure (proposed § 164.506(b)).

The proposed minimum necessary standard did not apply to uses or disclosures that were made by covered entities at the request of the individual, either to allow the individual access to protected health information about him or her or pursuant to an authorization initiated by the individual. The requirement also did not apply to uses and disclosures made: pursuant to the compliance and enforcement provisions of the rule; as required by law and permitted by the regulation without individual authorization; by a covered health care provider to a health plan, when the information was requested for audit and related purposes. Finally, the standard did not apply to the HIPAA administrative simplification transactions.

The proposed implementation specifications would have required a covered entity to have procedures to: (i) identify appropriate persons within the entity to determine what information should be used or disclosed consistent with the minimum necessary standard; (ii) ensure that those persons make the minimum necessary determinations, when required; and (iii) within the limits of the entity's technological capabilities, provide for the making of such determinations individually. The proposal allowed a covered entity, when making disclosures to public officials that were permitted without individual authorization but not required by other law, to reasonably rely on the representations of such officials that the information requested was the minimum necessary for the stated purpose(s).

The preamble provided further guidance. The preamble explained that covered entities could not have general policies of approving all requests (or all requests of a particular type) without carefully considering certain criteria (see "Criteria," below) as well as other information specific to the request. The minimum necessary determination would have needed to be consistent with and directly related to the purpose of the use or disclosure. Where there was ambiguity regarding the information to be used or disclosed, the preamble directed covered entities to interpret the "minimum necessary" standard to "require" the covered entity to make some effort to limit the amount of protected health information used/disclosed.

The proposal would have required the minimum necessary determination to take into consideration the ability of a covered entity to delimit the amount of information used or disclosed. The preamble noted that these determinations would have to be made under a reasonableness standard: covered entities would be required to make reasonable efforts and to incur reasonable expense to limit the use or disclosure. The "reasonableness" of limiting particular uses or disclosures was to be determined based on the following factors (which were not included in the regulatory text):

a. The extent to which the use or disclosure would extend the number of persons with access to the protected health information.

b. The likelihood that further uses or disclosures of the protected health information could occur.

c. The amount of protected health information that would be used or disclosed.

d. The importance of the use or disclosure.

e. The potential to achieve substantially the same purpose with de-identified information. For disclosures, each covered entity would have been required to have policies for determining when protected health information must be stripped of identifiers.

f. The technology available to limit the amount of protected health information used/disclosed.

g. The cost of limiting the use/disclosure.

h. Any other factors that the covered entity believed were relevant to the determination.

The proposal shifted the "minimum necessary" burden off of covered providers when they were being audited by a health plan. The preamble explained that the duty would have been shifted to the payor to request the minimum necessary information for the audit purpose, although the regulatory text did not include such a requirement. Outside of the audit context, the preamble stated that a health plan would be required, when requesting a disclosure, to limit its requests to the information required to achieve the purpose of the request; the regulation text did not include this requirement.

The preamble stated that disclosure of an entire medical record, in response to a request for something other than the entire medical record, would presumptively violate the minimum necessary standard.

This final rule significantly modifies the proposed requirements for implementing the minimum necessary standard. For all uses and many disclosures and requests for disclosures from other covered entities, we require covered entities to implement policies and procedures for "minimum necessary" uses and disclosures. Implementation of such policies and procedures is required in lieu of making the "minimum necessary" determination for each separate use or disclosure as discussed in the proposal. Disclosures to or requests by a health care provider for treatment purposes are not subject to the standard (see § 164.502).

Specifically (and as further described below), the proposed requirement for individual review of all uses of protected health information is replaced with a requirement for covered entities to implement policies and procedures that restrict access and uses based on the specific roles of members of the covered entity's workforce. Routine disclosures also are not subject to individual review; instead, covered entities must implement policies and procedures to limit the protected health information in routine disclosures to the minimum necessary to achieve the purpose of that type of disclosure. The proposed exclusion of disclosures to health plans for audit purposes is deleted and replaced with a general requirement that covered entities must limit requests to other covered entities for individually identifiable health information to what is reasonably necessary for the use or disclosure intended. The other exclusions from the standard are unchanged from the proposed rule (e.g., for individuals' access to information about themselves, pursuant to an authorization initiated by the individual, for enforcement of this rule, as required by law).

The language of the basic "standard" itself is largely unchanged; covered entities must make reasonable efforts to use or disclose or to request from another covered entity, only the minimum amount of protected health information required to achieve the purpose of a particular use or disclosure. We delete the word "all" from the "reasonable efforts" that covered entities must take in making a "minimum necessary" determination. The implementation specifications are significantly modified, and differ based on whether the activity is a use or disclosure.

Similarly, a "minimum necessary" disclosure for oversight purposes in accordance with § 164.512(d) could include large numbers of records to allow oversight agencies to perform statistical analyses to identify deviations in payment or billing patterns, and other data analyses.

Uses of Protected Health Information

A covered entity must implement policies and procedures to identify the persons or classes of persons in the entity's workforce who need access to protected health information to carry out their duties, the category or categories of protected health information to which such persons or classes need access, and the conditions, as appropriate, that would apply to such access. Covered entities must also implement policies and procedures to limit access to only the identified persons, and only to the identified protected health information. The policies and procedures must be based on reasonable determinations regarding the persons or classes of persons who require protected health information, and the nature of the health information they require, consistent with their job responsibilities.

For example, a hospital could implement a policy that permitted nurses access to all protected health information of patients in their ward while they are on duty. A health plan could permit its underwriting analysts unrestricted access to aggregate claims information for rate setting purposes, but require documented approval from its department manager to obtain specific identifiable claims records of a member for the purpose of determining the cause of unexpected claims that could influence renewal premium rate setting.

The "minimum necessary"standard is intended to reflect and be consistent with, not override, professional judgment and standards. For example, we expect that covered entities will implement policies that allow persons involved in treatment to have access to the entire record, as needed.

Disclosures of Protected Health Information

For any type of disclosure that is made on a routine, recurring basis, a covered entity must implement policies and procedures (which may be standard protocols) that permit only the disclosure of the minimum protected health information reasonably necessary to achieve the purpose of the disclosure. Individual review of each disclosure is not required. Instead, under § 164.514(d)(3), these policies and procedures must identify the types of protected health information to be disclosed, the types of persons who would receive the protected health information, and the conditions that would apply for such access. We recognize that specific disclosures within a type may vary, and require that the policies address what is the norm for the type of disclosure involved. For example, a covered entity may decide to participate in research studies and therefore establish a protocol to minimize the information released for such purposes, e.g., by requiring researchers requesting disclosure of data contained in paper-based records to review the paper records on-site and to abstract only the information relevant to the research. Covered entities must develop policies and procedures (which may be standard protocols) to apply to disclosures to routinely hired types of business associates. For instance, a standard protocol could describe the subset of information that may be disclosed to medical transcription services.

For non-routine disclosures, a covered entity must develop reasonable criteria for determining, and limiting disclosure to, only the minimum amount of protected health information necessary to accomplish the purpose of the disclosure. They also must establish and implement procedures for reviewing such requests for disclosures on an individual basis in accordance with these criteria.

Disclosures to health care providers for treatment purposes are not subject to these requirements.

Covered entities' policies and procedures must provide that disclosure of an entire medical record will not be made except pursuant to policies which specifically justify why the entire medical record is needed. For instance, disclosure of all protected health information to an accreditation group would not necessarily violate the regulation, because the entire record may be the "minimum necessary" for its purpose; covered entities may establish policies allowing for and justifying such a disclosure. Disclosure of the entire medical record absent such documented justification is a presumptive violation of this rule.

Requests for Protected Health Information

For requests for protected health information from other covered entities made on a routine, recurring basis, the requesting covered entities' policies and procedures may establish standard protocols describing what information is reasonably necessary for the purposes and limiting their requests to only that information, in lieu of making this determination individually for each request. For all other requests, the policies and procedures must provide for review of the requests on an individualized basis. A request by a covered entity may be made in order to obtain information that will subsequently be disclosed to a third party, for example, to obtain information that will then be disclosed to a business associate for quality assessment purposes; such requests are subject to this requirement.

Covered entities' policies and procedures must provide that requests for an entire medical record will not be made except pursuant to policies which specifically justify why the entire medical record is needed. For instance, a health plan's request for all protected health information from an applicant for insurance would not necessarily violate the regulation, because the entire record may be the "minimum necessary" for its purpose. Covered entities may establish policies allowing for and justifying such a request. A request for the entire medical record absent such documented justification is a presumptive violation of this rule.

Reasonable Reliance

A covered entity may reasonably rely on the assertion of a requesting covered entity that it is requesting the minimum protected health information necessary for the stated purpose. A covered entity may also rely on the assertions of a professional (such as attorneys and accountants) who is a member of its workforce or its business associate regarding what protected health information he or she needs in order to provide professional services to the covered entity when such person represents that the information requested is the minimum necessary. As we proposed in the NPRM, covered entities making disclosures to public officials that are permitted under § 164.512 may rely on the representation of a public official that the information requested is the minimum necessary.

Uses and Disclosures for Research

In making a minimum necessary determination regarding the use or disclosure of protected health information for research purposes, a covered entity may reasonably rely on documentation from an IRB or privacy board describing the protected health information needed for research and consistent with the requirements of § 164.512(i), "Uses and Disclosures for Research Purposes." A covered entity may also reasonably rely on a representation made by the requestor that the information is necessary to prepare a research protocol or for research on decedents. The covered entity must ensure that the representation or documentation of IRB or privacy board approval it obtains from a researcher describes with sufficient specificity the protected health information necessary for the research. Covered entities must use or disclose such protected health information in a manner that minimizes the scope of the use or disclosure.

Standards for Electronic Transactions

We clarify that under § 164.502(b)(2)(v), covered entities are not required to apply the minimum necessary standard to the required or situational data elements specified in the implementation guides for HIPAA administrative simplification standard transactions in the Transactions Rule. The standard does apply for uses or disclosures in standard transactions that are made at the option of the covered entity.