Standards for Privacy of Individually Identifiable Health Information. Final Privacy Rule Preamble.. Section 164.530(a) - Designation of a Privacy Official and Contact Person

12/28/2000

Comment: Many of the commenters on this topic objected to the cost of establishing a privacy official, including the need to hire additional staff, which might need to include a lawyer or other highly paid individual.

Response: We believe that designation of a privacy official is essential to ensure a central point of accountability within each covered entity for privacy-related issues. The privacy official is charged with developing and implementing the policies and procedures for the covered entity, as required throughout the regulation, and for compliance with the regulation generally. While the costs for these activities are part of the costs of compliance with this rule, not extra costs associated with the designation of a privacy official, we do anticipate that there will be some cost associated with this requirement. The privacy official role may be an additional responsibility given to an existing employee in the covered entity, such as an office manager in a small entity or an information officer or compliance official in a larger institution. Cost estimates for the privacy official are discussed in detail in the overall cost analysis.

Comment: A few commenters argued for more flexibility in meeting the requirement for accountability. One health care provider maintained that covered entities should be able to establish their own system of accountability. For example, most physician offices already have the patient protections incorporated in the proposed administrative requirements - the commenter urged that the regulation should explicitly promote the application of flexibility and scalability. A national physician association noted that, in small offices, in particular, responsibility for the policies and procedures should be allowed to be shared among several people. A major manufacturing corporation asserted that mandating a privacy official is unnecessary and that it would be preferable to ask for the development of policies that are designed to ensure that processes are maintained to assure compliance.

Response: We believe that a single focal point is needed to achieve the necessary accountability. At the same time, we recognize that covered entities are organized differently and have different information systems. We therefore do not prescribe who within a covered entity must serve as the privacy official, nor do we prohibit combining this function with other duties. Duties may be delegated and shared, so long as there is one point of accountability for the covered entity's policies and procedures and compliance with this regulation.

Comment: Some commenters echoed the proposal of a professional information management association that the regulation establish formal qualifications for the privacy official, suggesting that this should be a credentialed information management professional with specified minimum training standards. One commenter emphasized that the privacy official should be sufficiently high in management to have influence.

Response: While there may be some advantages to establishing formal qualifications, we concluded the disadvantages outweigh the advantages. Since the job of privacy official will differ substantially among organizations of varying size and function, specifying a single set of qualifications would sacrifice flexibility and scalability in implementation.

Comment: A few commenters suggested that we provide guidance on the tasks of the privacy official. One noted that this would reduce the burden on covered entities to clearly identify those tasks during the initial HIPAA implementation phase.

Response: The regulation itself outlines the tasks of the privacy official, by specifying the policies and procedures required, and otherwise explaining the duties of covered entities. Given the wide variation in the function and size of covered entities, providing further detail here would unnecessarily reduce flexibility for covered entities. We will, however, provide technical assistance in the form of guidance on the various provisions of the regulation before the compliance date.

Comment: Some comments expressed concern that the regulation would require a company with subsidiaries to appoint a privacy official within each subsidiary. Instead they argued that the corporate entity should have the option of designating a single corporate official rather than one at each subsidiary.

Response: In the final regulation, we give covered entities with multiple subsidiaries that meet the definition of covered entities under this rule the flexibility to designate whether such subsidiaries are each a separate covered entity or are together a single covered entity. (See § 164.504(b) for the rules requiring such designation.) If only one covered entity is designated for the subsidiaries, only one privacy officer is needed. Further, we do not prohibit the privacy official of one covered entity from serving as the privacy official of another covered entity, so long as all the requirements of this rule are met for each such covered entity.