3.15: Stanford Medicine Policy for the Removal and Transport of PHI

Purpose

The purpose of this policy is to set forth controls related to removal of Protected Health Information (PHI) or Personal Information (PI) from the medical center and transport of medical information within the medical center. This policy does not replace IT Security policies for protection of electronic patient information including requirements related to emailing patient information.

Policy Statement

Stanford Health Care (including all SHC-affiliated locations), Lucile Packard Children’s Hospital (including all LPCH-affiliated locations), and the Stanford University School of Medicine (collectively, “Stanford Medicine”) are committed to complying with state and federal requirements related to the privacy and security of patient information. Workforce Members at Stanford Medicine, as well as those with whom Stanford Medicine conducts its business, have a legal and ethical responsibility to maintain the confidentiality, privacy and security of all PHI/PI, to protect PHI/PI at all times and to guard against the loss of, or unauthorized access to, use or disclosure of, PHI/PI when removing it from the medical center up through its return, and when transporting it within the medical center. Such removal and transport of PHI/PI shall not occur in a manner inconsistent with this policy. Principles and procedures in this policy apply to PHI/PI in all media, including paper and electronic format. Consistent with other policies, PHI/PI that is removed from the premises should never be verbally discussed with any unauthorized person.

Definitions

Protected Health Information (“PHI”) is defined as information that (i) is created or received by a health care provider, health plan, employer, or health care clearinghouse; (ii) relates to the past, present, or future physical or mental health or condition of an individual; the provision of health care to an individual; or the past, present or future payment for the provision of health care to an individual; and (iii) that identifies the individual, or provides a reasonable basis to identify the individual. PHI does not include employment records held by Stanford Medicine in its capacity as an employer, or information that has been de-identified in accordance with the HIPAA Privacy Standards.

Personal Information (“PI”) is a person’s first name and last name, or first initial and last name, in combination with any one of the following data elements that relate to such person:

  • Social Security Number (SSN);
  • Driver’s license or state-issued identification card number; or
  • Financial account number, credit or debit card number (e.g., health insurance policy number).
 

Personal information shall not include information that is lawfully obtained from publicly available information, or from federal, state or local government records lawfully made available to the general public.

De-identification is defined as the process by which PHI is stripped of specific data elements, as defined by HIPAA, in order to assure that personal identities cannot readily be identified from data sets.

Workforce Members are defined as faculty, employees (including temporary employees), researchers, volunteers, trainees, and other persons whose conduct, in the performance of work, is under the direct control of Stanford Medicine, whether or not they are paid by Stanford Medicine.

Supervisor: For the purposes of this policy, Supervisor is used in the context of approval for a Workforce Member to remove PHI/PI from the medical center or transport PHI/PI within the medical center. It is understood that from time-to-time the duties of senior operational leadership (Directors and above) and faculty will require them to conduct Stanford Medicine business for which this policy requires Supervisor approval. Such approval for senior operational leadership and faculty is self-granted, provided that they have ensured that all safeguards and other privacy and security controls are in place. For research activities, Supervisor means the Principal Investigator or Protocol Director.

Medical Center is any location owned, leased or operated by Stanford Medicine, wherever located. Principles

  1. PHI/PI shall be treated as confidential and shall be safeguarded according to Stanford Medicine policies at all times.
  2. Treatment, payment, healthcare operations, education, IRB-approved research and other Stanford Medicine business involving the permissible use or disclosure of PHI/PI should be conducted within the medical center whenever feasible. Removal of PHI/PI from the medical center by Workforce Members shall occur solely for job-related purposes and with the approval of the Workforce Member’s Supervisor. Removal of PHI/PI from the medical center should not be approved for reasons related to the convenience of the Workforce Member, but rather for instances where the work requiring the PHI cannot practically be conducted on-site in a timely manner, and only after due consideration of alternative ways to remotely perform the work, such as VPN access to PHI/PI or secure scanning of PHI/PI for access from the remote site.
  3. The Workforce Member taking the PHI/PI off-site and the approving Supervisor are responsible for ensuring that only the minimum amount of PHI/PI necessary to perform the off-site work is approved and removed from the medical center. De-identified patient information or limited data sets shall be used whenever possible. The approving Supervisor and the Workforce Member removing the PHI/PI, or the Workforce Member transporting the information within the medical center, should be able to account for every element of PHI/PI removed from or transported within the medical center, whether electronic or paper, and should be able to reconstruct the exact PHI/PI that was removed from or transported within the medical center.
  4. Appropriate safeguards shall be diligently followed regarding secure transport of PHI/PI off-site and within the medical center. PHI/PI must be in the immediate personal possession of the workforce member at all times during transport, for example, from the time the PHI/PI is taken from the medical center to the time of arrival at the off-site location, or from location-to-location within the medical center.
  5. Appropriate safeguards shall be diligently followed regarding securing PHI/PI at the off-site location. PHI must be secured in a manner so that it cannot be accessed by unauthorized individuals.
  6. PHI that is lost, stolen, accessed viewed or reviewed by unauthorized individuals, or the confidentiality of which has been otherwise compromised, it is essential that the Stanford University Privacy Office be notified immediately. There are a number of federal and state privacy laws which may require Stanford to take very specific actions within very defined timelines. The Privacy Office will work with you to gather all of the relevant facts to ensure Stanford complies with all of our privacy obligations. A loss or theft counts as a Privacy Incident; report it to the Privacy Office, by email at privacy@stanford.edu, or by phone: 650-725-1828. For more information about a lost or stolen device, see: https://med.stanford.edu/irt/security/help/lost-device.html

Procedures

  1. PHI should be saved or stored on secure medical center network servers whenever feasible. Saving or storing PHI/PI on computer or laptop hard drives, personal laptops or other personal devices,flash drives or USB drives, external drives, and other removable media is prohibited unless the device is encrypted to Stanford Medicine standards, password protected and meets other applicable Stanford Medicine security requirements.
  2. Before the decision is made by the Workforce Member and the Workforce Member’s supervisor to remove electronic PHI from the premises, IT Security must be contacted to determine whether a viable alternative is available to remotely access the PHI/PI needed to perform the job-related work.
  3. PHI/PI should not be printed at off-site locations, for example, home or public printers, unless a Stanford Medicine business need exists to do so.
  4. Safeguards must be in place to prevent unauthorized individuals, such as family members, conference attendees or the general public, from viewing or accessing PHI/PI at off-site locations.
  5. PHI/PI must be safeguarded during transport and in the personal possession of the Workforce Member at all times. PHI shall not be left unattended in publicly-accessible locations.
  6. PHI/PI transported for purposes such as off-site storage, office relocation and new location openings shall be safeguarded to prevent the loss of or unauthorized access to PHI/PI. Only medical center approved off-site storage locations may be used for storing records, documents and electronic media containing PHI/PI. Records and documents containing PHI must be inventoried before off- site storage. See Appendix B for securing documents and records containing PHI/PI for off-site storage or office/department relocation.

Compliance

  1. All Workforce Members are responsible for ensuring that individuals comply with those policy provisions that are applicable to their respective duties and responsibilities.
  2. Workforce Member failure to protect the privacy, confidentiality, and security of patient information is detrimental to the mission, goals, and operations of Stanford Medicine. Serious consequences can result from failing to protect patient information, up to and including termination.
  3. Violations of this policy will be reported to the Privacy Office and any other department as appropriate or in accordance with applicable Stanford Medicine policy. Violations will be investigated to determine the nature, extent, and potential risk to Stanford Medicine.