The HIPAA minimum necessary standard is relevant for uses and disclosures of PHI that are allowed under the HIPAA Privacy Rule, including the viewing of ePHI by healthcare workers and disclosures to business associates and other covered groups. The standard also applies to protected health information requests from different HIPAA covered bodies.
As per the HIPAA minimum necessary standard, HIPAA-covered entities must make reasonable efforts to ensure that access to PHI is limited to the minimum necessary information to achieve the intended purpose of a particular use, disclosure, or request.
The terms ‘reasonable’ and ‘necessary’ can be interpreted differently which can cause some confusion. The use of these terms leaves it up to the judgement of the covered entity as to what information is shared and the work should be done so that access to the information is limited. Any decisions that are made regarding the minimum necessary standard should be backed up by a rational justification, should reflect the technical capabilities of the covered entity, and should also take into account privacy and security dangers.
The HIPAA minimum necessary standard applies to anything that can be thought of as PHI, including physical documents, spreadsheets, films and printed pictures, electronic protected health information, including information stored on tapes and other media, and information that is communicated orally.
Security processes should be implemented to restrict access to ePHI to the minimum necessary amount and HIPAA-covered entities should create and keep logs of access which should be checked on an ongoing basis. If paper records need to be handed over that contain any additional PHI to what is required, unnecessary information must be redacted.
HIPAA Minimum Necessary Standard: When is it Not Applicable?
There are six exceptions to the HIPAA minimum necessary standard.
- Sharing PHI in response to a request by a healthcare provider for the final aim of providing treatment
- Disclosures to an individual that are allowed under the HIPAA Privacy Rule, including an individual who is using his/her right of access to obtain a copy of information included in a designated record set, once the information is maintained in that designated record set (with the exception of psychotherapy notes, information gathered for use in civil, criminal, or administrative actions)
- Any uses or sharing pursuant to an authorization
- Sharing with the Secretary of the HHS as outlined in 45 CFR Part 160 Subpart C
- Uses and disclosures required for compliance with HIPAA rules.
- Uses and disclosures that are necessary as epr legislation
Creating the Minimum Necessary Standard
There are many steps that can be taken to ensure compliance with this aspect of HIPAA which have been outlined here:
- Ensure that all systems including ePHI are recorded and it is clear what types of PHI that they include.
- Record what types of information need to be seen for different roles and responsibilities.
- Set up role-based permissions that limit access to specific types of PHI. Granular controls should be applied to all information systems, if possible, which restrict access to certain types of information. For instance, restricting access to health insurance numbers, Social Security numbers, and medical histories if it is not necessary for that information to be seen.
- Set up a sanctions policy for breaches of the minimum necessary standard.
- Make sure employees are given training on the types of information they are allowed to access and what information is not allowed. Make sure staff member are aware of the consequences of accessing information without proper authorization.
- Ensure logs are kept that include data on PHI access and access efforts.
- Configure alerts, if technically possible, that notify the compliance team of cases of unauthorized attempts to access PHI and successful attempts to view information of patients by staff with no legitimate work reason for viewing the records.
- Before allowing access to systems including ePHI to a business associate, assess what information is required to carry out the requested tasks and ensure that access to parts of a system or unnecessary data is restricted.
- Complete periodic audits of permissions and review logs constantly to identify individuals who have knowingly or unknowingly accessed restricted data.
- Record any actions taken as a reaction to cases of unauthorized access or viewing more information than is necessary and the sanctions that have been applied due to this.