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Re: HIPAA Covered Entities & Access Appeals


  • Date:   Tue, 19 Jun 2007 11:04:14 -0400
  • To:  sthc-l@lists.ucla.edu
  • From:   Phoebe Evans Letocha   < pletocha AT jhmi.edu >
  • Subject:   Re: HIPAA Covered Entities & Access Appeals
  • Message-ID:   f493f6fe9089.4677b82e@johnshopkins.edu

Shelia,

The instructions and background material in the Privacy Board application 
materials explain the criteria which our Privacy Board uses in evaluating 
cases. 
http://www.medicalarchives.jhmi.edu/forms/D2%20Waiver%2004.pdf 

Our Privacy Board is made up of faculty from the Johns Hopkins Medical 
Institutions, the head Archivist, and 2 non Hopkins lawyers. HIPAA 
requires that there be at least one outside member on the Privacy Board. 
Lawyers for the Hospital and University also serve as ex officio advisors. 
I also serve as Archives staff to the Privacy Board, conduct risk 
assessments of the cases, and present them at the meetings. I don't 
get a vote. If a Privacy Board application is granted then the 
researcher is allowed access to PHI for research purposes. They must 
have a plan to protect the PHI and they are not allowed to publish or 
otherwise re-disclose PHI without the authorization from the subject 
of the PHI or his/her personal representative. 

We do have a simpler review process for lower risk research requests that only 
involve access to PHI of decedents. 
http://www.medicalarchives.jhmi.edu/forms/B%20Decedents%202004.pdf

These requests are reviewed by myself or the Archivist. Any requests 
involving access to patient related records we send to the Privacy Board, 
even if all subjects are deceased. 

The definition of research that we use comes from HIPAA and states that 
research is a systematic investigation that contributes to generalizable 
knowledge. Genealogy doesn't qualify here as research since the 
results could not be considered generalizable to a larger population. 
We require authorization from the personal representative which usually 
is not a problem for genealogists. Depending on the nature of a 
biographical study and materials requested, we may also require 
authorization from the personal representative before the biographer 
is allowed access to holdings and the biographer is always required to 
seek permission to publish or re-disclose PHI. 

I'm happy to answer any other questions.


Phoebe Evans Letocha
Collections Management Archivist
Alan Mason Chesney Medical Archives
Johns Hopkins Medical Institutions
410-735-6785
pletocha@jhmi.edu
http://www.medicalarchives.jhmi.edu

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