The Minimum Necessary Standard (45 CFR 164.502(b), 164.514(d)) is part of the HIPAA Privacy Rule. It requires healthcare organizations to make reasonable efforts to limit disclosed protected health information (PHI) to the minimum amount necessary for a task.
The minimum necessary standard applies to covered entities and business associates when they use or disclose PHI, and when they request PHI from other covered entities or business associates. The minimum necessary standard does not apply to the following:
- Disclosures to or requests by a healthcare provider for treatment purposes.
- Disclosures to the individual who is the subject of the information.
- Uses or disclosures made according to an individual’s authorization.
- Uses or disclosures required for compliance with HIPAA Administrative Simplification Rules.
- Disclosures to HHS when disclosure of information is required under the Privacy Rule for enforcement purposes.
- Uses or disclosures that are required by other laws.
Patient records contain sensitive personally identifiable information, much of which will not be needed to address a given medical, billing, or other task. For example, it would be inappropriate for a billing specialist to access the entirety of your medical records. It would also be inappropriate for your physician to access your social security number or credit card information. That’s why healthcare organizations are generally required to limit access to PHI as much as possible.
The standard is vague, given that the terms “reasonable efforts” and “minimum amount necessary” have not been defined in the law or by HHS. Some clarifying changes to the standard have been proposed, but at this time covered entities must “evaluate their practices and enhance protections as needed to limit unnecessary or inappropriate access to protected health information,” building policies and procedures that reflect these protections. HHS believes that each organization is in the best position to make decisions on which staff members need access to what patient data.
HIPAA’s mandate that healthcare organizations guard the privacy, integrity, and accessibility of protected health information remains intact. Because there is still no specific guidance on the implementation of the standard, it remains important that all covered entities have strong policies and procedures that outline when and how your organization will use and disclose PHI. Regularly train employees on these policies to maintain a culture of HIPAA compliance.
If you have questions regarding this or another HIPAA standard, reach out to our team at Medcurity. We’re here to bring clarity and confidence to your HIPAA compliance so that you can continue to focus on providing the best patient care.