A False Choice

heavy_factory_workerImagine you work at a health insurance company.  Your title is “Claims Examiner” and you spend each day deciding if bills sent from doctors for the insurance company’s members should be paid.  You must be sure the treatments match the diagnosis, the member is eligible for the payment and the amount being asked for is correct. This work is performed in a “Claims System”.  Claims Systems are one of the first widespread uses of computers in business and have been around for 40 years.  This is the lifeblood of a health insurance company and seemingly all their other systems are related to it.  The data the Examiner uses to pay or adjust the bills doesn’t need to be obscured in any way because it is part of TPO (treatment, payment or health care operations).

A covered entity may disclose PHI (Protected Health Information) to facilitate treatment, payment, or health care operations (TPO) without a patient’s express written authorization. Any other disclosures of PHI (Protected Health Information) require the covered entity to obtain written authorization from the individual for the disclosure. However, when a covered entity discloses any PHI, it must make a reasonable effort to disclose only the minimum necessary information required to achieve its purpose.

When we talk about Privacy and Security of data, even though Claims Systems have the most information about a patient / member, they are rarely if ever the place where a breach of PHI (Protected Health Information) takes place.  Instead, breaches happen at the edges.  New systems being stood up, test / development systems, ancillary data stores for things like analytics or other systems, seem to be the place where PHI breaches tend to happen.  In most cases however, these systems really should not have had PHI at all.

So why did these systems have PHI to begin with?  Usually it is because an exemption was created.

This isn’t a story of malice, indifference or even incompetence.  It is a story of real life choices that are all very reasonable.

Imagine a new system being brought on line for claims or another vital function.  There are outside vendors and subject matter experts helping employees to ensure the environment will be capable and reliable when it replaces the existing system.  But if all the data being used to test is simple and looks like this:

 “John Doe, DOB 1/1/1950, DOS 1/1/2018, 15 Minute Office Visit, Common Cold”

the team will never uncover all the potential problems that come with complicated, real world scenarios.

While the organization knows where the PHI is in the data, sometimes just de-identifying the real data in such a way can be a six-month project on its own.  How would one test if the system would be able to find duplicates if names are randomly replaced in the test data?  How can a test Examiner check eligibility if the names in the eligibility file are randomly replaced in a different way than in the test claims data?  If dates are randomized, how would claims be paid for Dates of Service (DOS) that occur before Date of Birth (DOB)?

Usually an exemption is granted for the testing of the new system that allows previously run, real world PHI data to be used.  This is very reasonable of course and the systems and environments are all secured as they should be.  Either way, this is the type of place a breach happens.   A port is left open, test data is left on a remote machine, or any number of other ways things can happen to even careful, conscientious people.

Whether for test or development systems or for an analytics project that is delayed or never happens while the PHI is scrubbed, this represents a false choice.  We have been dealing with this problem formally for 20 years and realistically even before people started mis-spelling the HIPAA acronym.  Technology is getting faster, better and cheaper all the time.

So why is this so hard? 

FULL DISCLOSURE: My company, The EDI Project™ has developed a tool to address this problem and I’m not a disinterested party in my recommendation.

Link to Part 1: Minimum Necessary or Optional? 

Link to Part 3: Shouldn’t This Be Easier By Now? 

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2 thoughts on “Are We Disregarding Privacy Rules Because They Are Hard? Part 2 of 3

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