Consumer advisory | PHRs and privacy -- The World Privacy Forum has issued a consumer advisory about the privacy of PHRs to help consumers understand and approach the complex privacy issues PHRs can raise. Consumers need to know that not all PHRs protect privacy in the same way, and some PHR systems can undermine consumer privacy in serious ways that consumers may not be expecting.
This report is a legal analysis of PHRs and what privacy issues are at stake in PHRs, especially PHRs that exist outside of HIPAA, the federal privacy rule.
Personal health records – or PHRs – are a relatively new phenomenon in health care today. As discussed here, a PHR is a health record about a consumer that includes data gathered from different sources (e.g., health care providers, insurers, the consumer, and third parties such as gyms and others) and is made accessible, often online, to the consumer and to those authorized by the consumer. Businesses large and small are moving to take advantage of the potentially lucrative new business model PHRs provide, especially as leveraged through the Internet. Some of the newest PHR players include large and well-known technology companies, but some health care providers, insurers, and employers also promote PHRs. There are dozens of different PHR vendors.
The HIPAA privacy rule provides a degree of privacy protection for covered health records. The rule has problems and gaps, but it does establish minimum national privacy standards for disclosure, access, correction, and other elements of fair information practices. State laws that provide additional privacy protections remain in effect and can provide additional legal protections for privacy.
Many people are aware that health information may be privileged, but few – including some physicians – fully understand what that means. The physician-patient privilege (and the sometimes separate psychotherapist-patient privilege) offers some protections for confidential communications between physician and patient.
Health records, like just about any other record containing personal information held by a third party, can be subpoenaed under a variety of circumstances. For example, a consumer’s records could be sought in a tort suit (e.g., auto accident or medical malpractice), in a divorce or other family lawsuit, or sought if the records are relevant to someone else’s lawsuit. The rules governing subpoenas for health records are complex, and HIPAA includes some significant procedural protections.
Perhaps the biggest single concern about commercial PHRs is the possibility that a consumer’s health information will leak into the marketing system. The terms under which a PHR operates could allow the sale or rental of consumer information in the same way that magazines, catalog companies, magazines, charities, or other merchants and activities share information with limited or no consumer knowledge or consent. Consumers generally have some sense about how readily companies and agencies pass personal information around, but they do not expect the same kind of sharing when it comes to personal health information.
Some PHRs present themselves as a depository of health information under the control of the consumer. The suggestion is that the records have inherent privacy protections because the consumer has some choices or control over the record, including who may see, add to, or change the record. By contrast, covered entities under HIPAA can disclose health records to many institutions for many purposes without consumer consent. That is one of the controversial aspects of HIPAA. HIPAA allows many disclosures without the consent of – and indeed over the objections of – the consumer.
Some privacy protections exist because independent health care providers maintain separate records about consumers. A dentist has one set of records; a family doctor has another set. It will often be the case that the two sets of records are not linked or shared routinely. However, those who obtain health care from a single health maintenance organization may already have centralized records. Linkage of health records offers some advantages, but not all linkages are necessarily welcome to consumers.
Security is an important part of privacy. Are PHR records more secure? The answer depends on who maintains the PHR and whether the security of the PHR is sufficient. Information held by health care vendors and insurers is subject to the HIPAA health record security rule. For what it is worth, the HIPAA security rule has attracted less criticism than the HIPAA privacy rule. Whether any given health record keeper is actually doing a good job of complying is hard to say.
One basic privacy right is the right to seek correction of personal information that is incorrect or incomplete. This is a difficult area for health records because health care providers do not like to change records, and they strongly resist removing information from a record. Often, the resistance is reasonable. For example, a preliminary diagnosis may turn out to be wrong, but the record of the diagnosis must remain in the record to explain a particular test or treatment.
Under HIPAA, if a consumer wants to authorize a covered entity to disclose her records, she will usually be obliged to sign an authorization form. The HIPAA rule prescribes the content of the authorization form and its scope. That rule provides some protections because it makes it harder for a consumer to unknowingly sign a form authorizing the disclosure of health records. For example, if a consumer signs a one-sentence form authorizing anyone with records about the consumer to disclose the records to the bearer of the form, it is unlikely that any doctor or hospital would or should honor that form.
For a non-HIPAA covered PHR, the privacy policy becomes a key document, if it is available. The privacy policy of a PHR vendor may tell consumers how the vendor plans to use personal information. It is possible that a commercial or advertising-supported PHR will do a good job of protecting its clients from uninformed or casual disclosures of personal or health information. It is also possible that a cautious client will not be able to evaluate a PHR vendor’s policy or practice.
PHRs that operate outside of HIPAA can negatively affect the privacy interests of consumers in various ways. The best to hope for is that a PHR will not make privacy significantly worse. However, it is not likely that even that weak standard can be met. The existence of electronically available and centralized health information outside the traditional health care system will attract new users and create new risks. The mere adding of health records to a PHR vendor’s files may undermine existing privacy protections of old records. Security is a concern for any electronic records. A consumer’s ability to control the disclosure of PHR records can easily be compromised. The consumer’s ability to correct errors in PHR records may be problematic. Advertising support may not meet a PHR’s profit goals unless at least some consumer information is available for close targeting of ads. Promised PHR privacy protections may vanish overnight if the privacy policy is changed.
Financial privacy / credit reports -- The NCLC, Consumer's Union, and the World Privacy Forum filed extensive joint comments today regarding the proposed rulemaking, Procedures to Enhance the Accuracy and Integrity of Information Furnished to Consumer Reporting Agencies under Section 312 of the Fair and Accurate Credit Transactions Act. The results of the proposed rulemaking will have a significant impact on how the accuracy of credit reports is defined for consumers, and will have a substantive influence over how consumers may handle credit report disputes directly with those who furnish information for the reports.
The NCLC, Consumer's Union, and the World Privacy Forum filed extensive joint comments today regarding the proposed rulemaking, Procedures to Enhance the Accuracy and Integrity of Information Furnished to Consumer Reporting Agencies under Section 312 of the Fair and Accurate Credit Transactions Act. The results of the proposed rulemaking will have a significant impact on how the accuracy of credit reports is defined for consumers, and will have a substantive influence over how consumers may handle credit report disputes directly with those who furnish information for the reports.
Financial privacy | credit reports -- Consumers and organizations have an opportunity to submit public comments about the accuracy and integrity of credit reports. Until February 11, the Federal Reserve Board, the Federal Trade Commission and other banking agencies will be accepting comments on their draft rulemaking regarding how creditors and other furnishers provide information to consumer reporting agencies, and which types of direct disputes they must handle. This proposed rulemaking is a key one; it defines what accuracy and integrity of information provided to consumer reporting agencies means, how disputes may be handled directly with the furnishers, and which types of direct disputes furnishers may ignore. The NCLC, Consumer's Union, and the World Privacy Forum have written a sample letter that may be downloaded and used or modified for the comments. To file your letter, submit your comments to the Board of Governors of the Federal Reserve System by mailing the comments to regs.comments@federalreserve.gov with the subject line "Docket No. R–1300."
Opt-out | Financial privacy -- The World Privacy Forum has updated its popular Top Ten Opt Out list to reflect several new change made to the Direct Marketing Association opt outs. In the past, some of the DMA opt-outs, like the Direct Marketing Association's mailing preference lists, used to cost $1. That fee has now been removed for people opting out online. Please see item #3 on the Opt Out list for the complete update.
The World Privacy Forum's Workplace Privacy Project is a long term project to study and document privacy practices in the areas of job applicant privacy, workplace privacy, background checks, and related areas.
Information about fair information practices.
Genetic privacy | SACGHS -- The World Privacy Forum filed extensive comments with the Secretary's Advisory Committee on Genetics, Health and Society (SACGHS) regarding its draft report on genetic testing oversight, U.S. System of Oversight of Genetic Testing: A Response to the Charge of the Secretary of HHS. The World Privacy Forum requested SACGHS pay more attention in its final report to the privacy consequences of unregulated genetic testing that occurs outside the health care sector. The WPF comments note that current and proposed remedies for the misuse of genetic information tend to focus on the use of the information within the health care treatment, payment, and insurance systems. What is crucially important is to analyze how to protect genetic information in the realm of commercial collection, maintenance, use and disclosures. Another area the comments discuss is the potential for new forms of fraudulent activity related to genetic testing (Phantom genetic testing, that is, genetic tests marketed to consumers that are not even real or viable genetic tests.) The World Privacy Forum specifically recommended that the National Committee on Vital and Health Statistics be tasked with looking at this matter, that an independent pre-market assessment mechanism is created for genetic tests offered outside the clinical setting, and that privacy be expressly discussed in the overarching recommendations in the final report.
Fair Information Practices -- The World Privacy Forum has updated its page on Fair Information Practices to include the new work by Robert Gellman in this area. His article, Fair Information Practices: A Basic History, December 2007, is an important history of the development of Fair Information Practices. It includes information that even experts familiar with FIPs may not know.
The World Privacy Forum filed extensive comments with the Secretary's Advisory Committee on Genetics, Health and Society (SACGHS) regarding its draft report on genetic testing oversight, U.S. System of Oversight of Genetic Testing: A Response to the Charge of the Secretary of HHS. The World Privacy Forum requested SACGHS pay more attention in its final report to the privacy consequences of unregulated genetic testing that occurs outside the health care sector. The WPF comments note that current and proposed remedies for the misuse of genetic information tend to focus on the use of the information within the health care treatment, payment, and insurance systems. What is crucially important is to analyze how to protect genetic information in the realm of commercial collection, maintenance, use and disclosures. Another area the comments discuss is the potential for new forms of fraudulent activity related to genetic testing (Phantom genetic testing, that is, genetic tests marketed to consumers that are not even real or viable genetic tests.) The World Privacy Forum specifically recommended that the National Committee on Vital and Health Statistics be tasked with looking at this matter, that an independent pre-market assessment mechanism is created for genetic tests offered outside the clinical setting, and that privacy be expressly discussed in the overarching recommendations in the final report.
Medical identity theft update -- The Federal Trade Commission released its national ID theft survey, which for the first time contains statistics specific to medical identity theft. According to the FTC report (p. 21), 3 percent of all identity theft victims in 2005 were victims of medical identity theft, which means of 8.3 million ID theft victims, approximately 250,000 people were victimized by medical identity theft in that year alone. The purpose of the World Privacy Forum 2006 report was to prove that medical identity theft existed, and was already occurring in large numbers. At the time the report was published, the crime of medical identity theft had not been specifically studied, nor was it understood to exist. The FTC statistics abundantly affirm the thesis and conclusions of the WPF report.
Security Freeze update | Financial privacy -- As of November 1, 2007, the ability to place a security freeze is available nationwide at the three major credit reporting bureaus. To date, 39 states and the District of Columbia have some form of security freeze law. But now, even in the states that did not pass security freeze legislation, consumers will be able to place a security freeze. A security freeze lets you stop the disclosure of your credit report by a credit bureau. A security freeze can be especially helpful to individuals who are having persistent problems with identity theft. For more information: