Privacy Program Management Flashcards

A healthcare system's Privacy Officer is reviewing third-party vendor relationships. Which of the following vendors requires a Business Associate Agreement?

Answer: A medical transcription company that transcribes physician notes containing PHI

A medical transcription company creates, receives, or maintains PHI on behalf of the covered entity and is a business associate requiring a BAA.

In healthcare privacy program management, what is the purpose of conducting periodic privacy audits?

Answer: To verify ongoing compliance with privacy policies, identify gaps, and drive continuous improvement

Privacy audits verify that policies are being followed, identify compliance gaps and risks, and provide data to drive program improvement over time.

Which of the following is a key privacy consideration when implementing a Health Information Exchange (HIE)?

Answer: Establishing governance agreements that address consent models, data use limitations, and break-the-glass procedures

HIE governance agreements must address how participant organizations handle consent, limit data use to appropriate purposes, and manage emergency access (break-the-glass) scenarios.

Under HIPAA, what must a covered entity do if it maintains PHI about deceased individuals?

Answer: Maintain HIPAA protections for PHI of deceased individuals for 50 years after death

HIPAA protections extend to PHI of deceased individuals for 50 years following death, after which the information is no longer subject to HIPAA.

When designing a privacy compliance monitoring program, which approach provides the strongest ongoing assurance?

Answer: Periodic random audits combined with automated access log monitoring and incident trend analysis

Combining periodic random audits with automated log monitoring and trend analysis provides multi-layered, continuous assurance across the privacy program.

A hospital's privacy program is undergoing an external assessment. Which standard would be MOST appropriate for benchmarking privacy program maturity in a US healthcare context?

Answer: NIST Privacy Framework (PF)

The NIST Privacy Framework (PF) provides a voluntary, risk-based framework for managing privacy risks that aligns well with US healthcare privacy requirements including HIPAA.