October 16, 2016

HIPAA Privacy Officer and Security Officer: Too Much for One Person?

Perhaps your organization is becoming a HIPAA covered entity or a business associate for the first time, and you now understand that your organization will have to comply with HIPAA. One of your first, and most important, tasks will be to designate a Privacy Officer and Security Officer.  This post describes some considerations you should think through when making this decision.

One person or two?
The HIPAA Privacy Rule requires a privacy officer be designated and the HIPAA Security Rule each requires a security officer be designated.  It is legally permissible to have on person designated as both, or split the roles. You'll need to decide whether to combine or bifurcate these roles.  




First, you need to decide whether you have one person within your organization who has the capabilities required for both roles.  The Privacy Officer is responsible for understanding who is allowed to access protected health information (PHI), and will need to answer questions about practices, address requests for information, and handle training and monitoring of other staff. The Security Officer is primarily focused on protecting electronic protected health information (ePHI) from unauthorized access (e.g., meeting encryption requirements, etc.). If the person you would prefer to designate as the Privacy/Security Officer does not have an understanding of the technological aspects of protecting ePHI, there are two solutions: (a) designate someone with the technological understanding to be the Security Officer, or (b) instruct someone with the technological understanding (either inside or outside of the organization) to assist the Privacy/Security Officer.


What is most effective? The benefit of designating two officers is that each can be more specialized, and potentially more effective in their respective areas. However, the risk associated with having two officers is that things that are not clearly just privacy or just security might fall through the cracks if the two do not coordinate well.

What is most efficient? For administrative purposes, it's hard to argue that having one designated officer isn't substantially easier than having two. There is so much overlap in the two areas of responsibility that if you can have one person be responsible for both, it may avoid a lot of duplication of effort. Combining the roles is more common in smaller organizations.

All that said, there's no legally incorrect answer here. Just like the debate over whether a CEO should also be the Chairman of the Board, there are good arguments on either side, and the answer often boils down to the size of the organization and administrative ease.
 

Can (and should) an organization have more than one Privacy Officer or Security Officer?  Some organizations are both a HIPAA "covered entity" (e.g., healthcare provider or sponsor of an employee health plan) as well as a "business associate" (e.g., service provider to a covered entity). Those organizations will need to decide whether the Privacy and Security Officer(s) they designate for themselves as a covered entity should be the same person(s) designated for purposes of the protected health information they acquire as a business associate.  Generally speaking, an organization's obligations as a covered entity are similar to its obligations as a business associate. With the exception of contractual obligations in business associate agreements, the basic legal obligations are almost identical. (The Security Rule obligations to protect ePHI are basically identical. The Privacy Rule obligations are very, very similar.)  


Generally, I don't think there is a compelling reason to have separate Privacy Officers (or Security Officers) for these two capacities in which an organization might be acting, and I don't believe that is a common practice.  I think it is most efficient to have one Privacy Officer and Security Officer who is responsible in both contexts, and who understands the subtle differences in those contexts.  Organizations that find themselves acting as both a covered entity and a business associate should be aware of the distinctions, however, and should have policies and procedures that reflect those distinctions.  Here is one practical example:  Most employees should be shielded from access to PHI that is held by a plan sponsor of an employee benefit plan.  However, within the same organization, far more employees might have a legitimate need to access the PHI of in the capacity as a business associate of other organizations. 




Once you've made this important decision, you can begin building a HIPAA compliance policy and procedures around the basic structure you've chosen. (Let me know if you'd like some help with that.) - Matt





















YOU CAN READ MORE ABOUT THIS AND SIMILAR ISSUES ON MY OTHER BLOG: THE NORTH CAROLINA PRIVACY AND INFORMATION SECURITY LAW BLOG AT WWW.PRIVACYLAWNC.COM.






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