The Health Insurance Portability and Accountability Act of 1996 (HIPAA) and its regulations,
including the Privacy Rule and the Security Rule, as well as the Health Information
Technology for Economic and Clinical Health (HITECH) Act, govern the way certain health
information is collected, maintained, used, and disclosed. The Privacy Rule establishes
a set of safeguards on certain types of health information known as protected health
information, or PHI. HIPAA is designed to protect individual’s privacy and to inform
patients and research participants how their health information is used and disclosed.
See list of 18 PHI identifiers.
HIPAA requires specified language in the informed consent for the collection, use
and/or disclosure of PHI for research. The HIPAA Subject Authorization template below includes University specific language
which must be included in the Confidentiality Section of the Informed Consent form in
order to comply with HIPAA requirements.
HIPAA Forms And Compliance Procedures
Databases containing protected health information (PHI) used for research purpose
are impacted by the HIPAA Privacy Rule. The Privacy Rule regulations cover the use
of databases containing PHI just as they apply to any other research using PHI.
Training
Faculty, fellows, staff, and students conducting human subjects research involving
Protected Health Information (PHI) are required to complete the USA HIPAA Research tutorial. Training must be completed before participating in human subjects research involving
PHI.
HIPAA Certifications
There are four ways to perform HIPAA compliant research. They are:
- Obtain participant Authorization
- Obtain a waiver of authorization from the IRB
- Use of de-identified information
- Use of limited data set
Reviews Preparatory to Research
Reviews Preparatory to Research Certain activities involving the use/disclosure of
PHI are permitted without Authorization. The “preparatory to research” provision allows
researchers to use PHI for limited purposes, such as a feasibility assessment (e.g.,
whether a sufficient population exists to conduct research). However, the Privacy Rule does not permit the researcher to remove PHI. To comply with HIPAA Privacy Rule and human subjects regulations, researchers are
permitted to review PHI, but identifiers may not be recorded. To conduct a review
preparatory to research, a researcher must provide CERTIFY all of the following representations:
- The use or disclosure is requested solely to review PHI as necessary to develop a
research protocol or for similar purposes preparatory to research
- PHI will not be removed in the course of review
- The PHI for which use or access is requested is necessary for the research
INVESTIGATOR’S ACCESS PREPARATORY TO RESEARCH
Research Involving Deceased Individuals
The Privacy Rule provides protections to living and deceased individuals. To use decedents’
PHI for research purposes, a researcher must CERTIFY all of the following:
- Representation that the use or disclosure is solely for research involving the PHI
of decedents (e.g., and not also the living relatives of decedents)
- Representation that the PHI is necessary for the research
- Documentation (at the request of the covered entity holding the PHI) of the death
of the individuals whose PHI is sought.
Note: If the participant population contains both living and deceased individuals,
the requirements for Authorization (or waiver or alteration) apply.
RESEARCH INVOLVING DECEASED INDIVIDUALS
External Resources and Guidance
What are the research documents required by HIPAA?
HIPAA compliant research documents include:
- Authorization (HIPAA language template form - to be inserted in the consent form)
- Waiver of Authorization
- Data use agreement
What about releasing data outside of the USA HIPAA Covered Entities?
Intentional releases of research data outside USA must be made clear in the research
study documents submitted for IRB approval. Such releases should be described within
the authorization portion of the informed consent. Upon IRB approval, then such releases
are permitted. Disclosures for studies involving de-identified information of a limited
data set are also permitted.
For additional information, please contact the Office of Research Compliance and Integrity
at (251) 460-6625 or email dlayton@southalabama.edu