AIS Newsletter Provides In-Depth Look at Settlement Affecting Transgender Patients

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The August issue of Atlantic Information Services’ Report on Patient Privacy takes a look at how a recent voluntary settlement between HHS’s Office for Civil Rights and a New York City medical center has set a new standard for policies and procedures when it comes to the privacy rights and care of transgender patients.

A voluntary settlement agreement between the Department of Health and Human Services’ (HHS) Office for Civil Rights (OCR) and The Brooklyn Hospital Center (TBHC) in New York City has set a new standard for policies and procedures when it comes to the privacy rights and care of transgender patients. The August 2015 issue of Atlantic Information Services, Inc.’s (AIS) Report on Patient Privacy (RPP) offers an in-depth look at the settlement, dubbed a “wake-up call” to all Health Insurance Portability and Accountability Act covered entities (CEs) by one HIPAA expert: this is not the only such complaint OCR is investigating, and hospitals and CEs should begin to pay more attention to transgender issues.

“The next settlement may not be a voluntary settlement and may include the levying of civil penalties,” Chris Apgar, president of HIPAA consulting firm Apgar & Associates, warns. Demoya Gordon, a regional and Transgender Rights Project adviser with Lambda Legal, calls the agreement “a great step forward” and says it “can be a model for other hospitals going forward who want to do the right thing before HHS comes knocking on their door.” Kristen Eckstrand, M.D., Ph.D., founding chair of a transgender advisory committee for the Association of American Medical Colleges, tells RPP the settlement is exciting for its “potential” to influence other hospitals. “There is not always a good understanding of what discrimination means,” she adds.

The settlement (OCR Transaction Number 12-147291) stems from allegations that TBHC violated a provision in the Affordable Care Act when it assigned a patient who identifies as female to a double-occupancy room with a male patient, according to RPP. Though OCR’s announcement of the settlement offers no additional details and the agency didn’t respond to RPP’s request for comment, both OCR and TBHC issued statements, which are summarized in the August issue. Under the terms of the settlement, TBHC agreed to adopt and train employees on new policies and procedures tailored for transgender patients, running the gamut from admitting and rooming to documenting patients’ legal and preferred names and their “gender and/or transgender status, if the Patient has identified that status and agrees that it should be recorded,” according to RPP. In addition, employees are to become familiar with terms such as “gender non-conformity” and “sex assigned at birth.”

TBHC must also post statements around the hospital’s facilities affirming patients’ rights to care free from discrimination and provide a process for filing grievances. A related provision in the voluntary settlement, which Gordon at Lambda hailed as particularly progressive, holds the hospital to account for not discriminating against individuals with an “association” to a transgender patient.

Although she praised the agreement, Gordon tells RPP that it leaves out many specifics and is “not as robust or explicit” as the policies Lambda and other lesbian, gay, bisexual and transgender advocacy organizations have recommended. For instance, under the agreement TBHC must not discriminate in its rooming policy. But OCR doesn’t say what that means. A report developed by Lambda, in contrast, recommends that if single rooms are not available that patients be roomed with other patients whose gender matches how they “self-identify.”

Visit to read the article in its entirety, including more details on the voluntary settlement, potential issues with electronic health records and segregating patient information, and the statements from OCR and TBHC. The full voluntary settlement can be read by visiting

About Report on Patient Privacy
Report on Patient Privacy is the health industry’s #1 source of timely news and business strategies for safeguarding patient privacy and data security. Published for hospitals and other providers, health plans and other HIPAA-covered entities and business associates, the 12-page newsletter focuses on privacy issues that can result in huge fines, penalties and public relations nightmares, including: security breach notification; business associate relations and agreements; and new federal privacy rules for marketing, fundraising, privacy notices, minimum necessary, patient rights and safeguarding privacy in EHRs. Visit for more information.

About Atlantic Information Services
Atlantic Information Services, Inc. (AIS) is a publishing and information company that has been serving the health care industry for more than 25 years. It develops highly targeted news, data and strategic information for managers in hospitals, health plans, medical group practices, pharmaceutical companies and other health care organizations. AIS products include print and electronic newsletters, websites, looseleafs, books, strategic reports, databases, webinars and conferences. Learn more at

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