On June 4, 2015, the Italian Data Protection Authority issued new guidelines governing the collection and processing of personal and sensitive data through the Electronic Medical Record.

• What is an Electronic Medical Record?

A record, kept by a hospital or a healthcare center, containing patients’ clinical history at that specific hospital or healthcare center.

• Patients’ rights

The guidelines set forth several rights to which patients treated at any hospital or healthcare center are entitled:

1. Patients are entitled to decide whether the hospital or the healthcare center may store their data through an Electronic Medical Record. If a patient denies his/her consent, physicians will be able to rely only on information gathered during examination and treatment, as well as on information previously conveyed by the patient, if any. Denial of consent will not affect the possibility of being treated at the hospital/healthcare center.
2. Specific consent is needed for the collection of certain categories of sensitive date, such as HIV infections, abortions, data relating to sexual assault. With respect to such data, patients will have the right to limit access to specific individuals/professionals.
3. In addition to all rights granted by the Data Protection Code (such as the right to receive confirmation on the existence of personal/sensitive data, to know the origin of the data, the purpose and means of processing, as well as the logic applied to the processing) patients will also be entitled to receive information on each access to their Electronic Medical Record.

• Hospitals and healthcare centers’ obligations

Hospitals and healthcare centers are required to provide patients with a thorough privacy notice concerning the processing of data through the Electronic Medical Record. Upon patients’ request, hospitals and healthcare centers shall also provide information concerning stored data and access logs to the Electronic Medical Record (including the professional accessing the data, date and time of access) within 15 days of the request. Patients will also be entitled to redact data or healthcare documentation that they do not wish to be included in their Electronic Medical Record.

The Data Protection Authority’s guidelines also address important technical aspects and provide that patients’ healthcare information contained in the Electronic Medical Record shall be segregated from other administrative data. Sensitive data will need to be encrypted. Furthermore, access to the record will be granted only to medical staff involved in the patient’s treatment and any access and processing will be recorded on log files to be kept by the hospital or healthcare center for at least 24 months.

Lastly, the guidelines set forth strict data breach requirements for hospitals and healthcare center, by providing that any data breach or unauthorized access shall be reported to the Data Protection Authority within 48 hours of knowledge of the breach. Failure to report will lead to the application of penalties.

See the Data Protection Authority’s presentation of the new guidelines