Healthcare Data Classification Policy

HEALTHCARE DATA CLASSIFICATION POLICY

Purpose

This policy establishes mandatory classification categories and associated handling requirements for all data created, received, maintained or transmitted by the organization in support of healthcare operations. Classification is intended to ensure confidentiality, integrity and availability of data and to protect patient privacy, business function continuity and regulatory compliance.

Scope

This policy applies to all workforce members, contractors, business associates, vendors, systems and devices that create, store, handle, or access healthcare-related data. It covers electronic, paper and verbal forms of information.

Definitions

For purposes of this policy, the following definitions apply: "Highly Confidential" means data that poses severe risk to patient safety or organizational operations if disclosed; "Confidential" means data that includes protected health information or proprietary business information; "Internal Use Only" means operational or administrative data not intended for public disclosure; "Public" means data approved for external release with no substantive risk to patients or the organization.

Classification Levels and Examples

All data must be assigned one of the following classification levels. Selected controls must be applied consistently with the classifications.

Public — Information approved for public release that does not contain patient identifiers or proprietary information.

Internal Use Only — Operational or administrative data intended for workforce use; disclosure outside authorized personnel is not permitted.

Confidential — Protected health information (PHI), personally identifiable information (PII), financial or contractual records that require access controls and auditing.

Restricted / Highly Confidential — Data that, if disclosed or altered, would cause significant harm to patient safety, legal exposure or critical operations (e.g., surgical plans, genetic test results, authentication keys).

Mandatory Handling Requirements

The following controls are mandatory according to the data classification assigned. Additional controls may be applied where risk assessment indicates.

Access Control: Access to Confidential and Restricted data must be granted on the principle of least privilege and documented by role-based access lists. Access requests and approvals must be auditable.

Encryption at rest required for Confidential and Restricted data.

Encryption in transit required for transmission of Confidential and Restricted data.

Multi-factor authentication required for remote or privileged access to systems containing Confidential or Restricted data.

Audit logging and periodic review required for systems storing Confidential or Restricted data.

Data Labeling and Marking

All data assets must be labeled to reflect classification. Labels must travel with the data to the extent technically feasible. Workforce must confirm classification before sharing externally.

Retention, Archival and Disposal

Retention periods must be established by data category. Disposal or destruction of Confidential or Restricted data must render the data unrecoverable and must be documented.

Incident Response and Breach Notification

Suspected or confirmed breaches involving Confidential or Restricted data must be reported immediately to the Chief Privacy Officer or designated incident response lead. Investigation and notification procedures will follow organizational incident response protocols and applicable legal requirements.

Roles and Responsibilities

Data Owners, Data Stewards, IT Security, Privacy Office, and workforce each have defined responsibilities to ensure classification, protection, access control, and compliance. Data Owners approve classification and exceptions; IT Security enforces technical controls; Privacy Office oversees policy and compliance.

Training and Acknowledgement

All workforce members with access to Confidential or Restricted data must complete role-based training prior to access and annually thereafter. Completion shall be documented and retained.

Exceptions and Waivers

Requests for exceptions to this policy must be submitted in writing, include documented compensating controls, and receive written approval from the Policy Owner and the Privacy Office. Exceptions are time-limited and must be reviewed at least quarterly until closed.

Review and Amendment

This policy will be reviewed periodically and amended as necessary to reflect changes in law, technology, organizational structure, or risk. Amendments require approval by the Policy Owner and the Privacy Office.

Compliance and Enforcement

Noncompliance with this policy may result in disciplinary action up to and including termination, civil liability or criminal prosecution as permitted by law. All personnel must report suspected violations to the Privacy Office or through established reporting channels.

By signing below, the Approving Official certifies that this policy has been reviewed, that the classification scheme and handling requirements are appropriate to the organization's risks and obligations, and that mechanisms are in place to enforce the policy.

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