COVID-19: Digital Contact Tracing and Privacy Law

COVID-19: Digital Contact Tracing and Privacy Law

Legal Sidebari
COVID-19: Digital Contact Tracing and
Privacy Law
July 9, 2020
Many states, territories, and localities have implemented public health orders to limit the spread of
Coronavirus Disease 2019 (COVID-19) in their respective communities, including stay-at-home orders,
orders temporarily closing schools and businesses, and orders limiting the size of public gatherings. In
preparation for the eventual relaxation and lifting of these orders, the Centers for Disease Control and
Prevention (CDC) have advocated that public health authorities use robust “contact tracing” procedures to
prevent the reoccurrence of widespread infections after communities reopen. While federal entities may
advise on these procedures, state and local authorities are responsible for contact tracing operations, as
provided by state law.
The term “contact tracing” general y refers to identifying and monitoring people who have been in
contact with someone diagnosed with an infectious disease, in order to locate other potential y infected
individuals quickly and take targeted control measures (such as quarantines) to prevent the broader spread
of the il ness. Contact tracing is standard procedure in public health investigations, and historical y
involves officials interviewing and contacting infected and potential y-exposed persons. However, some
of the contact tracing proposals aimed at controlling the spread of COVID-19 suggest supplementing
traditional contact tracing procedures with technology to collect data electronical y. These proposals raise
questions about how federal laws governing health information privacy may apply to electronic or digital
contact tracing. One such provision is the “HIPAA Privacy Rule,” which refers collectively to regulations
promulgated by the Department of Health and Human Services (HHS) under the Health Insurance
Portability and Accountability Act (HIPAA). This Sidebar discusses the HIPAA Privacy Rule’s
application to digital contact tracing and briefly discusses other federal laws that regulate data privacy.
HIPAA Privacy Rule Overview
The HIPAA Privacy Rule regulates the use and disclosure of protected health information (PHI) by
“covered entities” and their “business associates.” Covered entities include health plans, health care
clearinghouses, and “health care providers” who transmit electronic health information in connection with
a HIPAA-covered transaction (such as bil ing). A health plan is an “individual or group plan that provides,
or pays the cost of, medical care.” This includes health insurance companies, health maintenance
organizations (HMOs), and government programs, such as Medicaid and Medicare, that pay for
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healthcare. Health care clearinghouses are defined as entities that process health information in a
nonstandard format into a standard format, or vice versa. Lastly, health care providers include providers
of services covered by Sections 1861(u) or 1861(s) of the Social Security Act (which includes, among
other things, physicians’ services, hospital services, physical therapy services, and skil ed nursing facility
services) or any person who otherwise “furnishes, bil s, or is paid for health care in the normal course of
business.” Health care is defined as “care, services, or supplies related to the health of an individual.” A
business associate is one who, among other actions, “creates, receives, maintains, or transmits protected
health information” on behalf of a covered entity for an activity regulated under HIPAA general y (not
simply the Privacy Rule), such as claims processing, data analysis, processing or administration,
utilization review, quality assurance, bil ing, benefit management, practice management, and repricing.
The HIPAA Privacy Rule recognizes that entities may engage in conduct that makes them covered entities
(“covered functions”), while, at the same time, performing other functions that would not render them
covered entities. For instance, institutions of higher learning may, in addition to providing education, run
a health clinic that provides healthcare for students. Such an entity may become a “hybrid entity” by
complying with organizational requirements that include designating a specific component of its
organization as the “health care component.” In such situations, only the designated health care
component of a hybrid entity is required to comply with the HIPAA Privacy Rule.
As noted, the obligations of covered entities and their business associates under the HIPAA Privacy Rule
revolve around the use and disclosure PHI. PHI includes information that (1) “identifies,” or can
reasonably “be used to identify,” an individual; (2) is “created or received by a health care provider,
health plan, employer, or health care clearinghouse”; (3) relates to an individual’s past, present, or future
physical or mental health, health care provision, or payment for the provision of health care; and (4) is
transmitted by or maintained in electronic or any other form or medium. The HIPAA Privacy Rule, among
other things, limits covered entities from using PHI or sharing it with third parties without valid patient
authorization, unless the use is for purposes of treatment, payment, or “health care operations,” or fal s
within a specific statutory exception.
One such exception that is particularly relevant to contact tracing al ows covered entities to use or
disclose PHI—without individual patient authorization or the opportunity for the patient to agree or
object—to “a public health authority” that is legal y authorized to collect the information “for the purpose
of preventing or controlling disease, injury, or disability,” including “the conduct of public health
surveil ance.” A “public health authority” includes any agency or authority of the “United States, a State,
a territory, a political subdivision of a State or territory, or Indian tribe,” that is “responsible for public
health matters as part of its official mandate,” as wel as “a person or entity acting under a grant of
authority from or contract with” such an agency. This definition encompasses the CDC as wel as state
and local public health departments, among others. State and local health departments may engage in both
covered and non-covered activities, and many choose to designate themselves as a “hybrid entity,” so that
their non-covered components need not comply with the HIPAA Privacy Rule’s requirements.
Violations of the HIPAA Privacy Rule can lead to civil or criminal enforcement. The HHS Office of Civil
Rights is responsible for investigating and enforcing civil violations of HIPAA’s requirements and may
impose monetary penalties, which vary depending on the violator’s culpability. The U.S. Department of
Justice has criminal enforcement authority under HIPAA and may seek fines or imprisonment against a
person who “knowingly” obtains or discloses “individual y identifiable health information” or “uses or
causes to be used a unique health identifier” in violation of HIPAA’s requirements.
Mobile Application Contact Tracing Overview
Among the many chal enges public health authorities face in tracking and controlling the spread of
COVID-19 is that the disease is highly infectious and appears to be transmissible by people who do not

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show symptoms of COVID-19 and thus may not know that they are infected. In this environment, mobile
applications (apps) may facilitate public health authorities’ gathering data on potential exposures to use in
contract tracing. As explained in this CRS In Focus, governments and technology companies have
explored two schemes for gathering device data through contact tracing apps: location tracking and
proximity tracking. Location tracking schemes collect location information from individuals’ mobile
devices, including global positioning system (GPS) and cel site location information, to map their
locations over time. Proximity tracking schemes use Bluetooth technology to determine when two devices
remain within a particular distance of each other for a specified amount of time, without collecting
location data. Apps built using either scheme relate information to a unique identifier associated with a
particular mobile device. For location tracking apps, these identifiers are mapped to particular locations,
while proximity tracking apps broadcast identifiers over Bluetooth so app users may anonymously log
encounters with other app users. In certain app configurations, an app user may report a positive COVID-
19 diagnosis within the app, which then could relay a report of that diagnosis—anonymously—to those
app users who had been in proximity to the diagnosed person, and/or to public health authorities
undertaking contact tracing investigations.
North Dakota and South Dakota have both deployed a location tracking system, while Google and Apple
have changed their mobile operating systems to al ow developers to create proximity tracking apps. Some
apps may use both location and proximity tracking, such as an app previously deployed by Norway’s
government. In each case, app functionality may rely on several types of information with different
sources, including information from the app user’s device (such as the device’s unique identifier) and
information the app user voluntarily provides (such as a positive COVID-19 diagnosis).
Interaction of the HIPAA Privacy Rule with Mobile
Application Contact Tracing
As noted, the HIPAA Privacy Rule’s protections do not apply to al health-related data. Only PHI held by
covered entities and their business associates is subject to the Rule. Thus, the extent to which the Rule
applies to digital contact tracing applications depends on whether the parties developing the apps and
processing app information fal within the definitions of covered entities or business associates and
whether the app uses PHI.
Are public health authorities or app developers Covered Entities or Business
Associates?
Because state and local public health authorities are the primary users of data collected through contact
tracing, a critical threshold issue is whether they are covered entities subject to the HIPAA Privacy Rule.
This issue is complicated by the fact that a public health authority may perform various functions within
one agency. For example, a public health authority may provide clinical care (e.g., diagnostic testing), and
thus qualify as a health care provider subject to HIPAA’s requirements. The same agency might also
engage in community-wide or state-wide disease control activities, such as contact tracing, that do not
appear to be among the functions by which HIPAA defines covered entities.
Thus, a health department that engages in both health care activities and disease control functions may
choose to operate as a “hybrid entity.” In so doing, state and local health departments may limit their
obligations under the HIPAA Privacy Rule solely to their performance of discrete covered healthcare
functions. Any information the “hybrid” agency obtains for use in disease control activities such as
contact tracing would not be subject to HIPAA’s privacy protections. Moreover, under the public health
authority exception to the HIPAA Privacy Rule, this would include PHI received by the public health
authority from a covered entity, such as a healthcare provider.

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Third-party software developers standing alone are not general y covered entities subject to the HIPAA
Privacy Rule. Moreover, a third-party software developer that creates, maintains, or administers an app
used in a public health authority’s contact tracing operations would not qualify as a business associate
subject to the HIPAA Privacy Rule if the public health authority is not a covered entity when performing
its disease control functions. That is because, as explained above, HIPAA defines a business associate as
one who “creates, receives, maintains, or transmits protected health information” on behalf of a covered
entity.
Do contact tracing apps use PHI?
Even if an entity is a covered entity or a business associate under HIPPA, HIPAA’s Privacy Rule only
applies to PHI. To be sure, contact tracing apps rely on health-related information (e.g., information that
shows whether individuals have been diagnosed with, or exposed to, COVID-19). Thus, for any entities
involved in the development and operation of a contact tracing app that might be covered entities or
business associates, the applicability of the HIPAA Privacy Rule to them would largely depend on
whether the information used for digital contact tracing is individually identifiable.
HIPAA deems health information not identifiable if the covered entity takes either of two steps. One
option is that the covered entity can de-identify the information by ensuring that eighteen specific types of
identifiers have been removed (including, for example, “al geographic subdivisions smal er than a State,”
“telephone numbers,” and “device identifiers”). Alternatively, the covered entity may obtain
documentation showing that an expert has determined that there is a “very smal ” risk of identification
from the information. If this approach is chosen, the HHS Office of Civil Rights may assess the expert’s
qualifications in the course of an audit or investigation.
It is difficult to conceive how covered entities could de-identify the information required for contract
tracing apps to function. Contact tracing apps wil necessarily depend on information that accurately
tracks individual movements and contacts. Both location tracking and proximity tracking apps function
by associating a person who has tested positive for a disease with a device identifier generated by the app.
In the case of location tracking apps, this includes GPS or cel site location information, which provides
geographic information much smal er than a state. Apps also could request additional identifying
information: Singapore’s app, for example, requires app users to provide phone numbers. Accordingly,
the most likely option by which a covered entity could establish that the health information used for
digital contact tracing is not identifiable would be to obtain an expert determination that the risk of
identification from the information is “very smal .”
Any such determination would likely assess the steps taken by the app to make identification more
difficult. Google and Apple’s proximity tracking framework provides for apps that use randomly
generated identifiers, which cycle every 10-20 minutes to reduce the risk of linking any group of
identifiers to an individual. Location tracking apps may take similar measures to mitigate tracking risk.
For example, North Dakota’s app associates location information with a random ID number and only
stores location information when a device remains at a location for more than ten minutes. However, even
apps that associate information with randomly generated identifiers may be susceptible to “linkage
attacks” in which an entity might be able to identify a particular device, and apps that collect more
detailed information may pose even greater risks.
Other Relevant Privacy Laws
Even when HIPAA does not apply, other federal privacy laws may come into play. As discussed in this
CRS report, HIPAA is just one part of the “patchwork” of federal laws governing companies’ privacy
obligations. In particular, the companies that develop and maintain contact tracing apps must comply with
the Federal Trade Commission Act’s prohibition on unfair or deceptive acts or practices (UDAPs). The

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Federal Trade Commission (FTC), which enforces this prohibition, regularly brings enforcement actions
against persons or companies for col ecting or using personal information in a deceptive or unfair manner,
such as when a company’s privacy practices contradict its posted privacy policy. It is unclear, however,
whether the FTC could bring a UDAP action against state health departments or app developers acting on
their behalf. For example, courts have applied the state action doctrine—which provides immunity for
certain state actions that might otherwise violate federal antitrust laws—to FTC suits brought under the
FTC Act’s prohibition of “unfair methods of competition.” This doctrine may also apply to the FTC’s
UDAP authority. At least one district court has applied the state action doctrine to bar the FTC from using
its UDAP enforcement power against a state entity, although that decision was later vacated on other
grounds. However, the case law on this issue is relatively sparse.
Along with the FTC Act, the Communications Act may limit tracing apps’ ability to gather cel phone GPS
data. The Communications Act prohibits telephone carriers from using or disclosing “customer
proprietary network information” (CPNI) unless the customer consents or a specific exception applies.
The Act defines CPNI to include information relating to the “location” of a customer’s
“telecommunications service” that is available to the carrier by “virtue of the carrier-customer
relationship.” However, CPNI excludes “aggregate” customer information from which “individual
customer identities and characteristics have been removed,” similar to how companies like Google and
Apple claim they are endeavoring to de-identify information with their contact tracing frameworks.
Considerations for Congress
In summary, no single federal law creates consistent, clearly-applicable privacy protections for the
information that likely would be gathered and used in contact tracing activities. In the context of digital
contact tracing, state and local health departments conducting contact tracing and the app developers that
assist them in that activity may not qualify as covered entities or business associates subject to HIPAA’s
requirements. Other federal laws, such as the FTC Act and Communications Act, may provide some
privacy protections when HIPAA does not apply. Yet the reach of these laws is also limited. The FTC does
not require entities to adopt particular privacy practices; it only takes enforcement action against
corporate and private actors that it believes are engaged in unfair or deceptive conduct. The
Communications Act’s CPNI protections apply only to telephone carriers.
Members of the 116th Congress have proposed several COVID-19-related privacy bil s. While an in-
depth discussion of these bil s is beyond the scope of this Sidebar, the Public Health Emergency Privacy
Act (PHEPA), COVID–19 Consumer Data Protection Act of 2020 (CCDPA), and Exposure Notification
Privacy Act (EPNA) would general y provide additional privacy rights and obligations related to entities’
collection and use of personal information for contract tracing and exposure notification purposes. While
the CCDPA and PHEPA would apply specifical y to COVID-19, the EPNA would not be limited to the
current pandemic. For a further discussion of these bil s, see CRS Legal Sidebar LSB10501, “Tracing
Papers”: A Comparison of COVID-19 Data Privacy Bills, by Jonathan M. Gaffney. For a discussion of
Congress’s constitutional authority to regulate states’ contact tracing activities, see CRS Legal Sidebar
LSB10502, Constitutional Authority to Regulate the Privacy of State-Collected Contact-Tracing Data, by
Edward C. Liu.

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Author Information

Eric N. Holmes
Chris D. Linebaugh
Legislative Attorney
Legislative Attorney

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