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Administrative (Non-Clinical) Policy
This administrative policy applies to the operations and staff of the University of Wisconsin Hospitals and
Clinics Authority as integrated effective July 1, 2015, including the legacy operations and staff of
University of Wisconsin Hospital and Clinics and University of Wisconsin Medical Foundation.
Policy Title: UW Health Removal of Electronic Systems Access
Policy Number: 1.05
Effective Date: May 1, 2016
To establish guidelines for the removal of access to UW Health's electronic data systems for UW Health
employees and others who have voluntarily or involuntarily terminated their employment or working
relationship with UW Health and/or changed positions/reassigned within UW Health.
UW Health shall take reasonable measures to ensure the confidentiality of its patient and proprietary
business information. Reasonable measures include establishing internal procedures to remove access to
UW Health electronic systems, as well as working with outside organizations to ensure that those
organizations promptly notify UW Health when an employee or agent who has access to UW Health
electronic systems terminates or is reassigned.
This policy applies to involuntary and voluntary terminations and reassignments, including but not
limited to job transfer, resignation, employee’s death and job abandonment.
III. PERSONS AFFECTED
For purposes of this policy, it is understood that the term "employees" includes the staff of the University
of Wisconsin Hospitals and Clinics Authority (UW Health) as integrated effective July 1, 2015, including
the legacy operations and staff of University of Wisconsin Hospital and Clinics and University of
Wisconsin Medical Foundation, Authority temporary, Graduate Medical Education trainees, Authority
employees in training, and student employees assigned and paid to perform work at UW Health. The term
"employees" will also be used to refer to non-employees, such as non-UW Health-paid employees,
including physicians, students in training, volunteers, and third parties (i.e., vendors, contractors).
A. Pursuant to procedures defined in UWHC Hospital Administrative policy 9.36-End Appointment
and Appointment Change, and upon notice from Human Resources of employee termination, UW
Health Information Services (IS) will de-activate or disable any account for applications that
contain patient information (e.g., Health Link document imaging, etc.) and all other accounts
(e.g., Novell, e-mail, etc.) associated with data the employee created or used.
1. Additional IS responsibilities include:
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a. Monitoring existing accounts. If there is no activity on an account for ninety (90)
days, IS will contact the department where the account was generated. If there is
no response within one week, IS will delete the account.
b. Documenting the date that accounts are deleted.
c. Maintaining a history of access privileges for all employees.
2. In situations other than termination or re-assignment, electronic access to systems
containing patient information may be disabled for any employee on a leave of absence to
assure the security of the employee's accounts. The Leave of Absence Coordinator in the
HR department will notify Systems Access in IS of all approved leaves of absence
exceeding 30 days, for which the employee will not require access to his/her accounts. To
secure those accounts, IS will disable them until notified by HR or the employee's
manager that the employee is returning to work.
B. Non-Employee Status Change Notification By contract or other agreement. UW Health will work
with organizations outside of UW Health to establish processes that ensure that IS and other
relevant UW Health departments are notified in a timely manner of terminations or reassignments
of individuals who may have physical access to UW Health facilities or access to UW Health
UW Health Administrative Policy 1.02-UW Health Access to Electronic Information Systems
Hospital Administrative Policy 1.30-Photo Identification System and Security Access
Hospital Administrative Policy 6.21-Security of Paper Medical Records
Hospital Administrative Policy 9.04-Work Rules: UWHC Authority
Hospital Administrative Policy 9.36-End Appointment/Appointment Change
Hospital Administrative Policy 9.40 Leaves of Absence, Excluding Sick, Family & Medical Leaves
Sr. Management Sponsor: SVP, Chief Information Officer
Author: Director, Systems Security
Review: Employee and Labor Relations Consultant; Director, Compliance
Approval Committee: UW Health Administrative Policy and Procedure Committee
President, University of Wisconsin Hospitals
Chief of Clinical Operations
Previous revision: 052013
Next revision: 052019