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Healthcare and hospitals

DPDP for the Director in Healthcare

As a director, you are expected to ask whether patients' information is cared for as well as their health.

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What is different here

Hospital boards review clinical quality and accreditation. Patient data now deserves a place on the same agenda.

The first four things to sort out

  1. Ask who is accountable for patient data, by name.
  2. Ask when the hospital last tested recovery from a cyber attack.
  3. Ask which outside parties receive patient data.
  4. Ask for a plan to May 2027 with dates.

A worked example: The board reviews patient-data readiness

  1. BeforeDirectors ask for the accountability chain and the downtime plan.
  2. MeetingA director asks when recovery was last tested. The answer: four months ago, restored in 9 hours.
  3. Good answerA named lead, a rehearsal date, vendor list with contracts, and wrong-send numbers.
  4. AfterPatient data becomes a quarterly item.

Evidence kept: Board note; Minutes.

Ask for dates and numbers.

What others in the sector usually do. Some boards now get a short note every quarter on patient-data incidents, alongside the clinical incident report.

Where it usually goes wrong, by organisation type

Organisation typeHotspots
Multi-specialty hospital chainShared logins on ward computers; Reports forwarded on messaging apps; VIP or staff records viewed out of curiosity
Standalone hospital or nursing homePaper case sheets at nursing stations; Vendor remote access to the hospital software; Records room with no access log
Diagnostic labs and imagingReport links sent to the wrong number; Franchisees keeping patient lists; PCPNDT records and images
Health-tech and telemedicineAnalytics and ad SDKs in health apps; Chat transcripts kept with no period; Sharing user data with partner pharmacies for offers
Pharmacy chain and e-pharmacyPrescription images in the app and with stores; Refill reminders used for marketing; Delivery partners with addresses and order details

What a good answer from management sounds like

Question to askA good answer sounds likeEffort and time
Which records need extra protection under other health laws?“Sensitive records have restricted access and their own retention, with logs reviewed.”Medium
Can we share patient records with insurers and TPAs?“Claims go through portals with only the needed documents, and every transfer is logged.”Light to medium
How do we stop staff looking at records they do not need?“Flagged records need a reason, break-glass is reviewed weekly, and misuse is acted on.”Medium
What should the board of directors ask management about DPDP?“DPDP is a standing quarterly item. Management brings a short note with names, numbers and evidence.”Light · one agenda item every quarter
Do we need a DPO?“We have named an accountable person with a deputy, published the contact, and that person reports to management every month.”Light · 2 to 4 weeks
Something has gone wrong. What happens in the first 72 hours?“We have one plan that meets every clock. It was rehearsed this year, and the next rehearsal date is fixed.”Medium · 4 to 8 weeks, then a yearly drill
What must a vendor contract say about personal data?“Our top vendors have data terms with a short incident-notice time, and we review them every year.”Medium · 8 to 16 weeks for the top vendors
Could we be a Significant Data Fiduciary?“We have estimated our exposure. If we are notified, we can appoint a DPO and an auditor within weeks, because the groundwork is done.”Medium if you are a likely candidate
How much effort and time will it take to be ready by 13 May 2027?“We have a dated plan with named owners. Each month we see evidence, not just colours, and we expect to finish before March 2027.”Programme · six to nine months

9 guides for the Director, in full

Which records need extra protection under other health laws?

Short answer: Yes, tighter access than other records

HIV results, mental health records, MTP registers and PCPNDT records each have their own law. HIV status needs informed consent before disclosure. Mental health records are confidential and cannot go to the media without consent. The MTP admission register is a secret document. PCPNDT records are kept for two years. Give these the tightest access in the hospital.

From your seat: Director. Ask whether these records have tighter access than others.
What the law says

Section 8(5) asks for safeguards suited to the risk; the special laws set their own rules. Section 8(5) · Rule 6 · Section 8(7) · Rule 8

What a good answer from management sounds like: “Sensitive records have restricted access and their own retention, with logs reviewed.”
Effort and time: Medium.
Steps
  1. List where these records sit.
  2. Restrict access to the treating team.
  3. Keep the MTP register with the head of the hospital.
  4. Set retention as each law says.
  5. Log every access.
Evidence to keep
  • Access settings
  • Retention entries
  • Access logs
Common mistakes
  • HIV results visible to all clinicians
  • MTP details in general billing
  • PCPNDT records deleted early
Related questions

Can we share patient records with insurers and TPAs?

Short answer: Yes for the patient's claim; only what it needs

Yes, for a claim the patient has asked for, because that is part of the purpose. Share only what the claim needs, through the TPA portal or a secure channel, and keep a record of what was sent. Sharing for anything else, such as an insurer's own marketing, needs consent.

What the law says

Section 7(a) covers the claim purpose; Section 8(1) and 8(5) apply to how data is sent. Section 7 · Section 8(5) · Rule 6 · Sections 11–14 · Rule 14

What a good answer from management sounds like: “Claims go through portals with only the needed documents, and every transfer is logged.”
Effort and time: Light to medium.
Steps
  1. Use TPA portals, not email.
  2. Send only claim documents.
  3. Log what was sent, to whom, when.
  4. Answer patient questions about sharing.
  5. Check TPA agreements.
Evidence to keep
  • Sharing log
  • TPA agreement
Common mistakes
  • Full case files by email
  • No record of what was sent
  • Insurer representatives reading records on wards
Related questions

How do we stop staff looking at records they do not need?

Short answer: Role access, flags and weekly log review

Snooping on VIP, celebrity, colleague or neighbour records is a common problem. Give access by role, mark sensitive records, ask for a reason before opening them, allow break-glass access in emergencies, and review those logs every week.

What the law says

Rule 6 requires access control and monitoring. Section 8(5) · Rule 6 · Section 8(6) · Rule 7

What a good answer from management sounds like: “Flagged records need a reason, break-glass is reviewed weekly, and misuse is acted on.”
Effort and time: Medium.
Steps
  1. Flag VIP, staff and sensitive records.
  2. Ask for a reason to open them.
  3. Allow break-glass with review.
  4. Review logs weekly.
  5. Act on misuse consistently.
Evidence to keep
  • Flag settings
  • Review records
  • Action records
Common mistakes
  • Everyone can see everything
  • Break-glass never reviewed
  • No action on misuse
Related questions

What should the board of directors ask management about DPDP?

Short answer: Five plain questions, asked every quarter

Directors do not need technical detail. They need to know who is accountable, how the organisation would handle a breach, which outside parties hold data, and whether the plan to May 2027 is on track with evidence.

From your seat: Director. Ask the five questions every quarter, and record the answers in the minutes. The answers will improve when management knows the questions are coming.
In Healthcare

Ask about downtime, wrong sends and vendor lists.

What the law says

The Act places duties on the Data Fiduciary, the organisation itself. Directors oversee whether management has put those duties into practice. Section 8(1)–(2) · Section 8(6) · Rule 7 · Section 10 · Rule 13

What a good answer from management sounds like: “DPDP is a standing quarterly item. Management brings a short note with names, numbers and evidence.”
Effort and time: Light · one agenda item every quarter.
Steps
  1. Ask who is accountable for personal data, by name.
  2. Ask when the breach plan was last rehearsed and what was learnt.
  3. Ask for the list of vendors holding the most personal data.
  4. Ask how many requests and complaints came in, and how fast they were answered.
  5. Ask for the plan to May 2027 with evidence, not colours.
Evidence to keep
  • Quarterly note to the board
  • Minutes showing the questions asked
  • Management responses
Common mistakes
  • Discussing DPDP once and then never again
  • Accepting 'IT is handling it'
  • No date for the breach rehearsal
Related questions

Do we need a DPO?

Short answer: Not required by law unless notified as an SDF, but name one person

Only a Significant Data Fiduciary must appoint a DPO, based in India. Every other organisation must publish the contact of a person who can answer questions about personal data. In practice, most organisations of any size name one accountable person anyway, because someone has to own requests, complaints and breaches.

From your seat: Director. Ask who the accountable person is, what authority they have, and when they last reported to the board or a committee.
In Healthcare

Hospital chains and large labs should name a privacy lead.

What the law says

Section 8(9) and Rule 9 require a published contact person for every Data Fiduciary. Section 10 requires a DPO in India for Significant Data Fiduciaries. Section 8(9)–(10) · Rules 9, 14 · Section 10 · Rule 13

What a good answer from management sounds like: “We have named an accountable person with a deputy, published the contact, and that person reports to management every month.”
Effort and time: Light · 2 to 4 weeks.
Steps
  1. Name one accountable person, with a deputy.
  2. Publish the contact on your website, app and notices.
  3. Give the role time, a budget line and a route to management.
  4. Set a short monthly report: requests, complaints, incidents, actions.
  5. Review the role if you are notified as an SDF.
Evidence to keep
  • Appointment letter
  • Published contact
  • Monthly report
Common mistakes
  • Giving the job to IT as a side task
  • A contact email nobody reads
  • No authority to make changes
Related questions

Something has gone wrong. What happens in the first 72 hours?

Short answer: Six hours for CERT-In; without delay for people and the Board; 72 hours for the detailed report

Contain it, then tell people. A reportable cyber incident goes to CERT-In within six hours of being noticed. Under DPDP, each affected person and the Data Protection Board must be told without delay, and the Board needs a detailed report within 72 hours. Sector regulators may have their own clock too.

From your seat: Director. Ask when the plan was last rehearsed, who took part, and what went wrong in the drill. A drill with no findings was probably too easy.
In Healthcare

A ransomware attack on the HIS needs a CERT-In report in six hours and the DPDP messages.

What the law says

Section 8(6) and Rule 7 set the DPDP steps. The CERT-In Directions of 28 April 2022 set the six-hour report. A breach includes accidental disclosure and loss of access, not only hacking. Section 8(6) · Rule 7 · Section 8(5) · Rule 6

What a good answer from management sounds like: “We have one plan that meets every clock. It was rehearsed this year, and the next rehearsal date is fixed.”
Effort and time: Medium · 4 to 8 weeks, then a yearly drill.
Steps
  1. Name one incident lead and a back-up, with phone numbers that work at night.
  2. Write the first-hour steps: isolate, preserve logs, tell the DPO and the incident lead.
  3. Keep ready-made drafts for CERT-In, the regulator, the Board and affected people.
  4. Decide in advance who signs off each message.
  5. Rehearse once a year with the people who would actually be called.
Evidence to keep
  • Incident plan with clocks
  • Rehearsal record
  • Incident log with times of each step
Common mistakes
  • Waiting to finish the investigation before telling anyone
  • Treating a wrong email or a lost laptop as 'not a breach'
  • Only IT knowing the plan
Related questions

What must a vendor contract say about personal data?

Short answer: Yes, every vendor that touches personal data

You stay responsible for what your vendors do with personal data. The contract should say what data they get, for what purpose, the security they must keep, how fast they must tell you about an incident, that sub-contractors need your approval, and how data is returned or deleted at the end.

From your seat: Director. Ask which three vendors hold the most personal data, and when their contracts were last reviewed.
In Healthcare

Labs, teleradiology, HIS vendors, TPAs and ambulance services.

What the law says

Section 8(1) keeps responsibility with you. Section 8(2) allows a processor only under a valid contract. Rule 6 asks for security terms in that contract. Section 8(1)–(2) · Section 8(5) · Rule 6 · Section 8(6) · Rule 7 · Section 8(7) · Rule 8

What a good answer from management sounds like: “Our top vendors have data terms with a short incident-notice time, and we review them every year.”
Effort and time: Medium · 8 to 16 weeks for the top vendors.
Steps
  1. List vendors who receive or can see personal data.
  2. Rank them by how much and how sensitive.
  3. Add a data-protection schedule to each contract, starting with the top ten.
  4. Ask for evidence: certificates, test results, deletion confirmations.
  5. Review the top vendors every year.
Evidence to keep
  • Vendor register
  • Signed data-protection schedules
  • Annual review notes
Common mistakes
  • Relying on the vendor's standard terms
  • No incident-notice time
  • No exit and deletion clause
Related questions

Could we be a Significant Data Fiduciary?

Short answer: Only by notification; none notified yet

Only the government can notify an organisation or a class of organisations as a Significant Data Fiduciary, based on the volume and sensitivity of data and the risk to people or the State. None had been notified when this page was last reviewed. Large holders of sensitive data should plan as if it could happen.

From your seat: Director. Ask whether management has assessed the chance of notification. Large or sensitive data holders should have a view.
In Healthcare

Large hospital chains and health platforms hold sensitive data at scale; plan as a possible candidate.

What the law says

Section 10 and Rule 13 set the extra duties: a DPO in India, an independent data auditor, a yearly Data Protection Impact Assessment and audit, and checks on algorithms. Rule 13(4) allows the government to restrict some data from leaving India. Section 10 · Rule 13 · Section 16 · Rule 15

What a good answer from management sounds like: “We have estimated our exposure. If we are notified, we can appoint a DPO and an auditor within weeks, because the groundwork is done.”
Effort and time: Medium if you are a likely candidate.
Steps
  1. Estimate how many people's data you hold and how sensitive it is.
  2. Note any public or security role your data plays.
  3. If you are a likely candidate, run a trial impact assessment this year.
  4. Identify an auditor you could appoint.
  5. Watch MeitY notifications.
Evidence to keep
  • Volume and sensitivity note
  • Trial impact assessment
  • Board note
Common mistakes
  • Assuming 'not notified' means 'never'
  • Waiting for notification to start
  • Thinking only tech companies will be notified
Related questions

How much effort and time will it take to be ready by 13 May 2027?

Short answer: Six to nine months of steady work for most

For most organisations it is a programme of six to nine months, not a single project. The heavy parts are the data inventory, vendor contracts, access control and the request process. Notices, the contact person and training are lighter. Starting now leaves time to fix what you find.

From your seat: Director. Ask for evidence against the plan, such as signed contracts, rehearsal reports and request logs, not just status colours.
In Healthcare

Access control and vendor contracts take the longest.

What the law says

Most duties under the DPDP Rules start on 13 May 2027. Section 8(5) · Rule 6 · Section 8(1)–(2) · Sections 11–14 · Rule 14

What a good answer from management sounds like: “We have a dated plan with named owners. Each month we see evidence, not just colours, and we expect to finish before March 2027.”
Effort and time: Programme · six to nine months.
Steps
  1. Month 1: name the owner, set a budget line, start the inventory.
  2. Months 2 to 3: notices, consent records, contact person, request register.
  3. Months 3 to 6: vendor contracts, access control, logs, retention schedule.
  4. Months 6 to 8: breach rehearsal, training, internal review.
  5. Month 9: management review with evidence.
Evidence to keep
  • Programme plan with owners
  • Monthly status with evidence
  • Management minutes
Common mistakes
  • Leaving it to the last quarter
  • Buying a tool before knowing the gaps
  • Status colours with no evidence behind them
Related questions

Practical examples

Notice wording, request log, retention schedule, vendor clause and breach notice for healthcare and hospitals.

The sections you will use most

Other rules that sit alongside DPDP

RuleWhat it saysWhat it means alongside DPDPSource
Indian Medical Council (Professional Conduct, Etiquette and Ethics) Regulations, 2002Regulation 1.3.1: keep indoor patients' medical records for 3 years from the start of treatment. Regulation 1.3.2: issue records to patients, authorised attendants or legal authorities within 72 hours of a request. Regulation 2.2: keep patient confidences.Set retention at or above these minimums. Use the 72-hour record copy rule as the base for patient access requests.Code of Medical Ethics, 2002
Telemedicine Practice Guidelines, 2020 (Appendix 5 to the 2002 Regulations)Consent is implied when the patient starts a teleconsultation and must be explicit when a health worker or caregiver starts it. The doctor records consent and keeps logs, records and prescriptions as for in-person care.Telemedicine apps must add DPDP notices and protect chat, video and prescription data.MoHFW
Pre-Conception and Pre-Natal Diagnostic Techniques (PCPNDT) Act, 1994Records of tests and procedures, including Form F, must be preserved for 2 years, or until a legal proceeding ends.These records cannot be erased early on request; protect them carefully.Tamil Nadu health department FAQ
Medical Termination of Pregnancy Regulations, 2003The admission register is a secret document, kept by the head of the hospital, not open to inspection except under law, and kept for five years.MTP records need the tightest access in the hospital.MTP Regulations
Mental Healthcare Act, 2017Section 23: right to confidentiality. Section 24: no photos or information to media without consent. Section 25: right to access basic medical records.Psychiatry and counselling records need separate access and a careful request process.NHSRC copy of the Act
HIV and AIDS (Prevention and Control) Act, 2017HIV status may be disclosed only with informed consent, except in narrow cases. Establishments keeping HIV-related records must adopt data protection measures.Restrict HIV results and counselling notes to the treating team.Act
New Drugs and Clinical Trials Rules, 2019Informed consent of trial participants; ethics committees keep records for five years after the trial ends (Rule 13).Trial data needs both informed consent and DPDP safeguards.NDCT Rules
Drugs Rules: Schedule H1 registerPharmacies record prescriber's name and address, patient's name, drug and quantity, kept for three years.Keep the register for three years, then dispose of it.NHSRC
ABDM Health Data Management PolicyFor entities in the Ayushman Bharat Digital Mission, health records are shared through a consent manager, with consent artefacts for each request.If you are ABDM-linked, the ABDM consent flow and your DPDP notices must agree.ABDM / NHA
Clinical Establishments Act, 2010 and Rules, 2012 (states that adopted it)Registered establishments maintain medical records, and electronic records as the government specifies.Check whether your state follows this Act or its own nursing home law.MoHFW
IRDAI health insurance master circular, 2024Insurers decide cashless requests within one hour and final discharge within three hours.Fast TPA sharing is needed, but only the records the claim needs, through secure channels.IRDAI
CERT-In Directions, 2022Report specified cyber incidents within six hours; keep ICT logs 180 days in India.A ransomware attack needs a CERT-In report and the DPDP messages.CERT-In
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