This column was reprinted with permission from InfoComm International and originally appeared here.

By Tim Kriedel

Medical facilities can be the acoustical equivalent of hospital gowns: designed to leave everything hanging out there. But when a hospital gown leaves little to the imagination, it may only provoke giggles. When a poorly designed medical space allows eavesdropping on patient-physician conversations, a six-figure fine from the government may apply.

The difference? The Health Insurance Portability and Accountability Act (HIPAA). Although it became law 16 years ago, HIPAA, which among other things regulates patient privacy, has been used more for guidance than enforcement. But that’s changing. And if you can hear conversations from the next examination room, for example, you may have stumbled upon a HIPAA breach. In the growing market for AV in healthcare, acoustics may be fertile ground for new business.

“The HIPAA regulations have been in place for a long time, but just recently, people started getting hundred-thousand-dollar lawsuits for violations, including for speech privacy,” says Greg Coudriet, acoustical consultant for The Sextant Group. “The stakes for sound isolation in healthcare facilities are quite high.”

HIPAA is helping raise the profile of acoustical consultants among healthcare providers and the AV integrators who target the healthcare market. Acoustical pros can calculate privacy levels based on parameters such as how loud a speaker’s voice is, background noise levels, and a room’s size, shape and finishes.

“The HIPAA requirement came into play primarily because of administrators who didn’t realize there were consultants who could determine the level of acoustic privacy in a space,” says Dennis Paoletti, principal consultant at Paoletti Consulting. “It kind of took the acoustical consulting industry by surprise.”

HIPAA isn’t the only reason healthcare providers are devoting more attention and money to speech privacy. “Hospitals are now competing for patients and working hard to improve patient satisfaction,” says Kenric Van Wyk, president of Acoustics By Design.

Van Wyk says new practices are now being incorporated in the Facility Guidelines Institute’s (FGI) handbook for healthcare design in order to improve the acoustical conditions of healthcare facilities. The FGI is a non-profit, set up to maintain and publish a set of guidelines for designing hospitals and other facilities. It came out of a federal program that was discontinued in the 1980s and was taken on temporarily by the American Institute of Architects.

“These design changes will affect the layout of healthcare facilities, the types of finishes that will be used to reduce noise levels, attention to the mechanical system design to improve speech privacy, and a switch to single-patient rooms,” Van Wyk explains. “All of these factors are helping to improve speech privacy and reduce eavesdropping of patient-physician conversations.”

For acoustical consultants and other AV pros, one challenge to complying with HIPAA requirements for speech privacy is determining exactly what measures should be taken. HIPAA itself includes the words “reasonable and appropriate” about 440 times to describe the steps facilities must take to ensure privacy, but never defines what they mean. Despite that, Bill Braithwaite, a physician who worked on HIPAA while at the U.S. Department of Health and Human Services, says “reasonable and appropriate” are what you might normally expect in a healthcare environment.

“You do a risk analysis and then mitigate those risks,” Braithwaite says. “No solution can be 100 percent perfect, but that’s understood by the law and the rule.”

Diagnosing Problems

It’s not uncommon to walk through a clinic or hospital and see doors open. Sometimes it’s because the exam room has no windows and the physician wants to make an anxious patient feel less claustrophobic. Of course, doing so undermines door seals, soundproof walls, masking devices and other features designed to maximize privacy. Is that a HIPAA violation? If the staff inadvertently does it, probably not. But if the healthcare provider’s policy allows it, it’s considered a violation.

Here’s another scenario that highlights the importance of risk analysis when deciding what level of acoustical treatments to devote to a particular space: Do the HIPAA rules require more stringent eavesdropping safeguards in areas that the public can access versus areas that are off-limits to everyone except staff?

“The rule leaves it up to the entity’s risk analysis,” Braithwaite says. “If the analysis showed that the risk of an incidental disclosure was significantly less in areas where only staff were allowed, then less stringent safeguards could be justified.  As long as there is a documented rationale that is reasonable and appropriate, HIPAA has no problems with such variations.”

Still, good enough doesn’t necessarily come cheap.

“Acoustical solutions must often be repeated multiple times throughout patient rooms and floors,” Coudriet says. “In a large hospital, the cumulative cost for a small acoustical enhancement can quickly add up.”

And such solutions are not one-size-fits-all.

In any healthcare facility, part of the challenge in maximizing privacy is the widespread use of hard surfaces, which are easier to sanitize but also reflect speech. And in general, solutions for exam rooms and other areas with stringent sanitization requirements are more expensive.

That said, a waiting room or check-in area may have softer surfaces that absorb conversations, such as a patient explaining her ailment to the nurse. A low-cost, decidedly non-AV solution might be to hang a sign asking patients to queue up somewhere in the office where, based on acoustical calculations, it’s far enough away from other people to make eavesdropping difficult.

In short, addressing a healthcare facility’s acoustical challenges really requires a consultative approach, in which experts can lay out various options and best practices.

“There are fewer options for healthcare-grade ceiling tiles with high noise-reduction coefficient (NRC) ratings,” Coudriet says. “Acoustical wall and ceiling treatments can offer some relief, but they need to be durable and cleanable, as well. Acoustical panels must have a mold- and bacteria-resistant core and be encased with a cleanable vinyl cover. They must be placed on the upper walls or have an impact-resistant construction. Finally, these acoustical finishes must vie for valuable space on walls that are typically cluttered with medical and building infrastructure.”

Many acoustical consultants recommend building walls, such as between exam rooms, that extend all the way to the floor above, through any drop-ceiling, if applicable. “We won’t allow continuous acoustic ceilings over partitions because the sound goes through that ceiling material,” Paoletti says.

But achieving an ideal is easier said than done because physicians groups and hospital-owned clinics often move into spec office spaces and even malls. In those cases, adding soundproof walls or extending walls to the floor above might not be options that the budget or landlord allows.

“An outpatient facility today could be a spa, office building or something completely different next month,” Van Wyk says. “There is a desire to reduce construction costs during the fit out process. That’s one reason why this acoustical privacy is an issue in the first place.”

Leveraging Noise

HIPAA also presents fertile ground for AV integrators with expertise in HVAC and other building systems. In other verticals, HVAC expertise is useful for helping a project achieve STEP or LEED certification, for example. In health care, it’s useful for avoiding HIPAA fines.

Granted, the integrator won’t be responsible for designing and installing the HVAC infrastructure. But understanding, for example, that ductwork might transmit voice between rooms is an opportunity to recommend solutions.

“The HVAC system actually provides the background noise level that’s so important for acoustical privacy,” Paoletti says.

It’s here that privacy is sometimes at odds with sustainability; keeping an HVAC fan running purely for masking speech is a waste of energy. In such cases, pink/white noise generators can strike a balance between HIPAA and LEED.

“A successful sound-masking system requires careful planning during design,” Coudriet says. “However, once installed, these systems can be integrated into the facility’s paging and emergency notification systems. Further, building management systems can alter masking signals throughout the facility, gradually adjusting masking levels throughout the day and in different areas of the building.”

To analyze all types of scenarios, AV pros should work with the healthcare client’s privacy or security officer, which HIPAA requires every covered entity to have. And when it comes to creating designs to ensure compliance, it’s critical that integrators either bring in an acoustical consultant or have someone with those skills on staff.

“Many AV integrators will be familiar with room acoustics because it can impact the fidelity of installed audio systems,” Coudriet says. “Some AV integrators may even perform acoustic calculations and install acoustic finish treatments.

“That said, AV integrators will undoubtedly be less familiar with principles of sound isolation and mechanical system noise control. These areas of architectural acoustics are often counter-intuitive. Unlike room acoustics, where a solution may involve hanging an acoustic panel on a wall to address an issue in the field, sound isolation and mechanical system noise control don’t lend themselves to post-construction trial-and-error.”