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HIPAA Training by Greater Baltimore Medical Center
HIPAA Training by Greater Baltimore Medical Center
HIPAA Training by Greater Baltimore Medical Center
HIPAA Training by Greater Baltimore Medical Center
HIPAA Training by Greater Baltimore Medical Center
HIPAA Training by Greater Baltimore Medical Center
HIPAA Training by Greater Baltimore Medical Center
HIPAA Training by Greater Baltimore Medical Center
HIPAA Training by Greater Baltimore Medical Center
HIPAA Training by Greater Baltimore Medical Center
HIPAA Training by Greater Baltimore Medical Center
HIPAA Training by Greater Baltimore Medical Center
HIPAA Training by Greater Baltimore Medical Center
HIPAA Training by Greater Baltimore Medical Center
HIPAA Training by Greater Baltimore Medical Center
HIPAA Training by Greater Baltimore Medical Center
HIPAA Training by Greater Baltimore Medical Center
HIPAA Training by Greater Baltimore Medical Center
HIPAA Training by Greater Baltimore Medical Center
HIPAA Training by Greater Baltimore Medical Center
HIPAA Training by Greater Baltimore Medical Center
HIPAA Training by Greater Baltimore Medical Center
HIPAA Training by Greater Baltimore Medical Center
HIPAA Training by Greater Baltimore Medical Center
HIPAA Training by Greater Baltimore Medical Center
HIPAA Training by Greater Baltimore Medical Center
HIPAA Training by Greater Baltimore Medical Center
HIPAA Training by Greater Baltimore Medical Center
HIPAA Training by Greater Baltimore Medical Center
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HIPAA Training by Greater Baltimore Medical Center

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  • This is a diagram of HIPAA the statute and its various aspects.
  • Transcript

    • 1. Back Menu Next GBMC HIPAA Compliance Program Health Insurance Portability and Accountability Act
    • 2. Back Menu Next HIPAA Requires Standards for Electronic Transactions and Code Sets -Compliance -Enforced Date: October 16, 2003 by: Centers for Medicare and Medicaid (CMS) Standards for Privacy of Individually Identifiable Health Information -Compliance -Enforced Date: April 14, 2003 by: Office of Civil Rights (OCR) Standards for Security of Electronic Protected Health Information -Compliance -Enforced Date: April 20, 2005 by: Centers for Medicare and Medicaid (CMS) 2
    • 3. Back Menu Next Diagram of the HIPAA Statute Security Code Sets 3
    • 4. Back Menu Next Training Focus The training that you are receiving today will focus on learning what responsibilities you have in order to ensure GBMC complies with HIPAA Privacy and HIPAA Security Regulations. The following topics will be covered: HIPAA PRIVACY HIPAA SECURITY Protected Health Information Protected Health Information Electronic Protected Health Information Electronic Protected Health Information Minimum Necessary Minimum Necessary User Identity User Identity Patient Rights Patient Rights Password Management Password Management Notice of Privacy Practices Notice of Privacy Practices Appropriate Use of Computing Devices Appropriate Use of Computing Devices Privacy Policies Privacy Policies Security Policies Security Policies Privacy Officer Privacy Officer Security Officer Security Officer Reporting Privacy Concerns Reporting Privacy Concerns Reporting Security Concerns Reporting Security Concerns 4
    • 5. Back Menu Next HIPAA Privacy The Privacy Rule Protects information known as PROTECTED HEALTH INFORMATION (PHI) that exists in written, oral, and electronic formats. Protected Health Information Protected Health Information 5
    • 6. Back Menu Next HIPAA Privacy Examples of PHI              Name Birth Date Fax Number Account Number Web Universal Resource Locator (URL) Street Address Admission Date Electronic mail address Certificate/License Number License Plate Number City Discharge Date Social Security Number Protected Health Information Protected Health Information             Vehicle and Serial Number Device Identifier and Serial Number Precinct Date of Death Medical Record Number Internet Protocol Number Full Face Photographic Images Zip Code Telephone Number Health Plan Beneficiary Number Biometrics Identifiers (i.e. finger prints) Any Other Unique Identifying Number, Characteristic, or Code 6
    • 7. Back Menu Next HIPAA Privacy The Privacy Rule   Limits the way in which members of the GBMC workforce may use and disclose (release) PHI. GBMC workforce must have a job-related reason to use and or disclose PHI. Requires that all GBMC workforce use only the minimum amount of PHI necessary to get the job done. This is what HIPAA defines as the MINIMUM NECESSARY Standard. “Workforce” means employees, volunteers, trainees, and other persons who conduct work for GBMC and are under the direct control of GBMC, whether or not they are paid by GBMC. Minimum Necessary Minimum Necessary 7
    • 8. Back Menu Next Annual Acknowledgment of the Minimum Necessary Standard   Every year, employees affirm their commitment to this standard by electronically signing the GBMC Code of Business Ethics Acknowledgment, Confidentiality of Information Agreement, and Appropriate Use Agreement. Failure to comply with this standard will lead to disciplinary action, up to and including termination. Minimum Necessary Minimum Necessary 8
    • 9. Minimum Necessary Scenarios  A patient that I cared for in the ICU was transferred to a medical unit. May I look in the patient’s record to see how she is doing? May I call the unit and talk to the nurse who is now caring for her?  As much as this may reflect your compassion and concern for patients whom you have taken care of in the past, you may not inquire into her status unless there is a job-related reason. For example, if you have to complete a note in her record after she has left your unit, you may access her record to complete your note. Minimum Necessary Minimum Necessary 9
    • 10. Minimum Necessary Scenarios  I am a unit clerk and while I was working night shift, a nurse named Mary became very ill. Another nurse named Alice transported Mary to the Emergency Dept (ED) & described for the nursing staff in the ED what symptoms Mary had complained of having. Alice was thanked for her assistance & told that she could return to her floor. Later that evening, I walked by Alice while she was on the computer & she called me over. She had Mary’s lab results up on her screen. Can she do this?  No, Alice should not look at this information. She has violated the minimum necessary standard. Such violation is punishable up to and including termination. Minimum Necessary Minimum Necessary 10
    • 11. Back Menu Next HIPAA Privacy The Privacy Rule    Provides patients with certain rights - these rights are commonly referred to as the PATIENT PRIVACY RIGHTS. These rights are communicated to the patient in the Notice of Privacy Practices. If a patient wishes to exercise any of these Patient Privacy Rights (which are outlined on the next slide), they must do so in writing. You should contact Medical Records Correspondence Department (443-849-2274) for the correct forms. Patient Rights Patient Rights 11
    • 12. Back Menu Next HIPAA Privacy The Patient Privacy Rights  Right to access PHI  Right to request an amendment to PHI  Right to request restrictions on how PHI is used for treatment, payment, and healthcare operations  Right to receive confidential communications  Right to request an accounting of disclosures  Right to complain to the Department of Health and Human Services’ Office for Civil Rights Patient Rights Patient Rights 12
    • 13. Back Menu Next HIPAA Privacy The Privacy Rule    Requires that GBMC provide all patients with a copy of its NOTICE OF PRIVACY PRACTICES (NOPP). Each patient must sign an acknowledgment after receiving the NOPP unless the patient is unable to do so at the time of registration. Copies of the NOPP may be ordered from Purchasing. Notice of Privacy Practices Effective April 14, 2003 Notice of Privacy Practices Effective April 14, 2003 Notice of Privacy Practices Effective April 14, 2003 Notice of Privacy Practices Effective April 14, 2003 GBMC includes Greater Baltimore Medical Center, Gilchrist Hospice Care and GBMC Foundation. GBMC includes Greater Baltimore Medical Center, Gilchrist Hospice Care, and GBMC Foundation. GBMC includes Greater Baltimore Medical Center, Gilchrist Hospice Care, and GBMC Foundation. GBMC includes Greater Baltimore Medical Center, Gilchrist Hospice Care, and GBMC Foundation. Notice of Privacy Practices Notice of Privacy Practices 13
    • 14. Back Menu Next HIPAA Privacy The Notice of Privacy Practices  Notice of Privacy Practices Effective April 14, 2003 GBMC includes Greater Baltimore Medical Center, Gilchrist Hospice Care and GBMC Foundation. Notice of Privacy Practices Notice of Privacy Practices The Notice is a useful tool not only for you but also for the patient. The NOPP:  describes how GBMC may use a patient’s PHI  provides a clear and concise description of the patient’s rights  discusses how a patient may opt-out of the facility directory  discusses how the medical staff may interact with the patient’s family 14
    • 15. Back Menu Next HIPAA Privacy The Privacy Rule     Requires that GBMC create policies regarding how GBMC’s workforce is allowed to use and disclose (release) PHI. Also requires that GBMC make available to and educate its workforce on those policies. All of GBMC’s PRIVACY POLICIES are located on the Compliance Page of the GBMC InfoWeb. Hardcopies of the policies may be printed directly from the InfoWeb or obtained from the Compliance Department. Privacy Policies Privacy Policies 15
    • 16. Back Menu Next HIPAA Privacy THE GBMC Privacy Policies  Examples of GBMC Privacy Policies include:    Privacy Policies Privacy Policies #003.102 Minimum Necessary Use and Disclosure of Protected Health Information #003.105 Uses and Disclosures for Involvement in the Individual’s Care and Notification Purposes #003.114 Uses and Disclosures of Protected Health Information for Law Enforcement Purposes 16
    • 17. Back Menu Next HIPAA Privacy The Privacy Rule  Requires that GBMC designate someone who is responsible for  the development and implementation of the privacy policies  privacy related training and education  investigating privacy related complaints   conducting routine audits to make sure that all of GBMC’s workforce are complying with the privacy policies The PRIVACY OFFICER for GBMC is Tara Miller. Privacy Officer Privacy Officer 17
    • 18. Back Menu Next HIPAA Privacy THE Privacy Rule  Requires that GBMC provide a way for patients and workforce to REPORT PRIVACY CONCERNS or ask privacy questions. Tara Miller, GBMC Privacy Officer 443-849-4327 HIPAA GroupWise Resource To send an email, type HIPAA in the “To” field The Business EthicsLine is now the Privacy Hotline too 1-800-299-7991 The Compliance Home Page is your source for HIPAA information. GBMC Infoweb Reporting Privacy Concerns Reporting Privacy Concerns 18
    • 19. Back Menu Next HIPAA Privacy Privacy Compliance Tips  Keep all PHI locked and secured when you are away from your work area.  Do not include any patient identifiers in the subject line of an email.  Do not discuss PHI in public or common areas.  Make sure to check the fax number for accuracy before sending a fax that contains PHI. All faxes must include a completed GBMC standard fax cover sheet (see fax policy for limited exceptions).  If a fax is sent to the wrong recipient in error, you must complete the Accounting of Disclosures log located on the Compliance page of the InfoWeb and send it to Medical Records.  Sign-in sheets are allowed as long as we continue to follow the standard protocols that have always been in place at GBMC. Sign - in sheets should be limited to patient name and appointment time. 19
    • 20. Back Menu Next HIPAA Security The Security Rule   Requires administrative, physical, and technical safeguards be implemented to address the confidentiality, integrity, and availability of ELECTRONIC PROTECTED HEALTH INFORMATION (ePHI). Security of patient information is EVERYONE’S job! We owe it to our patients! Electronic Protected Health Information Electronic Protected Health Information 20
    • 21. Back Menu Next HIPAA Security The Security Rule     Requires GBMC provide each computer system user with a unique USER IDENTITY. Your user identity is the combination of your user id and your password – do not share or write down your password where it can be easily retrieved by someone other than you. Your user identity is what is used to monitor your activity on the system(s). Do not leave yourself signed onto a computer and then walk away without signing off. You are responsible for any activity that occurs under your user identity. Your user identity appears on audit reports which are frequently monitored. User Identity User Identity 21
    • 22. Back Menu Next HIPAA Security Protecting Your Password    In order to protect against unauthorized access to our computers, GBMC has taken appropriate steps to monitor all activity on the network to ensure that people are not trying to break-in to those systems. However, as a user of a GBMC system, it is important that you also take measures to ensure that people cannot access GBMC systems – this is partly accomplished through PASSWORD MANAGEMENT. Password management includes selecting a strong password, protecting your password, as well as frequently changing your password. “A password should be like a toothbrush. Use it every day; change it regularly and DON’T share it with friends” - Usenet Password Management Password Management 22
    • 23. Back Menu Next HIPAA Security Examples of How to Create a Strong Password 1. Mix upper and lowercase characters  3bLINdmice  5gOLDenrings  4cALLingbirdS 3. Combine two words by using a special character  Roof^Top  Sugar$Daddy  B@tterup! 2. Replace letters with numbers  Replace “E” with “3”  “Sp3cial” or “3l3gant” 4. Use the first letter from each word of a phrase from a song “Oops! I did it again” becomes “O!idia” In general, passwords should have a minimum length of 6 characters but each application may have other requirements/limitations. Password Management Password Management 23
    • 24. Back Menu Next HIPAA Security The Security Rule   Requires that GBMC train its workforce on appropriate computer security and APPROPRIATE USE OF COMPUTING DEVICES. As a user of a GBMC system (including the Internet) you are required to:    Use only your officially assigned user identity (e.g. user id and password) Save GBMC data only to the GBMC Network unless prior GBMC approval has been granted Notify your manager and the HIPAA Security Officer if your password has been disclosed, or otherwise compromised, and immediately change your password Appropriate Use of Computing Devices Appropriate Use of Computing Devices 24
    • 25. Back Menu Next HIPAA Security The “Do Not’s” When Using GBMC Systems  As a user of a GBMC system (including the Internet) you may not:  Install unauthorized software (e.g. screensavers, games, or instant messenger programs)  Install any unlicensed software on a GBMC computer or device  Abuse your Internet or e-mail access privileges  Relocate any computer equipment without prior MIS approval  Bring into GBMC any personal computer equipment without prior MIS approval (e.g. printer, burner, scanner, PDA, or digital camera) Appropriate Use of Computing Devices Appropriate Use of Computing Devices 25
    • 26. Back Menu Next HIPAA Security The Security Rule    Requires that GBMC create SECURITY POLICIES regarding how GBMC will implement appropriate safeguards to ensure the confidentiality, integrity, and availability of ePHI. Examples of existing GBMC security policies are:  # 304 Email Policy  # 348 Information Security Policy All GBMC policies are located on the GBMC InfoWeb. Security Policies Security Policies 26
    • 27. Back Menu Next HIPAA Security The Security Rule  Requires that GBMC designate someone who is responsible for:     The development and implementation of information security policies and procedures Regular reviews of records of information system activity, such as audit logs, access reports, and security incident tracking reports The development of awareness and training programs for all members of its workforce The SECURITY OFFICER for GBMC is Tara Miller. Security Officer Security Officer 27
    • 28. Back Menu Next HIPAA Security The Security Rule   Requires that GBMC establish a way for all GBMC workforce to REPORT SECURITY CONCERNS. Report all risks you are currently aware of and as you see them, such as:  Unauthorized or suspicious visitors  Logged-on but unattended workstations  Uncontrolled access to areas that house equipment and/or PHI  Passwords on Post-it™ notes  Staff accessing records without a need to know  Report all security concerns to Tara Miller. Reporting Security Concerns Reporting Security Concerns 28
    • 29. Back Menu Next HIPAA Privacy & Security We hope this Computer-Based Learning course has been both informative and helpful. Feel free to review this course until you are confident about your knowledge of the material presented. Click the Take Test button on the left side when you are ready to complete the requirements for this course. Click on the My Records button to return to your CBL Courses to Complete list. Click the Exit button on the left to close the Student Interface. 29

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