This training module covers HIPAA privacy and security rules for protecting protected health information (PHI). It addresses recognizing situations where PHI could be mishandled, practical ways to protect privacy and security of sensitive information, and that employees will be held responsible for improperly handling PHI. The module covers forms of PHI, examples of PHI, HIPAA privacy and security rules, covered entities' duty to protect PHI, and consequences for violations.
HIPAA establishes national standards to protect individuals' medical records and other personal health information. It gives patients more control over their health information and sets boundaries on how health records can be used and shared. Covered entities like health plans and healthcare providers must implement appropriate administrative, physical, and technical safeguards to secure protected health information. This includes conducting risk analyses, limiting access to authorized users, tracking access to records, training employees, and establishing security incident response plans and contingency plans to backup data and ensure business continuity.
HIPPA-Health Insurance Portability and Accountability ActHarshit Trivedi
This document provides an overview of the Health Insurance Portability and Accountability Act (HIPAA). It discusses the objectives of HIPAA, which are to improve portability and continuity of health insurance, prevent healthcare fraud and abuse, and simplify administration of health insurance. It outlines the key areas covered by HIPAA: insurance portability, fraud enforcement, and administrative simplification. The document also discusses HIPAA regulations around protected health information, privacy laws, audits of access to medical records, and penalties for non-compliance.
This document provides an overview of HIPAA compliance requirements. It discusses the Health Insurance Portability and Accountability Act (HIPAA), which established national standards for protecting sensitive patient health information. It also discusses the HITECH Act, which strengthened HIPAA and incentivized adoption of electronic health records. Key aspects of HIPAA covered include privacy rules, security rules, breach notification requirements, penalties for noncompliance, and definitions of protected health information and covered entities. The document also provides an overview of 42 CFR Part 2 regulations regarding confidentiality of substance abuse treatment records.
The Health Insurance Portability and Accountability Act (HIPAA) was created primarily to modernize the flow of healthcare information, stipulate how Personally Identifiable Information maintained by the healthcare and healthcare insurance industries should be protected from fraud and theft, and address limitations on healthcare insurance coverage – such as portability and the coverage of individuals with pre-existing conditions.
https://www.hipaajournal.com/hipaa-training-requirements/
A brief introduction to hipaa compliancePrince George
As you can imagine, complying with federal regulations around privacy and healthcare data is no small task. This presentation is to help you wade through what you need to know about HIPAA compliance as it relates to your application and what steps you’ll need to take to ensure you don’t end up in violation of the law.
There is plenty to research about HIPAA guidelines. This presentation is not meant to be comprehensive, but rather give you a framework and reference to help you understand the major portions of the law.
The document discusses HIPAA regulations regarding patient privacy. It explains that HIPAA was passed in 1996 to set national standards for protecting patients' medical records and personal health information. Key aspects of HIPAA include defining protected health information, requiring facilities to implement privacy policies and provide privacy training, and giving patients rights over their health information including access and confidentiality. Facilities and individuals can face penalties for HIPAA violations.
The document discusses the Health Insurance Portability and Accountability Act (HIPAA). It provides information on the legislative act that established HIPAA, the administrative simplification rules enforced by the Office for Civil Rights, and covered entities that must comply with HIPAA. It also summarizes key aspects of HIPAA regulations including protected health information, use and disclosure limitations, notice requirements, penalties for violations, and examples of HIPAA violation cases.
The document discusses HIPAA regulations and responsibilities. It defines HIPAA and protected health information (PHI). It outlines the responsibilities of healthcare organizations, clinicians, and employees to protect patient privacy and ensure compliance with HIPAA rules and policies. Violations of HIPAA are taken seriously by the organization and are grounds for immediate termination. The goal is to educate all involved and enforce strict privacy standards.
HIPAA establishes national standards to protect individuals' medical records and other personal health information. It gives patients more control over their health information and sets boundaries on how health records can be used and shared. Covered entities like health plans and healthcare providers must implement appropriate administrative, physical, and technical safeguards to secure protected health information. This includes conducting risk analyses, limiting access to authorized users, tracking access to records, training employees, and establishing security incident response plans and contingency plans to backup data and ensure business continuity.
HIPPA-Health Insurance Portability and Accountability ActHarshit Trivedi
This document provides an overview of the Health Insurance Portability and Accountability Act (HIPAA). It discusses the objectives of HIPAA, which are to improve portability and continuity of health insurance, prevent healthcare fraud and abuse, and simplify administration of health insurance. It outlines the key areas covered by HIPAA: insurance portability, fraud enforcement, and administrative simplification. The document also discusses HIPAA regulations around protected health information, privacy laws, audits of access to medical records, and penalties for non-compliance.
This document provides an overview of HIPAA compliance requirements. It discusses the Health Insurance Portability and Accountability Act (HIPAA), which established national standards for protecting sensitive patient health information. It also discusses the HITECH Act, which strengthened HIPAA and incentivized adoption of electronic health records. Key aspects of HIPAA covered include privacy rules, security rules, breach notification requirements, penalties for noncompliance, and definitions of protected health information and covered entities. The document also provides an overview of 42 CFR Part 2 regulations regarding confidentiality of substance abuse treatment records.
The Health Insurance Portability and Accountability Act (HIPAA) was created primarily to modernize the flow of healthcare information, stipulate how Personally Identifiable Information maintained by the healthcare and healthcare insurance industries should be protected from fraud and theft, and address limitations on healthcare insurance coverage – such as portability and the coverage of individuals with pre-existing conditions.
https://www.hipaajournal.com/hipaa-training-requirements/
A brief introduction to hipaa compliancePrince George
As you can imagine, complying with federal regulations around privacy and healthcare data is no small task. This presentation is to help you wade through what you need to know about HIPAA compliance as it relates to your application and what steps you’ll need to take to ensure you don’t end up in violation of the law.
There is plenty to research about HIPAA guidelines. This presentation is not meant to be comprehensive, but rather give you a framework and reference to help you understand the major portions of the law.
The document discusses HIPAA regulations regarding patient privacy. It explains that HIPAA was passed in 1996 to set national standards for protecting patients' medical records and personal health information. Key aspects of HIPAA include defining protected health information, requiring facilities to implement privacy policies and provide privacy training, and giving patients rights over their health information including access and confidentiality. Facilities and individuals can face penalties for HIPAA violations.
The document discusses the Health Insurance Portability and Accountability Act (HIPAA). It provides information on the legislative act that established HIPAA, the administrative simplification rules enforced by the Office for Civil Rights, and covered entities that must comply with HIPAA. It also summarizes key aspects of HIPAA regulations including protected health information, use and disclosure limitations, notice requirements, penalties for violations, and examples of HIPAA violation cases.
The document discusses HIPAA regulations and responsibilities. It defines HIPAA and protected health information (PHI). It outlines the responsibilities of healthcare organizations, clinicians, and employees to protect patient privacy and ensure compliance with HIPAA rules and policies. Violations of HIPAA are taken seriously by the organization and are grounds for immediate termination. The goal is to educate all involved and enforce strict privacy standards.
Powerpoint on electronic health record lab 1nephrology193
This presentation provides an overview of electronic health records (EHR). It defines EHR as a digital format for documenting a patient's medical history maintained by healthcare providers. EHR files contain sections for different types of health information. The presentation outlines benefits of EHR such as reducing medical errors, improving quality of care through better disease management and education, and decreasing healthcare costs. It also discusses how EHR protects patient privacy through security measures and restrictions on who can access records.
This is a slideshow explaining the importance of protecting patient privacy and confidentiality. This slideshow is for education and training purposes only.
The document discusses HIPAA privacy and security requirements. It defines key terms like protected health information and confidentiality. HIPAA established standards to protect personal health information and privacy. It requires covered entities to implement safeguards to ensure the security and confidentiality of protected health information, whether in paper or electronic format. HIPAA also gives patients rights over their medical records and information. Covered entities must notify patients of breaches or improper disclosures as required under HIPAA and HITECH.
A training powerpoint presentation for employees in patient confidentiality as a follow up on multiple breaches of confidentiality and privacy of protected health information of celebrities in a hospital setting.
The document provides an overview of the Health Insurance Portability and Accountability Act (HIPAA) including what information it protects, the entities it covers, and requirements for things like privacy practices, consent, and authorization. Central Michigan University is described as a "hybrid entity" under HIPAA, with some departments fully covered and others only indirectly affected. The presentation aims to familiarize staff with HIPAA regulations and the university's policies and procedures for protecting health information.
This document discusses patient confidentiality and preserving privacy of patient health records. It aims to increase awareness of legal requirements and best practices for maintaining confidentiality. The goals are to promote awareness of confidentiality laws, advocate for compliance with procedures to protect medical records, and exercise caution when handling documented and electronic patient information. Healthcare professionals must attend annual training on patient privacy laws like HIPAA and ensure sensitive patient data is only accessed by authorized individuals. Any breaches of confidentiality must be reported immediately and can result in penalties.
The document discusses electronic medical record (EMR) systems. It begins by explaining how the healthcare sector has evolved from relying on physical files to using EMR systems. It then defines EMR systems as electronic health records created and managed by healthcare organizations. The key benefits of EMR systems include improved patient safety, care quality, and access to information. However, barriers like costs have limited widespread adoption. Current research focuses on improving interoperability between different EMR systems. Overall, EMR systems play important roles in healthcare by facilitating information sharing, collaboration and patient care.
What is Health Informatics?
HI Goals
HI stakeholders
HI subfields / subspecialties
Healthcare trends & HI
HI professional environments
HI education / training opportunities & degrees
HI organizations / journals / meetings / events
HI professional certificates
HI books
Electronic Health Record System and Its Key Benefits to Healthcare IndustryCalance
This case study discusses how Electronic Health Record can turn out to be a solution to the problems associated with paper based clinical records. It’s a future-proof solution decreasing chances of error and loss while increasing patient-provider communication. Find out the key challenges faced by US health industry, key benefits of EHRs, and how Calance can help developing an HER solution. For more info about Calance, visit http://www.calanceus.com
This document provides an overview of HIPAA privacy and security training for employees at a covered entity. It discusses key topics including what constitutes protected health information (PHI) under HIPAA, how PHI can be used and disclosed, minimum necessary standards, security safeguards, breach notification requirements, and penalties for noncompliance. Employees are informed that strict compliance with HIPAA privacy and security policies is required to protect patient information.
Health Information Technology & Nursing InformaticsJil Wright
This document discusses health information technology and nursing informatics. It begins with an introduction by Jil Wright who identifies herself as a nursing informatics "geek". The document then provides resources for more information on health IT and nursing informatics. It discusses how nursing informatics integrates nursing science, computer science, and information science to support patients, nurses, and healthcare providers. Examples of clinical information systems and technologies that can help transform nursing practice are also provided, such as electronic medical records, wireless systems, and RFID technologies. Meaningful use requirements and examples of how health IT can improve documentation and the nursing process are summarized as well.
The document provides an overview of biomedical informatics. It defines biomedical informatics as the interdisciplinary field that studies and pursues the effective uses of biomedical data, information, and knowledge for scientific inquiry, problem solving, and decision making, motivated by efforts to improve human health. It notes that biomedical informatics develops theories, methods and processes for generating, storing, retrieving, using, and sharing biomedical data, information, and knowledge, building on computing, communication and information sciences. Biomedical informatics investigates reasoning, modeling, simulation and translation across scales from molecules to populations.
This document discusses security and privacy of health data. It begins with an introduction to information privacy and security. It then discusses privacy laws in Thailand that protect health information. It outlines various threats to health data security such as hackers, viruses, and employee errors. Consequences of attacks can include privacy breaches, data modification, and financial losses. The document emphasizes the importance of maintaining data confidentiality, integrity and availability through various security measures for users, systems, networks and databases. It provides recommendations for a strong password policy and techniques for remembering passwords.
The document provides an overview of the Health Insurance Portability and Accountability Act (HIPAA) for health care professionals. Some key points:
- HIPAA aims to protect patients' protected health information (PHI) and set standards for handling electronic health data.
- PHI includes any individually identifiable health information like names, birthdates, diagnoses. Healthcare workers may only access and share PHI as needed for treatment, payment or operations.
- Permitted uses of PHI include treatment, payment, health operations. Disclosures require patient authorization except as required by law like public health reporting. Incidental disclosures must be limited in nature.
- Violations can result in fines or imprisonment.
This document discusses security issues related to health information systems. It notes that as more patient data is stored electronically, ensuring privacy and security of electronic health records is important. The document outlines advantages of electronic health records like providing complete patient histories, but also disadvantages such as privacy and confidentiality concerns. It discusses laws like HIPAA that are meant to protect patient privacy and discusses methods used to increase security, such as encryption, authentication, and educating staff.
HIPAA in 2023: Changes, Updates, and Best PracticesConference Panel
HIPAA 2023 Guidance and Compliance refers to the latest regulations and guidelines for protecting patient privacy in healthcare. Healthcare organizations need to stay current on the rules and guidelines related to privacy, security, and breach notification. This includes understanding the key changes to HIPAA regulations, ensuring compliance for covered entities and business associates, implementing best practices for maintaining HIPAA compliance, and addressing the impact of technology and innovation on healthcare privacy and security. Training, risk assessments, audits, and patient rights are also essential aspects of HIPAA compliance.
Register for the HIPAA 2023 Guidance and Compliance Webinar,
https://conferencepanel.com/conference/hipaa-2023-latest-guidance-and-compliance-focus
This document provides a summary of the Health Insurance Portability and Accountability Act (HIPAA) for nursing students. It discusses the purpose and key aspects of HIPAA such as protecting patient privacy and confidentiality. It outlines the rules for use and disclosure of protected health information, and the consequences of violating HIPAA regulations, which can include civil penalties, criminal charges, and dismissal from nursing programs. Students are instructed to only access the minimum health information needed for their roles and to protect patient data.
Developers building healthcare applications for mobile devices, wearables and the desktop need to understand HIPAA requirements in order to build apps that are in compliance. This deck gives application developers an overview of the HIPAA rules and what it means for their software development.
This document provides an overview of key rules and regulations under HIPAA regarding the privacy and security of protected health information (PHI). It discusses the Privacy Rule, Security Rule, Transaction and Code Sets Rule, Enforcement Rule, and how the HITECH Act expanded the scope and penalties of HIPAA. The rules establish national standards to protect individuals' medical records, require safeguards for PHI, and give patients rights over their health information. The Security Rule addresses electronic PHI and technical, physical and administrative safeguards. The HITECH Act strengthened HIPAA enforcement and increased penalties for violations.
HIPAA establishes national standards to protect patients' personal health information. It applies to covered entities like health care providers and insurers, as well as their business associates. HIPAA protects individuals' medical records and other personal health information by setting rules for use and disclosure of protected health information. It provides patients rights over their health information including rights to examine and obtain a copy of their records, and to request corrections. HIPAA also protects security of health information whether stored electronically or on paper. Violations of HIPAA can result in fines and penalties.
Powerpoint on electronic health record lab 1nephrology193
This presentation provides an overview of electronic health records (EHR). It defines EHR as a digital format for documenting a patient's medical history maintained by healthcare providers. EHR files contain sections for different types of health information. The presentation outlines benefits of EHR such as reducing medical errors, improving quality of care through better disease management and education, and decreasing healthcare costs. It also discusses how EHR protects patient privacy through security measures and restrictions on who can access records.
This is a slideshow explaining the importance of protecting patient privacy and confidentiality. This slideshow is for education and training purposes only.
The document discusses HIPAA privacy and security requirements. It defines key terms like protected health information and confidentiality. HIPAA established standards to protect personal health information and privacy. It requires covered entities to implement safeguards to ensure the security and confidentiality of protected health information, whether in paper or electronic format. HIPAA also gives patients rights over their medical records and information. Covered entities must notify patients of breaches or improper disclosures as required under HIPAA and HITECH.
A training powerpoint presentation for employees in patient confidentiality as a follow up on multiple breaches of confidentiality and privacy of protected health information of celebrities in a hospital setting.
The document provides an overview of the Health Insurance Portability and Accountability Act (HIPAA) including what information it protects, the entities it covers, and requirements for things like privacy practices, consent, and authorization. Central Michigan University is described as a "hybrid entity" under HIPAA, with some departments fully covered and others only indirectly affected. The presentation aims to familiarize staff with HIPAA regulations and the university's policies and procedures for protecting health information.
This document discusses patient confidentiality and preserving privacy of patient health records. It aims to increase awareness of legal requirements and best practices for maintaining confidentiality. The goals are to promote awareness of confidentiality laws, advocate for compliance with procedures to protect medical records, and exercise caution when handling documented and electronic patient information. Healthcare professionals must attend annual training on patient privacy laws like HIPAA and ensure sensitive patient data is only accessed by authorized individuals. Any breaches of confidentiality must be reported immediately and can result in penalties.
The document discusses electronic medical record (EMR) systems. It begins by explaining how the healthcare sector has evolved from relying on physical files to using EMR systems. It then defines EMR systems as electronic health records created and managed by healthcare organizations. The key benefits of EMR systems include improved patient safety, care quality, and access to information. However, barriers like costs have limited widespread adoption. Current research focuses on improving interoperability between different EMR systems. Overall, EMR systems play important roles in healthcare by facilitating information sharing, collaboration and patient care.
What is Health Informatics?
HI Goals
HI stakeholders
HI subfields / subspecialties
Healthcare trends & HI
HI professional environments
HI education / training opportunities & degrees
HI organizations / journals / meetings / events
HI professional certificates
HI books
Electronic Health Record System and Its Key Benefits to Healthcare IndustryCalance
This case study discusses how Electronic Health Record can turn out to be a solution to the problems associated with paper based clinical records. It’s a future-proof solution decreasing chances of error and loss while increasing patient-provider communication. Find out the key challenges faced by US health industry, key benefits of EHRs, and how Calance can help developing an HER solution. For more info about Calance, visit http://www.calanceus.com
This document provides an overview of HIPAA privacy and security training for employees at a covered entity. It discusses key topics including what constitutes protected health information (PHI) under HIPAA, how PHI can be used and disclosed, minimum necessary standards, security safeguards, breach notification requirements, and penalties for noncompliance. Employees are informed that strict compliance with HIPAA privacy and security policies is required to protect patient information.
Health Information Technology & Nursing InformaticsJil Wright
This document discusses health information technology and nursing informatics. It begins with an introduction by Jil Wright who identifies herself as a nursing informatics "geek". The document then provides resources for more information on health IT and nursing informatics. It discusses how nursing informatics integrates nursing science, computer science, and information science to support patients, nurses, and healthcare providers. Examples of clinical information systems and technologies that can help transform nursing practice are also provided, such as electronic medical records, wireless systems, and RFID technologies. Meaningful use requirements and examples of how health IT can improve documentation and the nursing process are summarized as well.
The document provides an overview of biomedical informatics. It defines biomedical informatics as the interdisciplinary field that studies and pursues the effective uses of biomedical data, information, and knowledge for scientific inquiry, problem solving, and decision making, motivated by efforts to improve human health. It notes that biomedical informatics develops theories, methods and processes for generating, storing, retrieving, using, and sharing biomedical data, information, and knowledge, building on computing, communication and information sciences. Biomedical informatics investigates reasoning, modeling, simulation and translation across scales from molecules to populations.
This document discusses security and privacy of health data. It begins with an introduction to information privacy and security. It then discusses privacy laws in Thailand that protect health information. It outlines various threats to health data security such as hackers, viruses, and employee errors. Consequences of attacks can include privacy breaches, data modification, and financial losses. The document emphasizes the importance of maintaining data confidentiality, integrity and availability through various security measures for users, systems, networks and databases. It provides recommendations for a strong password policy and techniques for remembering passwords.
The document provides an overview of the Health Insurance Portability and Accountability Act (HIPAA) for health care professionals. Some key points:
- HIPAA aims to protect patients' protected health information (PHI) and set standards for handling electronic health data.
- PHI includes any individually identifiable health information like names, birthdates, diagnoses. Healthcare workers may only access and share PHI as needed for treatment, payment or operations.
- Permitted uses of PHI include treatment, payment, health operations. Disclosures require patient authorization except as required by law like public health reporting. Incidental disclosures must be limited in nature.
- Violations can result in fines or imprisonment.
This document discusses security issues related to health information systems. It notes that as more patient data is stored electronically, ensuring privacy and security of electronic health records is important. The document outlines advantages of electronic health records like providing complete patient histories, but also disadvantages such as privacy and confidentiality concerns. It discusses laws like HIPAA that are meant to protect patient privacy and discusses methods used to increase security, such as encryption, authentication, and educating staff.
HIPAA in 2023: Changes, Updates, and Best PracticesConference Panel
HIPAA 2023 Guidance and Compliance refers to the latest regulations and guidelines for protecting patient privacy in healthcare. Healthcare organizations need to stay current on the rules and guidelines related to privacy, security, and breach notification. This includes understanding the key changes to HIPAA regulations, ensuring compliance for covered entities and business associates, implementing best practices for maintaining HIPAA compliance, and addressing the impact of technology and innovation on healthcare privacy and security. Training, risk assessments, audits, and patient rights are also essential aspects of HIPAA compliance.
Register for the HIPAA 2023 Guidance and Compliance Webinar,
https://conferencepanel.com/conference/hipaa-2023-latest-guidance-and-compliance-focus
This document provides a summary of the Health Insurance Portability and Accountability Act (HIPAA) for nursing students. It discusses the purpose and key aspects of HIPAA such as protecting patient privacy and confidentiality. It outlines the rules for use and disclosure of protected health information, and the consequences of violating HIPAA regulations, which can include civil penalties, criminal charges, and dismissal from nursing programs. Students are instructed to only access the minimum health information needed for their roles and to protect patient data.
Developers building healthcare applications for mobile devices, wearables and the desktop need to understand HIPAA requirements in order to build apps that are in compliance. This deck gives application developers an overview of the HIPAA rules and what it means for their software development.
This document provides an overview of key rules and regulations under HIPAA regarding the privacy and security of protected health information (PHI). It discusses the Privacy Rule, Security Rule, Transaction and Code Sets Rule, Enforcement Rule, and how the HITECH Act expanded the scope and penalties of HIPAA. The rules establish national standards to protect individuals' medical records, require safeguards for PHI, and give patients rights over their health information. The Security Rule addresses electronic PHI and technical, physical and administrative safeguards. The HITECH Act strengthened HIPAA enforcement and increased penalties for violations.
HIPAA establishes national standards to protect patients' personal health information. It applies to covered entities like health care providers and insurers, as well as their business associates. HIPAA protects individuals' medical records and other personal health information by setting rules for use and disclosure of protected health information. It provides patients rights over their health information including rights to examine and obtain a copy of their records, and to request corrections. HIPAA also protects security of health information whether stored electronically or on paper. Violations of HIPAA can result in fines and penalties.
The document provides training on the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Rule. It discusses what protected health information (PHI) is and the rules around using and disclosing PHI. Key points include:
- PHI is individually identifiable health information that is protected by HIPAA.
- PHI can generally be used or disclosed for treatment, payment, and healthcare operations without patient authorization. Other uses require authorization or fall under other exceptions.
- The Privacy Rule establishes patient rights regarding access to and restrictions on use of their PHI, and requires covered entities to implement privacy protections and provide privacy training to staff. Non-compliance can result in civil and criminal penalties.
health insurance portability and accountability act.pptxamartya2087
This document discusses new requirements for clinical studies under HIPAA. It provides an overview of HIPAA, including its goals of ensuring portability of health insurance and protecting privacy and security of patient health information. Key points include that HIPAA establishes standards for privacy of health information, electronic data interchange, and security of electronic protected health information. It also outlines requirements for clinical studies regarding informed consent, authorization of use or disclosure of protected health information, and institutional or privacy board review and waivers.
This document provides an overview of HIPAA privacy and security requirements for USA as a hybrid covered entity. It discusses how PHI is defined and must be protected in all forms. Only authorized access is allowed and breaches must be reported. Penalties for improper access, use or disclosure of PHI can include civil and criminal penalties. The security rule focuses on safeguarding the confidentiality, integrity and availability of PHI through technical, administrative and physical safeguards.
The document provides an overview of the steps startups need to take to achieve HIPAA compliance when working with health systems and protected health information. It discusses the key rules under HIPAA including the Privacy Rule, Security Rule, and Breach Notification Rule. It outlines a high-level roadmap for startups to become HIPAA compliant which involves developing an understanding of HIPAA, embedding it into operations, documenting efforts, and ultimately conducting a self-assessment and audit. The document aims to prepare entrepreneurs to address the compliance concerns of health systems regarding data security and privacy.
This document provides an overview of HIPAA compliance requirements for healthcare startups selling to health systems. It discusses how health systems prioritize compliance and security above all else. The presenter, Jim Anfield, will prepare entrepreneurs on how to effectively communicate that their solutions meet HIPAA compliance and security standards to facilitate partnerships with health systems. He will cover common pitfalls in these discussions and provide insights on achieving HIPAA compliance.
The document provides an overview of HIPAA privacy and security laws, including how they have been enhanced by the HITECH Act and ARRA. It defines key terms like protected health information (PHI), covered entities, business associates, and their obligations to secure PHI and comply with privacy requirements. Patients' rights to access and restrict the use of their PHI are also summarized.
The document discusses the requirements of HIPAA for protecting patient privacy and securing their health information, including mandates for training and documentation, increased penalties for violations, and rights for patients to access electronic health records; it also outlines the entities covered by HIPAA, defines protected health information, and reviews standards for its use and disclosure for treatment, payment, and healthcare operations.
Week 1 discussion 2 hipaa and privacy trainingvrgill22
HIPAA was created to establish standards for electronic health information, privacy, and security. It aims to assure health insurance portability, decrease fraud and abuse, and guarantee privacy of patient health information. HIPAA applies to health care providers, health plans, and health care clearinghouses that transmit health information electronically. It protects individually identifiable health information and sets boundaries on its use and disclosure, requiring covered entities to only use and share patient health information as permitted. Covered entities must take steps to remain compliant with HIPAA's privacy and security requirements such as developing policies, training staff, and limiting disclosures to the minimum necessary information.
This document summarizes the key aspects of the Health Insurance Portability and Accountability Act (HIPAA) regulations regarding patient privacy and the handling of protected health information. It notes that HIPAA was passed as a federal law in 1996 and outlines regulations to protect individuals' health information privacy and ensure security of electronic personal data transfers. The document then discusses how health information is used by various medical professionals and entities involved in patient care and lists some examples. It also provides an overview of the objectives of HIPAA, patients' rights to their information, and consequences for violations.
Marc etienne week1 discussion2 presentationMarcEtienne6
The document discusses HIPAA training requirements for healthcare providers and staff. It explains that the Health Insurance Portability and Accountability Act (HIPAA) was enacted in 1996 to establish privacy standards for protected health information (PHI) and requires covered entities like healthcare providers to provide annual HIPAA training and certification to their workforce. Unauthorized disclosure of PHI is considered a HIPAA violation which can result in civil penalties such as fines or criminal penalties like imprisonment depending on the nature and intent of the violation.
This document provides an overview of HIPAA privacy rules regarding access to medical records. It defines key terms like covered entity, business associate, and protected health information. It explains that patients have rights under HIPAA to access, inspect, and obtain copies of their medical records, as well as request amendments. There are additional rules for mental health and psychotherapy notes. Covered entities may charge reasonable fees for copying and mailing records.
Protected health information includes patients' demographics, medical records, and insurance information. Patient privacy is important and protected by HIPAA, which establishes standards to keep health information confidential. HIPAA requires healthcare providers to implement procedures protecting patient information and privacy when it is accessed or transferred. Violating HIPAA by inappropriately accessing, sharing, or discussing protected patient information without consent can result in penalties including job loss, fines, and imprisonment.
HIPAA is a national law that establishes standards to protect patient privacy and the confidentiality of patient health information. It applies to covered entities like health plans, providers, and clearinghouses, as well as their business associates. PHI, or protected health information, refers to individually identifiable patient information. HIPAA restricts the use and disclosure of PHI to treatment, payment, and healthcare operations. Covered entities must implement safeguards to secure PHI and provide patient rights and protections. Violations of HIPAA can result in penalties including fines and imprisonment.
The viability of personal health related information camillemaxwell2
This document discusses HIPAA regulations regarding access to and protection of personal health information. It outlines who can access protected health information under what circumstances according to HIPAA, such as for treatment, payment, and healthcare operations. It also discusses HIPAA guidelines including maintaining appropriate security of information, giving individuals control over their records, and establishing accountability for improper handling of protected health information. Finally, it provides examples of protected health information and emphasizes the importance of following HIPAA rules and regulations to avoid security breaches of personal health data.
The viability of Personal Health Information MHA690camillemaxwell2
This document discusses HIPAA regulations regarding protected health information. It outlines who has access to personal health information under HIPAA and what types of information are protected. It also discusses guidelines for handling protected health information, such as only accessing and sharing information for health purposes. The document highlights that security breaches of health information can result in civil and criminal penalties. It provides approaches for avoiding breaching HIPAA, such as implementing policies and procedures, access controls, and encryption.
This document provides an overview of HIPAA privacy laws and regulations for medical professionals. It discusses the significance of the Hippocratic Oath in establishing ethical principles of patient privacy and confidentiality. It then reviews key aspects of HIPAA, including how protected health information can be shared, patient rights regarding privacy violations, and consequences for non-compliance. Medical facilities must adhere to HIPAA's Privacy and Security Rules regarding paper and electronic protected health information to avoid penalties like fines or employee termination.
The document provides an introduction to the Health Insurance Portability and Accountability Act (HIPAA) for health care professionals. It discusses key aspects of HIPAA including protecting patient health information, permitted uses and disclosures of protected health information, and patients' rights to control their health information. The document emphasizes the importance of keeping patient information private and only accessing it when necessary to perform one's job. Violations can result in civil and criminal penalties.
This document provides an overview of the Health Insurance Portability and Accountability Act (HIPAA). It defines HIPAA and its purpose to protect private health information. It outlines the key aspects of HIPAA compliance including privacy rules, security rules, and breach notification rules. It also defines protected health information, covered entities, business associates, and user rights under HIPAA.
MBC Support Group for Black Women – Insights in Genetic Testing.pdfbkling
Christina Spears, breast cancer genetic counselor at the Ohio State University Comprehensive Cancer Center, joined us for the MBC Support Group for Black Women to discuss the importance of genetic testing in communities of color and answer pressing questions.
As Mumbai's premier kidney transplant and donation center, L H Hiranandani Hospital Powai is not just a medical facility; it's a beacon of hope where cutting-edge science meets compassionate care, transforming lives and redefining the standards of kidney health in India.
Comprehensive Rainy Season Advisory: Safety and Preparedness Tips.pdfDr Rachana Gujar
The "Comprehensive Rainy Season Advisory: Safety and Preparedness Tips" offers essential guidance for navigating rainy weather conditions. It covers strategies for staying safe during storms, flood prevention measures, and advice on preparing for inclement weather. This advisory aims to ensure individuals are equipped with the knowledge and resources to handle the challenges of the rainy season effectively, emphasizing safety, preparedness, and resilience.
Hypertension and it's role of physiotherapy in it.Vishal kr Thakur
This particular slides consist of- what is hypertension,what are it's causes and it's effect on body, risk factors, symptoms,complications, diagnosis and role of physiotherapy in it.
This slide is very helpful for physiotherapy students and also for other medical and healthcare students.
Here is summary of hypertension -
Hypertension, also known as high blood pressure, is a serious medical condition that occurs when blood pressure in the body's arteries is consistently too high. Blood pressure is the force of blood pushing against the walls of blood vessels as the heart pumps it. Hypertension can increase the risk of heart disease, brain disease, kidney disease, and premature death.
R3 Stem Cell Therapy: A New Hope for Women with Ovarian FailureR3 Stem Cell
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2. Course
CompetenciesThis training module addresses the essential elements of maintaining the
privacy and security of sensitive information and
protected health information (PHI) within the USA Health workplace.
During this course you will learn:
• about the Health Insurance Portability andAccountability Act (HIPAA)
Privacy and Security Rules;
• about the HIPAA identifiers that create protected health information
(PHI);
• how to recognize situations in which confidential and protected
health information can be mishandled;
• about practical ways to protect the privacy and security of
sensitive information, including PHI; and
• that employees will be held responsible if they improperly
handle confidential or protected health information.
2
3. Forms of Protected Health Information
(PHI)
It is the responsibility of every employee to
protect the privacy and security of protected health information
inALL forms.
printe
d
spoke
n
Electronic (data in motion or at rest)
Protected Health Information exists in various
forms…
3
4. Examples of
Protected Health Information(PHI)
• Social Security
numbers
• credit card numbers
• driver’s license
numbers
• patient clinical information
• research data
• computer passwords
• Individually identifiable
health information
The improper use or disclosure of protected health
information presents the risk of identify theft, invasion of
privacy, and can cause harm and embarrassment to
students, faculty, staff, patients, and USA Health. Breaches
of information privacy can also result in criminal and civil
penalties for both USA Health and those individuals who
improperly access or disclose protected health information,
as well as, disciplinary actions for responsible USA
employees.
Every employee must
protect the privacy and security of PHI.
4
5. HIPAA Privacy & Security
Rules
Section 1: The HIPAA Privacy Rule
1A: Overview
1B: Program Components
Section 2: The HIPAA Security Rule
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a
federal law designed to protect a subset of Sensitive Information known
as protected health information (PHI).
In 2009, HIPAA was expanded and strengthened by the HITECH Act (Health
Information Technology for Economic and Clinical Health). In January of
2013, the Department of Health and Human Services issued a final rule (Final
Rule) implementing HITECH’s statutory amendments to HIPAA. The deadline
for compliance was September 23, 2013.
This training module focuses on two primary
HIPAA rules, as amended by HITECH:
5
Note: There is also a Transaction Rule that is not covered in this course. Healthcare
providers need to be aware that under this Rule, treatment must be accurately billed using
the prescribed code sets.
7. Covered Entities
Have a Duty to Protect
PHI
A covered entity is any person or organization that
furnishes, bills, or is paid for health care services in
the normal course of business and electronically
transmits any health information in connection with
electronic standard transactions. Pursuant to HIPAA,
individually identifiable health information collected
or created by a covered entity is considered
protected health information or PHI. Departments
that use or disclose PHI are governed by HIPAA
requirements.
7
8. USA is a HIPAA Hybrid
Entity
A Hybrid Entity performs both covered and non-covered
functions under the HIPAA Rules.
• Healthcare components and components of USA that perform
Business Associate type of functions (such as: legal or computer
services)within USA are required to comply with HIPAA .
• Individuals who perform support services for both USA HIPAA
healthcare components and USA non-covered functions (such
as: non-healthcare academic departments) are prohibited from
using or sharing PHI obtained in the course of furnishing services
for HIPAA covered healthcare components.
• HIPAA treats the covered and non-covered functions as legally
separate entities and no PHI may be shared or disclosed without
the patient’s written authorization.
8
9. USA Health – Organized Health Care
Arrangement (OHCA)
• USA Health has been designated as an Organized Health Care
Arrangement (OHCA) which includes
• USA Health [Hospitals and Clinics]
• USA Mitchell Cancer Institute (MCI),
• University covered healthcare components (including, but not limited to):
• USA Allied Health Speech and Hearing Center
• USA Allied Health Physical Therapy
• USA Radiological Sciences
• USA Psychology Clinic
• USA College of Nursing
• USA College of Medicine
• These entities participate in a clinically and operationally integrated
health care setting in which it is necessary to share PHI for joint
management and operations.
• USA Health’s HIPAA Compliance Officer is charged with reviewing
HIPAA Policies and Procedures and recommending changes to USA
Health Administration, as well as, the University HIPAA Compliance
Committee in order to address specific compliance issues that may
arise.
9
10. PHI
definedPHI is generally defined as:
Any information that can be used to identify a patient – whether
living or deceased – that relates to the patient’s past, present,
or future physical or mental health or condition, including
healthcare services provided and payment for those services.
Employees may access the minimal necessary PHI
to perform their job-related duties.
10
11. For PHI to be considered de-identified, the
following identifiers must be removed:
• Patient names
• Geographic subdivisions
(smaller than state)
• Telephone numbers
• Fax numbers
• Social Security Numbers(SSN)
• Vehicle identifiers
• E-mail addresses
• Web URLs and IP addresses
• Dates (except year)
• Names of relatives
11
• Full face photographs
or identifiable images
• Healthcare record numbers
• Account numbers
• Biometric identifiers
(fingerprints or
voiceprints)
• Device identifiers
• Health plan
beneficiary numbers
• Certificate/license
numbers
• Any other unique number,
code, or characteristic that
can be linked to an
individual.
12. HIPAA violations are enforced by the Department of Health and
Human Services (HHS), Office of Civil Rights (OCR). However,
pursuant to HITECH, state attorneys general are also permitted
to bring civil actions and recover monetary awards that may be
shared with harmed individuals.
Affinity Health Plan, Inc. discovered and
reported to HHS that it had returned leased
photocopiers to the leasing agents without
first erasing the data contained on the copier
hard drives that included PHI. The breach
was estimated to have affected 344,579
individuals. Following an investigation, Affinity
entered into a settlement agreement with HHS
providing for a $1.2 million payment and a
corrective action plan.
reality
12
Copiers: all PHI data must be removed from hard drives.
Faxes: confirm authorization instructions; verify telephone
numbers before faxing; when possible, use verified pre-
programmed numbers. Devices: encrypt; enable and use
password protection.
13. A court ordered Walgreens to pay $1.44
million to a customer whose PHI was
impermissibly accessed and disclosed by a
pharmacy employee. The employee
suspected her husband’s ex-girlfriend gave
him an STD, looked up the ex-girlfriend’s
medical records to confirm her suspicion,
and shared the information with her
husband. He then texted his ex-girlfriend
and informed her that he knew about her
STD.
Multiple state courts have ruled that HIPAA establishes a standard
of care to which healthcare providers need to adhere, and liability
for negligence may arise when that standard of care is breached.
reality
13
14. Access Must be
Authorized
Except in very limited circumstances, if an employee
accesses or discloses PHI without a patient’s written
authorization or without a job-related reason for doing so, the
employee violates USA Health HIPAA Policies and
Procedures.
An employee may only access or disclose a
patient’s PHI when this access is part of the
employee’s job duties.
14
15. 15
Discharge
________
________
________
________
________
________
• Always use 2 patient identifiers when providing patients with their
Discharge Instructions or any other paperwork containing PHI.
• There have been several occurrences of patients receiving the
wrong discharge instructions which can be a HIPAA breach.
Review HIPAA Privacy Policy No. 5 “Safeguarding PHI” for
additional information.
Safeguard PHI – Patient Discharge
16. Unauthorized Access
It is never acceptable for an employee to look at
PHI “just out of curiosity,” even if no harm is
intended (i.e., retrieving an address to send a get
well card).
It also makes no difference if the information
relates to a “high profile” person or a close
friend or family member –ALL information is
entitled to the same protection and must be
kept private.
These rules apply to all employees, including
health care professionals.
Be aware that accessing PHI of someone involved in a divorce,
separation, break-up, or custody dispute may be an indication of
intent to use information for personal advantage, unless the access
is required for the individual to do his job. Such improper behavior
will be considered by USA Health when determining disciplinary
16
17. 17
The patient should be given an opportunity to verbally agree or
object to the disclosure of PHI unless an emergency situation
prevents the prior approval.
Review HIPAA Privacy Policy No. 15 “Uses and Disclosures Requiring
Patient Opportunity to agree or object: Facility Directory, Family and Friends,
Disaster relief agencies” for additional Information.
Doctors, nurses or other clinical staff should not discuss
patients’
information when visitors or family members are in the patient’s
room unless authorized by the patient or the information is
needed to instruct caregivers who are attending the patient.
Disclosures to Family and Friends
18. Breaches
A breach occurs when information that, by
law, must be protected is:
• lost, stolen or improperly disposed of (i.e.
paper or device upon which the
information is recorded cannot be
accounted for);
• “hacked” into by people or mechanized
programs that are not authorized to have
access (e.g. the system in which the
information is located is compromised
through a Virus, or Malware); or
• communicated or sent to others who
have no official need to receive it
(e.g. gossip about information
learned from a medical record).
18
Types of
Breaches
reported
(as of 5/2016) Percent
Theft 46%
Unauthorized
Access/
Disclosure
24%
Hacking/IT 12%
Loss 9%
Improper
Disposal
3%
Other/
Unknown
7%
19. 19
All workforce members must remain vigilant and
never leave paper PHI (patient lists, lab reports),
medical carts (SAVVY, OmniCell), or mobile devices
(Chromebooks, tablets, laptops) in unattended or
unsecured areas.
Safeguard PHI - Unattended Materials
20. reality
Facing the most severe level of HIPAA’s criminal provisions –
up to
10 years in prison and a $250,000 fine – because the
violations involved access and use of PHI for personal gain, an
employee of the Seattle Cancer Care Alliance agreed to plead
guilty and serve a 16 month prison sentence and pay back
both the impacted credit card companies and the patient from
whom he stole PHI. The employee accessed and used the
patient’s name, birth date, and Social Security number from the
medical record to fraudulently obtain four credit cards. He
then charged about $9,000 in the patient’s name.
Individual employees, and
not just the “covered
entities” for whom they
work, are subject to
HIPAA's sanctions.
20
21. 21
Patients are given the opportunity upon admission to agree or object to
be included in the Hospital Directory. The Publicity Indicator within the
Hospital Information System will be coded Yes or No depending on the
patient’s decision.
In the event the patient cannot agree or object due to emergency
treatment circumstances, all of the information in the Directory will be
included and the Publicity Indicator will be set to Yes; unless, in our
professional judgment we determine it would not be in the patient’s best
interest to release any or all of this Directory Information. Once the
patient is able to make a decision, he will be given the chance to agree
or object.
If a patient or patient’s representative decides to change the Publicity
Indicator at any point, the Patient Access Department must be notified
and the patient must complete a change of Publicity Indicator form.
Review HIPAA Privacy Policy No. 31 “Publicity Indicator” for
additional Information.
Publicity Indicator (Hospital Patients)
22. Employees Must Report
BreachesPart of your responsibility as an employee is to report privacy or security
breaches involving PHI to your supervisor AND the HIPAA Compliance
Office. Even if you are not sure whether an incident or action involves
a breach, it is your responsibility to notify so that it
can be investigated.
Employees, volunteers,students,or contractors of USA may
not threaten or take any retaliatory action against an
individual for exercising his or her rights under HIPAA or for
filing a HIPAA report or complaint, including notifying of a privacy or security breach.
Reports may be made via telephone by calling the
Compliance Hotline 251- 445-9192, 24 hours a day,
365 days a year. You may choose to remain
anonymous.
22
23. Penalties for Breaches
Breaches of the HIPAA Privacy and Security Rules have serious
ramifications for all involved. In addition to sanctions imposed by
USA Health, such breaches may result in civil and criminal penalties.
Multiple types of HIPAA violations can result in penalties exceeding
$1.5 million.
23
24. 24
In 2016 alone (January through October),
$22,919,800 in fines have been levied in
Resolution Agreements and Civil Money
Penalties.
25. Breach
Notification
RequirementsAny impermissible use or disclosure that compromises PHI or
other sensitive information may trigger breach notification
requirements. Depending upon the results of a risk analysis of the
impermissible use or disclosure, breach notification may have to be
made to:
• the Department of Health and Human
Services, Office of Civil Rights (OCR);
• all individuals whose information was breached or disclosed;
and
• the media.
Letters of explanation describing the circumstances may have to be
sent to responsible parties. Abreach can significantly impact both the
economic and human resources of USA. The estimated average cost
in a data breach can exceed $200 per compromised record. In
addition, a breach has great potential to harm the reputation of USA. 25
26. reality
USA workforce members must report the loss or theft of any
personal or USA Health-owned device as an Information
Security Incident to Health System InformationServices (HSIS)
at
251-445-9123 and submit a Help Desk ticket.
Refer to the HIPAA Security Policies and Procedures on the
USA Hospitals Intranet or USAAmbulatory Intranet sites.
Massachusetts Eye and Ear Infirmary agreed to pay
HHS $1.5 million and retain an independent
monitor for HIPAA violations resulting from the
theft of an unencrypted laptop containing PHI
of patients and research subjects. HHS’s
investigation determined that the Infirmary failed
to take necessary steps to ensure the
confidentiality and security of PHI created,
maintained, and transmitted using portable devices.
26
27. Quick
Revie
w
• Protected Health Information(PHI) exists in many forms: printed,
spoken, and electronic.
• Protected Health Information(PHI) includes Social Security numbers,
credit card numbers, driver’s license numbers, computer passwords,
and PHI.
• HIPAA is a federal law and imposes privacy and security requirements.
• Two primary HIPAA regulations are the Privacy Rule and the Security
Rule.
• When used to identify a patient and when combined with health
information, HIPAA identifiers create PHI.
• An employee must have a patient’s written authorization ora job-
related reason for accessing or disclosing patient information.
• Breaches of information privacy and security may result in both
civil and criminal penalties, as well as, USA Health sanctions.
Employees must report such breaches.
27
28. 28
Office of Civil Rights(OCR) Audit
• The audit program is an important part of OCR’s overall health
information privacy, security, and breach notification compliance
activities.
• After completion of audit, the OCR will review and analyze
information from the final reports.
• The OCR may apply a penalty on the Covered Entity (CE) if the
findings show the CE is violating HIPAA rules.
29. 29
Recent HIPAA Breaches
• Advocate Health Care Network
In 2013, 4 unencrypted laptops were stolen from Advocate,
the largest health care system in Illinois. The combined
breaches affected the ePHI of approximately 4 million
individuals. This settlement is the largest to-date against a
single entity - $5.55 million.
• St. Joseph Health
PHI of 31,800 individuals was publicly accessible on the
internet due to a server setting that was not securely
configured. The resolution agreement of this breach was
$2.14 million.
• University of Mississippi Medical Center
OCR leveled a $2.75 million fine against the medical center
when a password-protected laptop went missing. The
breach impacted about 10,000 patients. Investigators
discovered UMMC was aware of risks and vulnerabilities to
its systems as far back as April 2005, yet took no action to
avoid it.
31. Five HIPAA Program
Components
1. Individual (Patient) Rights
2. “Minimum Necessary” Information Standard
3. Procedures for Data Use in Research
4. Limits for Marketing and Fundraising Uses
5. Business Associates
Following is a brief overview of five HIPAA program
components that must be followed by USA Health covered
entities:
31
32. 1. Patient Rights
• To receive a copy of the USA Health’s Notice of
Privacy Practices.
To request restrictions* and confidential
communications
of their PHI;
To inspect and/or receive an electronic copy of
their healthcare records.
To request corrections of their healthcare records.
To obtain an accounting of disclosures (i.e., a list
showing when and with whom their information has
been shared).
To file a complaint with a healthcare provider or
insurer and the Office of Civil Rights if the patient
believes his or her rights have been denied or that
PHI is not being protected.
To receive notice of a breach of their unsecured PHI.
•
•
•
•
•
•
* The Final Rule requires that a covered entity must agree to a request
to restrict the disclosure of PHI to patient’s health plan for a health care
item or service for which the patient has paid in full out of pocket,
unless otherwise required by law.
HIPAA sets forth the
following
individual rights for patients.
32
33. 2. Minimum
Necessary
Generally, a patient’s authorization is required for the use or
disclosure of PH1. When a use or disclosure of PHI is
permitted, via patient authorization or otherwise, HIPAA
requires that only the amount of PHI that is the MINIMUM
NECESSARY to accomplish the intended purpose be used or
disclosed unless the use or disclosure is for treatment of the
patient.
33
34. Disclosures of PHI
HIPAA regulations permit use or disclosure of PHI for:
• providing medical treatment
• processing healthcare payments
• conducting healthcare business operations
• public health purposes as required by law
Employees may not otherwise access or disclose PHI unless:
• the patient has given written permission
• it is within the scope of an employee’s job duties
• proper procedures are followed for using data in
research
• required or permitted by law
Note: the Final Rule now protects the PHI of a deceased
individual
for period of 50 years following the death of that individual. 34
35. reality
Imagine that you work with patients to help find ways to pay their
medical bills. Through your work, you become aware of a family
under substantial financial hardship.You believe that kindhearted
members of the community would provide help “If they only knew”
of these circumstances. In order to tell this story you must get
specific written authorization from thepatients or their legal
representatives that identifies whom you will tell. In addition, you
may communicate only the minimum amount of information
necessary to describe the need.
Note: This type of “outreach” needs to be approved by the HIPAA
Office and must be consistent with institutional policy.
35
36. 3. Research
Data
HIPAA regulates how PHI may be obtained and
used for research. This is true whether the PHI
is completely identifiable or partially “de-identified”
in a limited data set.
A researcher or healthcare provider is not entitled to use PHI in
research without the appropriate HIPAA documentation, including an
individual patient authorization
or
an institutionally approved waiver of authorization.
HIPAA requirements for accessing and using PHI in
research are explained on USA Office of Research
Compliance and Assurance webpage under Human
Subjects.
36
37. 4. Marketing &
Fundraising
Without first obtaining a patient authorization, USA Health may not receive payment for
the use or disclosure of PHI, nor may USA Health sell PHI.
USA Health may only use demographic information, including name, address, other contact
information, age, genderand date of birth, as well as, certain other limited information
about the medical treatment of an individual for fundraising purposes.
The Notice of Privacy Practices must advise patients of the prohibitions on marketing and
the sale of PHI and of their right to “opt out” of being contacted for fundraising purposes.
Each fundraising solicitation whether oral or written must contain an easy means for
patients to “opt out” of receiving such communications in the future. 37
38. 5. Business
AssociatesAn outside company or individual is a BusinessAssociate of
USA when performing functions or providing services involving
the use or disclosure of PHI maintained by USA.
Under the Final Rule, a Business Associate is directly liable for
compliance
with HIPAA Privacy and Security requirements and must:
• enter into a Business AssociateAgreement (called a BAA) with the covered
entity (USA Health);
• use appropriate safeguards to prevent the access, use or disclosure of PHI
other than as permitted by the contract, or BAA, with the covered entity;
• obtain satisfactory assurances from any subcontractor that appropriate
safeguards are in place to prevent the access, use or disclosure of PHI
entrusted to it;
• notify the covered entity of any breach of unsecured PHI for which the
Business Associate was responsible upon discovery;
• ensure its employees and/or those of its subcontractors receive HIPAA training;
and 38
39. Quick
Revie
w
Under HIPAA, patients have the right to:
• receive a copy of USA Health’s Notice of Privacy Practices.
• receive a copy of their healthcare records in electronic form.
• ask for corrections to their healthcare records.
• receive an accounting of when and to whom their PHI has been
shared.
• restrict how their PHI is used and shared.
• authorize confidential communications of their PHI to others.
• receive notice of a breach of their unsecured PHI.
• file a HIPAA complaint.
39
40. Quick
Revie
w
• USA may use or share only the minimum necessary information to
perform job duties.
• Patients must sign an authorization form before USA can release PHI to
a third party not involved in providing healthcare.
• A researcher or healthcare provider is not entitled to use PHI in
research without the appropriate HIPAA authorization or a waiver of
authorization.
• USA must obtain an individual’s specific authorization before using his or
her PHI for the sale of PHI, marketing, and some fundraising efforts.
• A contractor providing services involving PHI is called a Business
Associate.
• A covered entity and business associate must enter into a Business
Associate Agreement (“BAA”).
• Business Associates are directly liable for HIPAA compliance and must
ensure that their employees or subcontractors receive HIPAA training
and employ appropriate safeguards for PHI.
• HIPAA protections apply to a deceased person’s PHI for 50 years
after death.
40
42. HIPAA Security Rule
The HIPAA Security Rule concentrates on safeguarding
PHI by focusing on the confidentiality, integrity, and
availability of PHI.
Confidentiality means that data or information is not
made available or disclosed to unauthorized persons or
processes.
Integrity means that data or information has not been
altered or destroyed in an unauthorized manner.
Availability means that data or information is
accessible and useable upon demand only by an
authorized person.
42
43. Security
Standards/SafeguardsUSA Health is required to have administrative, technical, and
physical safeguards in place to protect the privacy of PHI.
Safeguards
must:
Protect PHI from accidental or intentional
unauthorized use/disclosure in computer
systems (including social media networking
sites such as Facebook, Twitter and others) and
work areas;
Limit accidental disclosures (such as PHI
discussions in waiting rooms and hallways); and
Include practices such as encryption,
document shredding, locking doors and file
43
44. reality
USA employees should never disclose work-related sensitive
information through social media or any internet sites, such as
Facebook, Twitter, or Google.
Irritated by a patient who was always late to her
pre-natal appointments, a Missouri doctor posted
to her personal Facebook page,“may I show up
late to her delivery?”A reader took a screen shot
of the doctor’s comment and posted it to the
employing hospital’s Facebook page for expectant
mothers where many wrote to demand the
doctor’s termination.
The doctor’s post revealed the patient’s
induction date and that she had previously
suffered a stillbirth making identification
likely. The employing hospital publicly
issued a comment decrying the incident.
44
45. Malicious
Software
Viruses, worms, spyware, ransomware, and spam are examples of
malicious software, sometimes known as “malware.”
Antivirus and anti-spyware software can be utilized for protection.
These should be updated regularly with patches.
Safe Internet browsing habits can also reduce the likelihood of an
infection; do not open email or click on embedded links from an
unknown or untrusted site.
If the computer or mobile device you are using is approved for storage
of work-related sensitive information, personal use of the web is not
recommended.
45
46. Viruses
Another major threat to USA’s
information system and to your data
is computer viruses.
• Viruses “infect” your computer by modifying how it operates
and, in many cases, destroying data.
• Viruses spread to other machines by the actions of users,
such as opening infected email attachments.
• Viruses can forward PHI to unauthorized persons by
attaching themselves to documents, which are then
emailed by the virus.
• Newer viruses have their own email engines, enabling them to
send email without having to use an email client or server.
• Many viruses also install a “backdoor” on affected computer
systems allowing for unauthorized access and collection of
PHI.
46
47. Worms
Worms are programs that can:
• run independently without user action;
• spread complete working versions of themselves onto
other computers on a network within seconds; and
• quickly overwhelm computer resources with the potential
for data destruction as well as unauthorized disclosure of
sensitive information.
47
48. Spywar
eSpyware is software that is secretly loaded onto your
computer, monitors your activities, and shares that
information
without your knowledge.
Malicious websites
can install spyware on every
computer
that visits those sites.
48
49. Ransomware
Ransomware is a type of malicious software designed to encrypt
data, which then blocks access to a computer system until a sum of
money is paid.
49
• Fastest growing malware threat – on average there are 4,000
attacks daily
• Ransomware can be downloaded onto systems when
unsuspecting users visit malicious or compromised websites.
However, most ransomware arrives in some sort of email
attachment, along with a message that encourages you to open
the file and look at it.
50. Spam and
PhishingSpam is an unsolicited or “junk” electronic mail
message, regardless of content.
Spam usually takes the form of bulk advertising
and may contain viruses, spyware, inappropriate
material, or “scams.”
Spam also clogs email
systems.
Phishing is a particularly dangerous form of spam that seeks
to trick users into revealing sensitive information, such as
passwords.
REMEMBER: USA will never ask you to disclose
passwords, social security numbers, or other sensitive
information via email.
Questions?
Call HSIS at 445-9123 or
the Office of HIPAA Compliance (OHC) at 445-9192
50
51. Safe Browsing
Habits• Safeguard sensitive information
Look for signs of security when providing sensitive information (i.e. the web address
starts with “https” or a padlock icon is displayed in the status bar).
• Equipment should have updated browsers and
security settings enabled
• Security software should be utilized when possible
There are a number of free and easily available software products to protect your
computer from malware, spyware, and virus threats. Talk to your IT support personnel
to find out which software best fits your needs.
• Safe downloading & streaming
• When in doubt just don’t do it! If a download looks too good to be true, it
might be malware.
• Downloaded files like software or other media can contain hidden malware.
• Streaming media Web sites might seem harmless, but watching or listening to
streaming media may require downloading a special media player that may
contain malware.
51
52. Safe Computing and Email
Use
See USA Health Privacy Policy # 5- Safeguarding Protected Health
Information and HIPAA Security Policy # 25- Use of Mobile Devices
for Computing and Data Storage
Mobile Devices are not approved for storage of PHI without prior
Administrative approval unless they are part of a designated Health
System Information System.
Encryption is required when a USA Health employee sends or receives
PHI to a destination address outside the USA Health network. Always use
#secure in the subject line.
When traveling, working from home, or using a mobile device, an
employee whose work involves the transmission of PHI must encrypt the
data UNLESS the employee uses a VPN connection AND transmits data
only to a destination within the secure network.
Do not open email attachments if the message looks the least bit
suspicious, even if you recognize the sender. “When in doubt, throw it out.”
Do not respond to “spam” – simply discard or delete it, even if it
has an “unsubscribe” feature.
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53. Mobile Devices
• Never leave mobile computing devices unattended in unsecured
areas.
• Immediately report the loss or theft of any mobile computing
device to your supervisor, HSIS, and the Office of HIPAA
Compliance.
• Remember, for any mobile device, encryption is the best defense!
Review HIPAA Security Policy No. 25 Use of Mobile Device for
USA Health policy requires approval from an Administrator or the HIPAA Compliance
Office in order to store Sensitive Information, including PHI, on encrypted mobile
devices. This applies to all mobile computing devices, such as laptops, iPads,
smart phones, or even regular cell phones.
Employees must utilize the following security controls when storing and
transmitting sensitive information:
strong power-on passwords
automatic log-off
display screen lock at regular intervals while the device is inactive
Encryption
Anti-Virus
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54. Password Control
Many security breaches come from within
an organization and many of these occur
because of bad password habits.
• Use strong passwords where possible (at least 7 characters,
containing a combination of letters, numbers, and special
characters).
• Change your passwords frequently (90 days) to prevent hackers
from using automated tools to guess your password.
• It is a violation of USA Health Policy to share your password with
anyone.
• Electronic audit records track information based on activity
associated with user IDs .
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55. reality
An employee , who stored his email in his phone, lost his phone while on vacation.
The phone was not password protected. Eventually the phone was returned, but
no one knows who may have had possession of the device while it was not in the
employee’s control.
The employee violated HIPAA by storing PHI on an unsecure device, creating a
breach that required notification to each affected patient whose data was
contained on the phone, as well as reporting the incident to the government.
There were also disciplinary implications for the employee.
The costs of a lost or stolen mobile device go far beyond the cost of replacing the
device itself. Any loss, sale, trade-in, upgrade, or replacement of a phone that
may contain PHI must be reported to HSIS at 445-9123.
The majority of expenses include:
•investigative costs
•reporting data breaches
•liability for data breaches (e.g. government penalties)
•restoring hard-to-replace information
•preventing further misuse of the data
•lost intellectual property
•lost productivity
•damage to reputation 55
56. 56
reality
A recent study found that laptop loss led to losses of $2.1
billion for the 329 organizations surveyed during a one year
period. Cleaning up the resulting data breaches accounted for
80% of that total.
According to a 2013 Ponemon Institute report: 41% of
breaches are due to malicious/criminal attacks, 29% are due
to a system glitch, 33% are due to the “human factor.”
Report any missing, lost, or stolen
device to HISIS and the Office of HIPAA
Compliance immediately!
57. Remote Access
DO NOT let your personal computer and device antivirus subscription
expire!
All computers and mobile devices used to connect to USA
Health networks or systems from home or other off-site
locations should meet the same minimum security
standards that apply to your work computer.
You
should:
• Make use of the Virtual Private Network (VPN) or VMware at home or off-
site, AND transmit PHI only to locations within the secure campus network.
Otherwise, sensitive data must be encrypted.
• RunWindows Updates or the update feature of the particular operating
system that you are using.
• Keep virus definitions current by using the antivirus software recommended and
supported by your IT support team.
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58. reality
USA Health workforce members must received approval from the USA
Health HIPAA Compliance Committee or USA Health Senior
Administrator to use any external storage devices to store PHI, including
“thumb” or “flash” drives. These devices must use encryption and
adhere to the following:
• Use portable storage media only for transporting information, and
not to
permanently store information.
• Once you’ve used the information, erase it from the device.
• Consider attaching your memory stick to your key ring -- you are
less
A Rochester Medical Center physician misplaced an unencrypted USB
drive containing PHI of 537 patients, including demographic and
diagnostic information. Because of this negligence, the Medical Center
was required to notify all of the individuals affected by this breach, the
attorney general, and the OCR, triggering the possibility of further
investigation and large fines.
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59. Employee
Responsibiliti
es
Avoid storing sensitive information on mobile devices and portable
media, but if you must, use encryption.
Always keep portable devices physically secure (under lock
and key) to prevent theft and unauthorized access.
Access information only as necessary for your
authorized job responsibilities.
Keep your passwords confidential.
Comply with USA Health’s HIPAA Security and Privacy policies.
Report to your supervisor and the USA Office of HIPAA Compliance
the loss or misuse of devices storing PHI or other Sensitive
Information promptly.
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60. Appropriate Disposal of
DataObserve the following procedures for the
appropriate disposal of Sensitive Information,
including PHI.
• Hard copy materials such as paper or microfiche must be properly
shredded or placed in a secured bin for shredding later.
• Magnetic media such as diskettes, tapes, or hard drives must be
physically destroyed or “wiped” using approved software and procedures.
Contact HSIS or the Office of HIPAA Compliance for more information.
• CDs and DVDs must be rendered unreadable by shredding, defacing the
recording surface, or breaking.
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Sensitive information and PHI should
never be placed in the regular trash!
61. reality
On several occasions sensitive materials, such as
patient files, have been left in file cabinets or office
desks that were being sent to storage or before being
sold at the Surplus sale. Environmental Services staff
found the sensitive materials and notified the
appropriate department before anyone picked up the
furniture. If any of that furniture had been sold to the
public before the sensitive materials were found, it
would have been difficult and costly for USA to retrieve
the materials and manage the breach.
You cannot be too careful when disposing of desks, file cabinets and
other office furniture that may hold documents in them. Please check
them carefully and confirm that all documents have been removed and
properly disposed of before sending furniture or equipment for storage or
disposal.
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62. Physical
Security
Equipment such as PCs, servers,
mainframes, fax machines, and copiers must be
physically protected.
◦ Computer screens, copiers, and fax machines must be placed
so that they cannot be accessed or viewed by unauthorized
individuals.
◦ Computers must use password-protected screen savers.
◦ PCs that are used in open areas must be protected against
theft or unauthorized access.
◦ Servers and mainframes must be in a secure area where
physical access is controlled.
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63. What if there is a breach of
confidentiality?
Breaches of USA Health HIPAA policies or an
individual’s confidentiality must be reported to the
employee’s supervisor AND the Office of HIPAA
Compliance as soon as possible.
USA Health is required to take reasonable steps to lessen harmful
effects of a confirmed breach involving compromised PHI.
This includes notifying individuals whose information has been
breached. USA Health must report breaches to the Secretary of Health
and Human Services.
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64. Disciplinary
Actions
Individuals who violate USA Health’s
HIPAA Policies will be subject to
appropriate disciplinary action, up to
and including termination, as outlined
in USA Health Human Resources and
HIPAA policies, as well as subject to
possible criminal or civil penalties.
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65. Best Practice
Reminder
s
• DO keep computer sign-on codes and passwords confidential, and DO NOT allow
unauthorized persons access to your computer. Also, use locked screensavers for added
privacy.
• DO keep notes, files, memory sticks, and computers in a secure place, and be careful NOT
to leave them in open areas outside your workplace, such as a library, cafeteria, or airport.
• DO NOT place PHI on a mobile device without required approval. DO use encryption
when sending or storing PHI on mobile devices, including “thumb” or “flash” drives.
• DO hold discussions of PHI in private areas and for job-related reasons only. Also, be
aware of places where others might overhear conversations, such as in reception areas.
• DO make certain when mailing documents that no sensitive information is shown on
postcards or through envelope windows, and that envelopes are closed securely.
• DO NOT use unsealed campus mail envelopes when sending sensitive information
to another employee.
• DO follow procedures for the proper disposal of sensitive information, such as
shredding documents.
• When sending an e-mail, DO NOT include PHI or other sensitive information such
as Social Security numbers, unless you have the proper written approval to store the
information or the Protected Health Information is encrypted.
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66. 66
HIPAA Resources
USA Office of HIPAA Compliance
Linda Hudson, Director, HIPAA Compliance
470-5802 lhudson@health.southalabama.edu
Thad Phillips, Asst Chief, HIPAA Comp/Security
410-4550 tphillips@health.southalabama.edu
Cynthia Holland, HIPAA Audit Coordinator
471-7621 cholland@health.southalabama.edu
Elizabeth Will, Compliance Programs Coordinator
ewill@health.southalabama.edu
MCI
Cindy Nelson, Mgr, MCI Clin & Res Systems
445-9849 crnelson@health.southalabama.edu
Feel free to print this page for your reference
Editor's Notes
Sensitive information and PHI should never be placed in the regular trash!