The document provides an overview of GBMC's HIPAA compliance program and training. It discusses the HIPAA privacy rule's requirements regarding protected health information, patient rights, notice of privacy practices, privacy policies, and the privacy officer. It also covers the HIPAA security rule and topics that will be addressed in the training, including electronic protected health information, user identity, password management, security policies, and the security officer.

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GBMC HIPAA Compliance Program
Health
Insurance
Portability and
Accountability
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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)
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Diagram of the HIPAA Statute
Security
Code Sets
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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
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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
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HIPAA Privacy
Examples of PHI
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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
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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
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HIPAA Privacy
The Privacy Rule

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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
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Annual Acknowledgment of the Minimum
Necessary Standard
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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
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9. Minimum Necessary Scenarios
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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
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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
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HIPAA Privacy
The Privacy Rule
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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
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HIPAA Privacy
The Patient Privacy Rights
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Right to access PHI
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Right to request an amendment to PHI
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Right to request restrictions on how PHI is used for
treatment, payment, and healthcare operations
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Right to receive confidential communications
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Right to request an accounting of disclosures
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Right to complain to the Department of Health and Human
Services’ Office for Civil Rights
Patient Rights
Patient Rights
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HIPAA Privacy
The Privacy Rule
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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
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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
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discusses how the medical
staff may interact with the
patient’s family
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HIPAA Privacy
The Privacy Rule
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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
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HIPAA Privacy
THE GBMC Privacy
Policies
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Examples of GBMC
Privacy Policies include:
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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
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HIPAA Privacy
The Privacy Rule
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Requires that GBMC designate someone who is
responsible for
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the development and implementation of the privacy
policies
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privacy related training and education
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investigating privacy related complaints
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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
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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
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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.
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HIPAA Security
The Security Rule
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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
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HIPAA Security
The Security Rule
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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
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HIPAA Security
Protecting Your Password
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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
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HIPAA Security
Examples of How to Create a Strong Password
1. Mix upper and lowercase
characters
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3bLINdmice
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5gOLDenrings
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4cALLingbirdS
3. Combine two words by
using a special character
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Roof^Top
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Sugar$Daddy
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B@tterup!
2. Replace letters with
numbers
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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
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HIPAA Security
The Security Rule
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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:
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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
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HIPAA Security
The “Do Not’s” When Using GBMC Systems
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As a user of a GBMC system (including the Internet) you
may not:
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Install unauthorized software (e.g. screensavers, games, or
instant messenger programs)
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Install any unlicensed software on a GBMC computer or device
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Abuse your Internet or e-mail access privileges
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Relocate any computer equipment without prior MIS approval
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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
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HIPAA Security
The Security Rule
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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
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HIPAA Security
The Security Rule
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Requires that GBMC designate someone who is responsible
for:
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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
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HIPAA Security
The Security Rule
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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:
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Unauthorized or suspicious visitors
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Logged-on but unattended workstations
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Uncontrolled access to areas that house equipment and/or PHI
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Passwords on Post-it™ notes
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Staff accessing records without a need to know
 Report all security concerns to Tara Miller.
Reporting Security Concerns
Reporting Security Concerns
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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.
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