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Privacy and Security Training Session Draft v12 4815 Disclaimer This HIPAA Privacy amp Security Training Session Copyright by the HIPAA Collaborative of Wisconsin HIPAA COW may be freely redistributed in its entirety provided that this copyright notice is not removed ID: 373169

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Slide1

Welcome to the

Privacy and Security Training Session!

Draft v.12

4/8/15Slide2

Disclaimer

This HIPAA Privacy & Security Training Session Copyright



by the HIPAA Collaborative of Wisconsin (“HIPAA COW”) may be freely redistributed in its entirety provided that this copyright notice is not removed. When information from this document is used, HIPAA COW shall be referenced as a resource. It may not be sold for profit or used in commercial documents without the written permission of the copyright holder. This

HIPAA Privacy & Security Training Session is provided “as is” without any express or implied warranty. It is for educational purposes only and does not constitute legal advice. If you require legal advice, you should consult with an attorney. Unless otherwise noted, HIPAA COW has not addressed all state pre-emption issues related to this HIPAA Privacy & Security Training Session. Therefore, this document may need to be modified in order to comply with Wisconsin/State law.This document is not a complete summary covering every aspect of the Privacy and Security Rules. You may need to modify content to suit your organization’s policies and procedures. Slides are provided for informational purposes only.It is recommended to select only those slides or groups of slides that are relevant to your training purposes. This Training Session is not meant to be presented as is, but as a starting point or idea generator only.

2Slide3

What is HIPAA?

Why is HIPAA Important?HIPAA DefinitionsHIPAA Enforcement

Patient Rights

HIPAA Privacy Requirements

The Breach Notification RuleRelease of Information (ROI)HIPAA Security RulePHI Safeguarding TipsBusiness Associate AgreementsHIPAA Violations and ComplaintsDiscussion Slides

Privacy and Security Training SectionsSlide4

Privacy and Security Training Presenters

Privacy

Officer:

[Insert Name and contact information]Security Officer:[Insert Name and contact information]Compliance Committee Members: [Insert Names and contact information]© Copyright HIPAA COW4Slide5

Section I

Introduction

What is HIPAA?

5Slide6

What is HIPAA?

Acronym for Health Insurance Portability & Accountability Act of 1996 (45 C.F.R. parts 160 & 164).

Provides a framework for

establishment of nationwide

protection of patient confidentiality, security of electronic systems, and standards and requirements for electronic transmission of health information.© Copyright HIPAA COW6Slide7

What is HIPAA

?Each part of HIPAA is governed by different laws

Health Information Privacy and Portability Act of 1996

7Slide8

Privacy Rule

Privacy Rule went into effect

April 14, 2003

Privacy refers to protection of an individual’s health care data.Defines how patient information used and disclosed.Gives patients privacy rights and more control over their own health information.Outlines ways to safeguard Protected Health Information (PHI).Note: Some Wisconsin Privacy Laws (e.g. WI Chapters 51, 146, 252 and DHS 92, are more stringent than HIPAA Privacy Rule© Copyright HIPAA COW8Slide9

Security Rule

Security (IT) regulations went into effect April 21, 2005.

Security means controlling:

onfidentiality of electronic protected health information (ePHI).Storage of electronic protected health information (ePHI)Access into electronic information© Copyright HIPAA COW9Slide10

Electronic Data Exchange (EDI)

Defines transfer format of electronic information between providers and payers to carry out financial or administrative activities related to health care.

Information includes coding, billing and insurance verification.

Goal of using the same formats is to ultimately make billing process more efficient.

Why Comply With HIPAA?

To show our commitment to protecting privacy

As an employee, you are obligated to comply with [Insert Your Organization Name] privacy and security policies and procedures

Our patients/members are placing their trust in us to preserve the privacy of their most sensitive and personal information

Compliance is not an option, it is required.If you choose not to follow the rules:You could be put at risk, including personal penalties and sanctionsYou could put [insert organization name] at risk, including financial and reputational harm© Copyright HIPAA COW11Slide12

HIPAA Regulations

HIPAA Regulations require we protect our patients’ PHI in all media including, but not limited to, PHI created, stored, or transmitted in/on the following media:

Verbal

Discussions (i.e. in person or on the phone)Written on paper (i.e. chart, progress notes, encounter forms, prescriptions, x-ray orders, referral forms and explanation of benefit (EOBs) formsComputer Applications and Systems (i.e. electronic health record (EHR), Practice Management, Lab and X-RayComputer Hardware/Equipment (i.e. PCs, laptops, PDAs, pagers, fax machines, servers and cell phones© Copyright HIPAA COW

12Slide13

This training session provides you with

REMINDERS of our organizational

POLICIES

and how YOU are required to PROTECT PHI Section IIWhy is HIPAA Important?© Copyright HIPAA COW13Slide14

Why is Privacy and Security Training Important?

Outlines ways to prevent accidental and intentional misuse of PHI.Makes PHI secure with minimal impact to staff and business processes.

It’s not just about HIPAA – it’s about doing the right thing!

Shows our commitment to managing electronic protected health information (ePHI) with the same care and respect as we expect of our own private information

Why

is Privacy and Security Training Important

It is everyone’s responsibility to take the confidentiality of patient information seriously.

Anytime you come in contact with patient information or any PHI that is written, spoken or electronically stored, YOU become involved with some facet

of the privacy and security regulations

The law requires us to train

you.

To ensure your understanding of the Privacy and Security Rules as they relate to your job.

15Slide16

Section III

HIPAA DefinitionsSlide17

HIPAA Definitions

Protected Health Information (PHI) is individually identifiable health information that is: Created or received by a health care provider, health plan, employer, or health care clearinghouse and that

Relates to the past, present, or future physical or mental health or condition of an individual;

Relates to the provision of health care to an individual

The past, present or future payment for the provision of health care to an individual. What is Protected Health Information (PHI)?© Copyright HIPAA COW17Slide18

What Does PHI Include?

Information in the health record, such as:Encounter/visit documentation

Lab results

Appointment dates/times

InvoicesRadiology films and reportsHistory and physicals (H&Ps)Patient IdentifiersHIPAA Definitions© Copyright HIPAA COW18Slide19

PHI includes information by which the identity of a patient can be determined with reasonable accuracy and speed either directly or by reference to other publicly available information.

HIPAA Definitions

What are Patient Identifiers?

19Slide20

What Are Some Examples of Patient Identifiers?

Names Medical Record Numbers

Social Security Numbers

Account Numbers

License/Certification numbersVehicle Identifiers/Serial numbers/License plate numbersInternet protocol addressesHealth plan numbersFull face photographic images and any comparable imagesWeb universal resource locaters (URLs)Any dates related to any individual (date of birth)Telephone numbersFax numbers

Email addresses

Biometric identifiers including finger and voice prints

Any other unique identifying number, characteristic or code

HIPAA Definitions

20Slide21

HIPAA Definitions

UsesWhen we review or use PHI internally (i.e. audits, training, customer service, or quality improvement).

What Are Uses and Disclosures?

Disclosures:

When we release or provide PHI to someone (i.e. attorney, patient or faxing records to another provider).

21Slide22

HIPAA Definitions

To use or disclose/release only the minimum necessary to accomplish intended purposes of the use, disclosure, or request.Requests from employees at [Organization]:

Identify each workforce member who needs to access PHI.

Limit the PHI provided on a

“need-to-know” basis.Requests from individuals not employed at [Organization]:Limit the PHI provided to what is needed to accomplish the purpose for which the request was made.What is Minimum Necessary?© Copyright HIPAA COW22Slide23

What is

Treatment, Payment and Health Care Operations (TPO)?HIPAA allows Use and/or Disclosure of PHI for purpose of:

Treatment

– providing care to patients.

Payment – the provision of benefits and premium payment.Health Care Operations – normal business activities (i.e. reporting, quality improvement, training, auditing, customer service and resolution of grievances data collection and eligibility checks and accreditation).HIPAA Definitions© Copyright HIPAA COW23Slide24

Section IV

HIPAA EnforcementSlide25

Why Do We Need to Protect PHI?

It’s the law.To protect our reputation.To avoid potential withholding of federal Medicaid and Medicare funds.

To build trust between providers and patients.

If patients feel their PHI will be kept confidential, they will be more likely to share information needed for care.

[p© Copyright HIPAA COW25Slide26

Who or What Protects PHI?

Federal Government protects PHI through HIPAA regulations

Civil penalties up to $1,500,000/year for identical types of violations

Willful neglect violations are mandatory!Criminal penalties:$50,000 fine and 1 year prison for knowingly obtaining and wrongfully sharing information.$100,000 fine and 5 years prison for obtaining and disclosing through false pretenses.$250,000 fine and 10 years prison for obtaining and disclosing for commercial advantage, personal gain, or malicious harm.Our organization, through the Notice of Privacy Practices (NPP).

You

by following our policies and procedures.

26Slide27

Enforcement

The Public. The public is educated about their privacy rights and will not tolerate violations! They will take action.Office For Civil Rights (OCR).

The agency that enforces the privacy regulations providing guidance and monitoring compliance.

Department of Justice (DOJ).

Agency involved in criminal privacy violations. Provides fines, penalties and imprisonment to offenders.How are the HIPAA Regulations Enforced?© Copyright HIPAA COW27HIPAA EnforcementSlide28

Section V

Patient RightsSlide29

HIPAA Regulations

The Right to Individual PrivacyThe Right to Expect Health Care Providers Will Protect These Rights

What Are the Patient’s Rights Under HIPAA?

Other Patient Rights Include

: Access, Communications, Special Requests, Amendment, Accounting of Disclosures, Notice of Privacy Practices and Reminders, and the Right to File Complaints.© Copyright HIPAA COW29Slide30

Patient Rights

Notice of Privacy Practices (NPP)What is the purpose of the NPP?

Summarizes how [Organization] uses and discloses patient’s PHI.

Details patient’s rights with respect to their PHI

The Organization must request that new patients sign the NPP acknowledgment form at the time of their first visit.Patients sign the Acknowledgment of Receipt to confirm that they have been offered and/or received the

NPP.

If unable to obtain a signed Acknowledgement, the Organization must document its good faith efforts to obtain such acknowledgement and the reason why it could not obtain it.

30Slide31

Patient Rights

Access and Inspect PHI

Patient’s have the right to inspect and copy their PHI.

However, there are some situations where access may be denied or delayed:

Psychotherapy notes.PHI compiled for civil, criminal or administrative action or proceedings.PHI subject to CLIA Act of 1988 when access prohibited by law.If access would endanger a person’s life or safety based upon professional judgment.If a correctional inmate’s request may jeopardize health and safety of the inmate, other inmates or others at the correctional institution.If a research study has previously secured agreement from the individual to deny access.If access is protected by the Federal Privacy Act.If PHI was obtained under promise of confidentiality and access would reveal the source of the PHI.

31Slide32

Patient has the right to request to receive communication by alternative means or location. For example:

The patient may request a bill be sent directly to him instead of to his insurance company.The patient may request we contact her on cell phone instead of home telephone number.

Patient Rights

Request Alternate Communication

Patient Rights

Special Access Request

Example:

If a patient requests that we always call a family member instead of her directly, what are some options:

Your organization may have specific form to complete Your organization may have a policy to refer such requests to Patient Relations or another customer service departmentUsually, organization will have a process in place to document the patient’s wishes in his/her medical record© Copyright HIPAA COW33Slide34

Patient Rights

Request Amendment

Patient has the right to request an amendment or correction to PHI

However, may be a situation when request may be denied, including:

[Organization] did not create the information.Record accurate according to health care professional that wrote it.Information is not part of the [Organization’s] record.If a patient indicates there is an error in his/her record, what are some options:Your organization may have a specific form to be completedYour organization may have process in place to direct requests to Member Relations or another customer service department

Usually, an approved amendment will be directed to the Health Information Management Department or Privacy Officer

34Slide35

Patient Rights

Request Restriction

Record Restriction

may be requested by the patient if he/she wishes to change or restrict how your organization uses and discloses your PHI.

Organization must honor request to restrict disclosure to a health plan:If the disclosure is for the purpose of carrying out payment or health care operations and is not otherwise required by law; andThe PHI pertains to items and services paid by the patient or patient representative in-full.For all other requests for restrictions, organization must make reasonable effort to honor request, but approval is not requiredOrganization typically has a form to complete to request the restrictionPatient may later revoke a request for record restriction.© Copyright HIPAA COW

35Slide36

Patient Rights

Accounting of Disclosures

is a request for a list of disclosures of a patient’s PHI that did not require an authorization or the opportunity for the patient to agree or object.

Organization typically has a form to complete to request the accountingThe HIPAA rules require the organization to provide certain information about the disclosure, such as date, name of person who received the PHI, a description of the PHI and the purpose of the disclosure.Individual may request accounting of disclosures as far back as six years before the time of the request.Organization must provide the first accounting without charge. Subsequent requests for accountings by the same individual within a 12 month period may be charged a reasonable, cost-based fee, as long as the organization provides notice to the individual.© Copyright HIPAA COW

36Slide37

Patient Rights

Accounting of Disclosures (cont’d)

Accounting of Disclosures Does Not Include Disclosures For:

Treatment (to

persons involved in the individual’s care), payment or health care operations.Individual subject of PHI.Incident to an otherwise permitted disclosure.Disclosure based

on individual’s

signed authorization.

For

facility

directory.

For national security or intelligence purposes.

To correctional facilities or law enforcement on behalf of inmates.

As part of a limited data set (see

45 CFR s. 164.514

37Slide38

Patient Rights

Accounting of Disclosures (cont’d)

Required by law

For public health activities

Victims of abuse, neglect, violenceHealth oversight activitiesJudicial/Administrative proceedingsLaw enforcement purposesOrgan/eye/tissue donationsResearch purposesTo avert threat to health and safety

For specialized government functions

About decedents

Workers’ compensation

Releases made in error to an incorrect person/entity (i.e. breach)

Accounting of Disclosures Does Include Disclosures For:

38Slide39

Section VI

HIPAA Privacy RequirementsSlide40

Privacy Officer ResponsibilitiesDevelopment and implementation of the policies and procedures of the entity

Designated to receive and address complaints regarding PrivacyProvide additional information as requested about matters covered by the Notice of Privacy PracticesDesignation of the Privacy Officer must be documented

Personnel Designation

Privacy Officer

Members of the workforce who handle PHI require training Required upon hire and recommended annually

As material changes are implemented, training to appropriate workforce members affected by that changeDocumentation of the training, who attended, the topic covered and date the training was held

Training

41Slide42

Implementation of administrative, physical and technical safeguards (work in tandem with Security rule).Safeguard PHI from any intentional or unintentional use or disclosure.

Limit incidental uses and disclosures that occur as a result of otherwise permitted or required uses and disclosures.Example: create safeguards to prevent others from overhearing PHI.Safeguards

42Slide43

Patient Right

File Privacy Complaint

Individuals may file complaints with [Organization’s] Privacy Official regarding health information privacy violations or [Organization’s] privacy compliance program.

Individuals may file complaints with the Department of Health and Human Services Office of Civil Rights.

Develop and apply appropriate sanctions for the non-compliance with [Organization’s] policies and procedures.Document sanctions that are applied.

NOTE: “Sanctions” can be referred to as discipline or corrective action.Sanctions

44Slide45

[Organization] must mitigate, to the extent practicable, any harmful effects known to the [Organization] of a use or disclosure of PHI (by the Covered Entity or Business Associate) in violation of the [Organization’s] policies and procedures or the requirements of the Privacy Rule.

Mitigation

45Slide46

[Organization] may not intimidate, threaten, coerce, discriminate against, or take other retaliatory action against:Individuals for exercising their rights or filing a complaint;

Individuals and others for:Filing a complaint with the Secretary;Testifying, assisting, or participating in an investigation, compliance review, proceeding, or hearing; orGood faith opposition to a prohibited act or practice

Refraining From

Intimidating or Retaliatory Acts

[Organization] cannot require an individual to waive their rights provided under this rule for the purpose of providing treatment, payment or enrollment in a health plan or eligibility for benefits.

Waiver of Rights© Copyright HIPAA COW

47Slide48

[Organization] must implement policies and procedures designed to comply with the Breach and Privacy Rules.[Organization ] must change policies and procedures as necessary and appropriate to comply with changes in the law and maintain consistency between policies, procedures and the Notice of Privacy Practices.

[Organization] must document all changes made to policies and procedures and maintain all policies for 6 years.[Organization] must train employees on changes made to policies and procedures.

Policies and Procedures

48Slide49

[Organization] must maintain all documentation for 6 years from the date of its creation, including:Policies and procedures in written or electronic form;

Communications in written or electronic form when such communications are required in writing;Written or electronic records of actions, activities, or designations as required.Documentation

49Slide50

Definition of PHI Misuse

AccessUsing

Taking

Possession

Release Editing Destruction The following activities occurring in the absence of patient authorization are considered misuse of p

rotected health

nformation

(PHI):

No! You must have authorization

first!

!Slide51

Type I -- Inadvertent or Unintentional Disclosure

Inadvertent, unintentional or negligent act which violates policy and which may or may not result in PHI being disclosed. Disciplinary action for a Type I disclosure will typically be a verbal warning, re-education, and review and signing of the Confidentiality Agreement. However, disciplinary action is determined with the collaboration of the Privacy Officer, Director of Human Resources and the department manager.

Type

II – Intentional

DisclosureIntentional act which violates the organization’s policies pertaining to that PHI which may or may not result in actual harm to the patient or personal gain to the employee.Breach notification processes will be followed as described in the Breach Notification Policy.Types of Privacy Violations

51Slide52

Section VII

Breach Notification RuleSlide53

Breach Notification

Definition of Breach (45 C.F.R. 164.402)

Impermissible

use or disclosure of (unsecured) PHI is assumed

to be a breach unless the covered entity or business associate, demonstrates a low probability that the PHI has been compromised based on a risk assessment. © Copyright HIPAA COW53Slide54

Breach Notification

Unsecured PHI

“Unsecured protected health information” means protected health information

(

PHI) that is not rendered unusable, unreadable, or indecipherable to unauthorized persons through the use of a technology or methodology required by the Breach Notification Rule.© Copyright HIPAA COW54Slide55

Breach Notification

Risk Assessment

Risk

Assessment

under the Final Rule requires consideration of at least these four factors:The nature and extent of the PHI involved, including the types of identifiers and the likelihood of re-identification;

The

unauthorized person who used the PHI or to whom

the disclosure was made;

Whether

the PHI was actually acquired or viewed;

and

The

extent to which the risk to the PHI has been mitigated

55Slide56

Breach Notification

Risk Assessment Factor #1

Evaluate the nature and the extent of the PHI involved, including types of identifiers and likelihood of re-identification of the PHI:

◦ Social security number, credit card, financial data (risk of identity theft or financial or other fraud) ◦ Clinical detail, diagnosis, treatment, medications ◦

Mental health, substance abuse, sexually transmitted

diseases, pregnancy

56Slide57

Breach Notification

Risk Assessment Factor #2Consider the unauthorized person who impermissibly used the PHI or to whom the impermissible disclosure was made

Does the unauthorized person who received the information have obligations to protect its privacy and security?

Is that person workforce of a covered entity or a business associate?Does the unauthorized person who received the PHI have the wherewithal to re-identify it?© Copyright HIPAA COW57Slide58

Consider whether the PHI was actually acquired or viewed or if only the opportunity existed for the information to be acquired or

viewedExample: Laptop

computer was stolen, later recovered and IT analysis shows that PHI on the computer was never accessed, viewed, acquired, transferred, or otherwise

compromised

The entity could determine the information was not actually acquired by an unauthorized individual, although opportunity existedBreach NotificationRisk Assessment Factor #3

58Slide59

Consider the extent to which the risk to the PHI has been mitigated:

Example: Obtain the recipient’s satisfactory

assurance that

information will not be further used or

disclosedConfidentiality AgreementDestruction, if credibleReasonable AssuranceBreach NotificationRisk Assessment Factor #4© Copyright HIPAA COW59Slide60

Evaluate the overall probability that the PHI has been compromised by considering all the factors in combination (and more, as

needed)Risk assessments should be:Thorough

Performed

in good

faith Conclusions should be reasonably based on the factsIf evaluation of the factors fails to demonstrate low probability that the PHI has been compromised, breach notification is required

Breach Notification

Risk Assessment Conclusion

60Slide61

Breach Notification

When Risk Assessment Not RequiredA

covered entity or business associate has the discretion to provide the required notifications following an impermissible use or disclosure or protected health information without performing a risk assessment

61Slide62

Guidance Specifying the Technologies and Methodologies that Render Protected Health Information Unusable, Unreadable, or Indecipherable to Unauthorized

IndividualsNo breach notification required for PHI that is encrypted in accordance with the guidance

Breach Notification

Safe Harbor

A breach is treated

as discovered:On first

day the

breach

is known to the covered entity, orIn the exercise of reasonable diligence, it should have been known to the covered entity.Notification time period for a breach begins when the organization did or should have known it existedBreach Notification

Discovery of Breach

63Slide64

How Do Privacy Violations Happen?

Fax Document to Wrong Location“Hello, this is Pizza Plaza on Stark Street. Did you mean to fax me this lab result for Fred Flintstone?”

Enter Incorrect Medical Record Number

“I guess I was just typing too fast.”

Forgetting to Verify Patient Identity“There were seven patients with the name Barney Rubble. I should have confirmed his date of birth.”© Copyright HIPAA COW64Slide65

Section VIII

Release of Information© Copyright HIPAA COW65Slide66

Release of

Information (ROI)When releasing PHI, it is important to know when a patient’s authorization is required. Patient authorizations are governed by state and federal law.

66Slide67

Release of Information

Applying the Steps

I received a request to release

PHI

. What now? Is the individual's authorization required before [Organization Name] can release PHI?Under certain circumstances (e.g., treatment, payment, or health care operations), the individual’s authorization is not required (more on this later).An authorization is required for disclosures of PHI not otherwise permitted by the Privacy Rule or more stringent state law.If so

has

the authorization been filled out completely and correctly?

67Slide68

Release of Information

Elements of a Valid Authorization

Individual's name

[Organization Name] (or

a [Organization Name] employee or department) as the party authorized to make the disclosureName of the person, organization or agency to whom the disclosure is to be madePurpose of the

disclosure

Specific

and meaningful description

of the

information

to be

disclosed

Note: If

the release includes

sensitive information (e.g., alcohol

or drug abuse

treatment records, developmental disability records, HIV test results, reproductive health), these must be affirmatively specified by the individual

The individual's right to revoke the authorization and either the exceptions on the right to revoke and a description of how to revoke or a reference to [Organization Name]’s Notice of Privacy Practices as appropriate

Statement

of the ability or inability to condition treatment, payment, enrollment or eligibility for

benefits

68Slide69

Release of Information

Elements of a Valid Authorization (cont’d)

Statement

on the potential for

re-disclosureIf the release will involve marketing remuneration to [Organization Name], a statement outlining this

If the authorization relates to Wisconsin Statute Chapter 51 treatment records, the authorization must include a statement that the

individual has

a right to inspect and receive a copy of the material to be

disclosed

Expiration

date or

event

Time period during which the authorization is

effective

Signature and

date

signed and

If signed by a

personal

representative, a description of his/her authority to

sign and relationship to individual must be provided

Must be written in plain language

If any element is missing, the authorization is not valid. Also, a

copy of the

authorization must be provided to

the

individual.

69Slide70

Release of Information

Evaluating Authorizations

Evaluating Authorizations:

Should

the access be denied? Has the access been denied?Is [Organization Name] providing only the information specified in the authorization?Is the authorization combined with another type of document to create an inappropriate compound authorization?In what form/format should the information be provided?How much time does [Organization Name] have to respond to the request?What fees can/should be applied?Note: If you are uncertain about any of these steps, ask [Organization]’s Privacy Officer.

70Slide71

Release of Information

An Authorization Mishap

The patient’s Authorization to Release Information stated only the records from 2002 to 2006 should be sent to the attorney. The Release of Information (ROI) Technician didn’t notice the limitation and sent documentation of a motor vehicle accident in 2010. She lost her court case and was fined $50,000.

The patient later filed a complaint with the ROI Technician’s employer and the Office for Civil Rights (OCR) and the ROI Technician was fired

71Slide72

Release of Information

When Authorization Not Required

Sometimes an

authorization is not

needed. Read on to learn more…….© Copyright HIPAA COW72Slide73

Release of Information

Permitted Uses and Disclosures of PHI Without Authorization

Uses and disclosures of PHI for (

TPO

):TreatmentPaymentHealth Care OperationsDisclosures required or permitted by law.If use of the information does not fall under one of these categories you must have the patient’s signed authorization (written permission) before sharing that information with anyone.© Copyright HIPAA COW73Slide74

Release of Information

When Authorization Is and Is Not RequiredWhen Authorization

Required:

Use or disclosure of psychotherapy notesExcept in limited circumstances, use and disclosure of PHI for marketing purposesWhen selling PHIWhen Authorization IS NOT Required:Disclosures to the individualUses and disclosures for treatment by your physicianUses and disclosures for quality assurance activities© Copyright HIPAA COW74Slide75

Release of Information

General Wisconsin “Confidentiality” Laws

Wisconsin

laws may require authorizations, even though HIPAA

doesn’t In 2014, Wisconsin passed the “HIPAA Harmonization Law,” at Wis. Stat. s. 146.816, which aligns Wisconsin’s confidentiality law with HIPAA for TPO uses and disclosuresThe next few slides summarize a few of the more commonly used Wisconsin confidentiality laws…© Copyright HIPAA COW75Slide76

Release of Information

General Wisconsin “Confidentiality” Laws

Statute

Summary

146.82, Wis. Stat.

Covers general medical health care PHI and authorization requirements

51.30, Wis. Stat.

Covers PHI relating to mental health, AODA, and developmentally disabled treatment, authorization requirements, and penalties

DHS 92 Adm. Code

Further covers confidentiality of mental health treatment records (with 51.30)

DHS 144, Adm. Code

Covers release of immunizations between vaccine providers, and to schools specifically for minors

76Slide77

Release of Information

General Wisconsin “Confidentiality” Laws

Statute

Summary

102.13 & 102.33 Wis. Stat.

Covers records reasonably related to a worker’s compensation claim and release to the employee (patient), employer, worker’s compensation insurer, or Department with a written request

610.70 Wis. Stat.

Covers disclosure of personal medical information by insurers

252.15, Wis. Stat.

Covers health care information relating to HIV testing and authorization requirements

77Slide78

Release of Information

Another Regulation to Consider

Statute

Summary

42 CFR, Part 2

Federal Alcohol and Drug Regulations which covers use and release of a patient’s drug and alcohol abuse records in a federally assisted program

78Slide79

Release of Information

Restrictions and Alerts

Your organization may have restrictions or alerts designed to bring an employee’s attention to specific information

For example:

Patient is adopted. Check [insert where to find flag/restriction] for special instructionsPatient has authorized spouse to receive lab results on her behalf. Check [insert where to find flag or restriction] for more information© Copyright HIPAA COW79Slide80

Release of Information

Identity Verification

Prior to releasing PHI, ask the individual to provide you with enough information to identify the patient, such as:

Name

Date of BirthAddressOther identifiers: Social security number, mother’s maiden nameIdentify someone other than the patient by requesting he or she provide you with all the above information, as well as his or her relationship to the patient.Check a physical signature against a known one on file

Make a call-back to a known

number

Ask for a photo ID

Ask for a business card

Provide only the minimum necessary to safeguard

PHI.

80Slide81

Release of Information

Authority Verification

Once you know who the requestor is, be sure he or she has the right to access this

information

Routine requests from employees you know in

[the organization]

who have

business related reason to obtain information are authorized to do so

Unusual requests from individuals you don’t know can be risky, so before sharing PHI:

Ask your

supervisor

And/or check

[organization’s] HIPAA Privacy Policies and Procedures

81Slide82

Release of Information

Individual Needs to Find Patient In Any Setting

If an individual would like to find out if a patient is in our facility, but

he or she is

not in our Facility Directory:Do not confirm or deny the patient is here until you:Obtain the names of the patient and individual making the requestInform the requesting individual that if the patient is in our facility, and agrees for us to notify them of this, you will…© Copyright HIPAA COW

Privately call the department in which the patient is located

That department should ask the patient if their location and/or condition may be released to this individual

If the patient agrees, provide information to requesting individual

If patient not in facility, or does not agree to notify the requesting individual he/she is here, inform the requesting individual that you are unable to confirm or deny whether or not the patient is in the facilitySlide83

Release of Information

Hospital Facility

Directory

Use the following protected health information to maintain a directory of individuals in its facility:

Individual’s name The individual’s location in the health care provider’s facility Individual’s general condition, no specific information The individual’s religious affiliation Use of disclosure for directory purposes of such informationTo members of the clergy; or except religious affiliation, to others who ask for individual by name

83Slide84

Release of Information

Hospital Facility Directory (cont’d)

Patients have the right to opt out of having their information disclosed from a facility

directory. There

may be State laws that also apply as to what qualifies as directory information.The patient must be provided an opportunity to express his or her preference about how, or if, facility directory information may be disclosed. Disclosure of directory information may still occur if doing so is in the individual’s best interest as determined in the professional judgment of the provider and would not be inconsistent with any known preference previously expressed by the individual. © Copyright HIPAA COW84Slide85

Release of Information

Minimum Necessary

HIPAA requires reasonable steps to limit the use and disclosures of, and requests for, protected health information to the minimum necessary to accomplish the intended purpose.

The standard does not apply to the following:

Disclosures to or requests by a health care provider for treatment purposesDisclosures to the individual subject of the informationUses or disclosures made pursuant to the individual’s authorizationUse or disclosures required for compliance with Health Insurance HIPAA administrative Simplification RulesDisclosures to the Dept. of Health and Human Services (HHS) when disclosure is required under the Privacy Rule for enforcement purposesUses or disclosures that are required by other laws © Copyright HIPAA COW

85Slide86

Release of Information

Documentation

Document the release, when required by law,

or [Organization’s] policies

Neither HIPAA nor Wisconsin law requires documentation of disclosures for purposes relating to treatment (providing and coordinating care); payment (billing for services rendered); and health care operations (internal business)HIPAA requires documentation of breaches and other releases of information© Copyright HIPAA COW86Slide87

Release of Information

Documentation (cont’d)

Why do we have to document when we release PHI (when required by law)?

Patients have the right to request

a record of what PHI was released and to whom (Accounting of Disclosures)Documentation of releases of information applies to both verbal and written disclosures © Copyright HIPAA COW87Slide88

Release of Information

Process

If you don’t know for sure if information can be released:

Don’t guess!

Contact [Organization] Privacy Officer at [insert number]Contact HIM Department at [insert number] Next, we’ll move on to some release of information examples…© Copyright HIPAA COW

88Slide89

Release of Information

Family and Friends

Verbal disclosure of information permissible when:

Patient

present and alert – patient decidesPatient incapable to make wishes known – inferred permission to discuss current careNeeded for care or paymentInformation needed for patient’s careFamily member/friend must

clearly be involved in payment for care (involvement is obvious, patient stated so

)

Notify

family or

friend(s

) who are involved

patient’s care of:

Patient’s

general

condition

Patient’s location

Patient being

ready for

discharge

Patient’s death

Disclosures of this nature exclude paper copies

89Slide90

Release of Information

Divorced Parents

A divorced parent

calls to get information on their child. Can you release it?

If the parents are divorced, either parent may get access to the records with a proper release. Assume that they can get records unless told otherwise.When parental rights are in question:Obtain the court documents for the child’s file from one of the parents.If parental rights for physical placement have been terminated, Wisconsin law allows only the parent with sole physical placement to access records.

90Slide91

Release of Information

Legal Guardians

individual calls to discuss appointment information with you for a patient and states he is the patient’s

legal guardian. May I discuss with the individual?Yes, after obtaining the court documents appointing the individual as the patient’s Legal Guardian. Make a copy of the court documents for the patient’s file. Confirm that the information being provided is appropriate and necessary. If unable to obtain court documents verifying legal guardianship, do not discuss PHI with the individual. © Copyright HIPAA COW

91Slide92

Release of Information

Step-Parents

step parent

calls to discuss her stepchild’s care. May you discuss this with her?No, unless the step-parent is a legal guardian and [Organization] has the guardianship papers on file, or a legal guardian has provided authorization. Step-parents may call to schedule appointments, but do not have access to their stepchildren’s PHI without authorization by a legal guardian.© Copyright HIPAA COW92Slide93

Release of Information

Foster Parents

What are the release of information rules for foster parents?

A foster parent must provide a copy of their WI driver’s license or state ID and one or more of the following:

Foster Parent ID Card (state-issued)Foster Parent Authorization Form (signed by biological parent or another individual of the proper authority). This form will describe the foster parent’s rights in health care situations. (Note: this may be limited)If the foster parent cannot produce these documents, are there other options?Provide [organization] with name and phone number of their [Insert County]Social

Worker[Organization]

may call the Foster Parent Intake Line at

[Insert phone number] to

confirm

[Organization]

may call either biological parent, if information available, to confirm status.

Give foster parent the

[organization] authorization form, if available, indicating

that it must be signed by a biological parent and returned to

[organization].

93Slide94

Release of Information

Power of Attorney

The Designated Agent on patient’s

power of

attorney (POA) for health care contacted me to discuss the patient’s care. May I discuss?It depends. The Designated Agent’s rights to access care, treatment and payment information are not effective until the patient is declared incapacitated by two physicians or one physician and one therapist (with few exceptions)The POA must be reviewed in detail to ensure the requested information is consistent with the rights outlined in the document. A Declaration of Incapacity Form should be submitted prior to honoring a request from the designated agent.

94Slide95

Release of Information

Disclosure of Workers’ Compensation PHI to Employer

What information can be disclosed in response to a Workers’ Compensation request?

We may disclose only

those records reasonably related to the Workers’ Compensation claim/condition without an authorizationPatient’s written authorization is required to release any PHI unrelated to the Workers’ Compensation claim© Copyright HIPAA COW

95Slide96

Release of Information

To Another Facility

Can I release a patient’s address and/or insurance information to a nursing home?

Yes, if you know the requesting individual and the request is legitimate

If you are unfamiliar with the individual requesting the information, ask for the following in writing:Patient’s name, date of birth, and addressWhy the information is neededSpecific reason (e.g. treatment or payment)

The

requestor’s name, name of the nursing home, and a direct telephone to the nursing home (switchboard

)

uncertain,

obtain patient authorization

96Slide97

Release of Information

Leaving Messages

A spouse answers the phone,

voice mail picks up. What information may I provide? State your first name and that you are calling from [Organization name] (include the site).Ask the patient to return your call, and provide your direct phone number.Do not provide lab results, or other detailed information, other than an appointment reminder.Example: “This is Sally from [Organization] calling for Johnny Doe. Please call me back at your earliest convenience at [number]. Thank you.”Ensure call is disconnected.

97Slide98

Release of Information

Item Pick Up

An individual arrives requesting to pick

up a prescription for his neighbor. Now what?

Request he provide you with the patient’s name, date of birth, address, and relationship to the patient.Confirm the patient’s and requestor’s information matches what the patient provided when informing [organization] this individual was picking up the prescription.If information is consistent, we can be assured that the patient requested prescription pick-up by this individual (according to Item Pick Up

Policy).

Request

that the individual sign

the Item Pick

orm

and provide him with the prescription.

98Slide99

Release of Information

Faxing PHI

May

PHI Be Transmitted via Fax Machine?Yes, but only when in best interest of patient care or payment of claims.Faxing sensitive PHI, such as HIV, mental health, AODA, and STD’s is strongly discouraged.It is best practice to test a fax number prior to transmitting information. If this is not possible:

Restate the fax number to the individual providing

it.

Obtain

telephone

number to contact the recipient with any questions.

Do not include PHI on the cover sheet

Verify

you are including only

correct

patient’s information (i.e.

check

the top and bottom pages).

Double check the fax number prior

to transmission

99Slide100

Release of Information

E-MailWe may

not

communicate with patients through

e-mail at this time. The patient portal will provide the opportunity to electronically communicate with our patients.When sending ePHI to other organizations for required business functions (i.e. treatment, payment or healthcare operations), encrypt the email per [organization’s] procedures.Note to Organization: Depending on your Email policy, include either this slide, or the

next, but not both

100Slide101

Release of Information

E-Mail (cont’d)

We may communicate with patients through

e-mail

only if the patient has signed the organization’s privacy and security E-Mail Agreement. When sending ePHI to anyone for treatment, payment or healthcare operations, encrypt the e-mail per [Organization’s] procedures, and verify the organization’s confidentiality disclaimer is included.

Note

to Organization:

Depending on your Email policy, include either this slide, or the

previous,

but not both

101Slide102

Section IX

HIPAA Security Rule© Copyright HIPAA COW102Slide103

HIPAA Security Rule

In general, the HIPAA Security Rule requires covered entities and business associates to do the following:Implement administrative, physical, and technical safeguards that reasonably and appropriately protect the confidentiality, integrity, and availability of electronic protected health information (ePHI) that is created, received, maintained or transmitted.

Protect against any reasonably anticipated threats or hazards to the security or integrity of ePHI.

Protect against any reasonably anticipated uses or disclosures of ePHI that are not permitted or required under the Privacy Rule.

Ensure compliance with security by its workforce. © Copyright HIPAA COW103Slide104

How We Apply the Security Rule

Administrative Safeguards

Policies and procedures are REQUIRED and must be followed by employees to maintain security (i.e. disaster, internet and e-mail use)

Technical Safeguards

Technical devices needed to maintain security. Assignment of different levels of accessScreen saversDevices to scan ID badgesAudit trailsPhysical SafeguardsMust have physical barriers and devices:Lock doors

Monitor

visitors

Secure unattended computers

104Slide105

How We Apply the Security Rule

Policies and ProceduresInternet Use

Access only trusted, approved sites

Don’t download programs to your workstation

E-MailKeep e-mail content professionalUse work e-mail for work purposes onlyDon’t open e-mails or attachments if you are suspicious of or don’t know the senderDon’t forward jokesFollow [Organization’s] policy for sending secure E-mails© Copyright HIPAA COW105Slide106

How We Apply the Security Rule

ePHI Access

How Do We Control ePHI Access?

User names and passwords

BiometricsScreen saversAutomatic logoff © Copyright HIPAA COW106Slide107

Access to

ePHI Information Access Management

[Organization]must implement technical policies and procedures for electronic information systems that maintain ePHI to allow access only to those persons or software programs that have been granted access rights as specified in the HIPAA Security Rule

107Slide108

Access to

ePHI User Names

[Organization]must assign a unique name and/or number for identifying and tracking user identity. It enables an entity to hold users accountable for functions performed on information systems with ePHI when logged into those systems.

108Slide109

Access to

ePHI Passwords

The Security Rule requires [organization] to implement procedures regarding access controls, which can include the creation and use of passwords, to verify that a person or entity seeking access to ePHI is the one claimed.

The use of a strong password to protect access to

ePHI is an appropriate and expected risk management strategy. © Copyright HIPAA COW109Slide110

What Makes a Strong Password?Use at least 6-8 characters.

Use a minimum of 2 letters and 1 number, and capital and lower case lettersUse a “pass-phrase” such as MbcFi2yo (My brown cat Fluffy is two years old)Do not use passwords that others may be able to guess:Spouse’s Name, Pet or Child’s Name

Significant Dates

Favorite sports teams

Access to ePHIUser Names and PasswordsUser Names and Passwords are required by the HIPAA Security Rule© Copyright HIPAA COW110Slide111

Workstation useRestrict viewing access to others

Follow appropriate log-on and log-off proceduresLock your workstation, press Ctrl-Alt-Del or Windows key

+ “L”

Use automatic screen savers that lock your computer when not in

useDo not add your own software and do not change or delete oursKnow and follow organizational policies If devices are lost, stolen or compromised, notify your supervisor immediately!Do not store PHI on mobile devices unless you are authorized to do so and appropriate security safeguards have been implemented by your organization

What Can I Do to

Help

Protect

Our

Computer Systems and Equipment?

111Slide112

Appropriate use of e-mail can prevent the accidental disclosure of ePHI. Some tips or best practices include:

Use email in accordance with policies and procedures defined by the [Organization].Use e-mail for business purposes and do not use e-mail in a way that is disruptive, offensive, or harmful.Verify email address before sending.

Include a confidentiality disclaimer statement.

Don’t open e-mail containing attachments when you don’t know the sender.

E-Mail Security© Copyright HIPAA COW112Slide113

The Security Rule requires organizations to implement hardware, software, and/or procedural mechanisms that record and examine activity in electronic information systems that contain or use ePHI.

Organizations should define the reasons for establishing audit trail mechanisms and procedures for its electronic information systems that contain ePHI.Reasons may include, but are not limited to, System troubleshooting

Policy enforcement

Compliance with the Security Rule

Mitigating risk of security incidentsMonitoring workforce member activities and actionsAudit Controls© Copyright HIPAA COW113Slide114

PHI Safeguarding Tips

What else can I do to protect our patients’ PHI?

Section X

114Slide115

Safeguarding PHI

Confidentiality

Securing information from improper disclosure also includes

Sharing PHI with only those that need to know (direct care workers, staff) in a discreet manner

Refraining from discussing patient visits, conditions, progress, etc. with family, friends, neighbors, and co-workers that do not have a need to knowEnsuring the disclosure of information reaches the intended person:Validating fax numbers prior to faxing PHIVerification of identity prior to releasing information without the patient presentRequesting

verbal authorization from the patient to discuss

their health, conditions, etc. with those that may

present

115Slide116

Safeguarding PHI

Availability

Ensuring those that require information for proper treatment, payment or health care operations have access to the information they need to fulfill their job obligations

Limiting the access to information to those that do not require access to perform the obligations of their job

Secure workstations by logging off, using strong passwords and keeping passwords confidential© Copyright HIPAA COW116Slide117

Safeguarding PHI

IntegrityEnsuring the electronic transmission of data is secured in a manner to protect the integrity of the data. Protecting data integrity may include using:

Secure e-mail or

Organization communication portals that transfer files within or external to the organization for treatment, payment or operation purposes

Safeguarding PHI

Family, Friends, You and PHI

not share with family, friends, or anyone else a patient’s name, or any other information that may identify him/her, for instance:

It would not be a good idea to tell your friend that a patient came in to be seen after a severe car accident. Why? Your friend may hear about the car accident on the news and know the person involvedDo not inform anyone that you know a famous person, or their family members, were seen at this organization© Copyright HIPAA COW118Slide119

Safeguarding PHI

Media and PHI

I am contacted by the media, may I release PHI to them?

If I am contacted by an individual offering to pay me for PHI, may I release it to them?No! You may not release PHI under either of these circumstances. Both are grounds for disciplinary action.Refer the requestor to the Privacy Officer.© Copyright HIPAA COW119Slide120

Safeguarding PHI

Delivery of PHI

need to transport paper records/PHI to another department.

Is this okay?Yes, you may transport documents to another department. Secure so you don’t drop them:Carry them close to your person.Carry them in a facility designated bag, box, or container.Ensure no names are visible.Ensure

no records are left unattended.

120Slide121

Safeguarding PHI

Transporting PHI OffsiteWhen

necessary to transport PHI externally:

Place in a locked briefcase, closed container,

sealed, self-addressed interoffice envelope;Place PHI in the trunk of your vehicle, if available, or on the floor behind the front seat;Lock vehicles when PHI is left unattended[Include if this applies to your organization]: You may not transport patient charts between departments or offsite unless authorized by the Director of Health Information Management.© Copyright HIPAA COW

121Slide122

Safeguarding PHI

Inter-Office Mail and PHI

Send

all PHI in sealed

Inter-Office envelopesVerify all PHI was removed from the envelope before stuffing itAddress to correct

individual and

department

Mark the envelope “

confidential”

Confirm you are

sending

correct

PHI

122Slide123

Safeguarding PHI

Paper

Turn

over/cover PHI when you leave your desk/cubicle so others cannot read it.

If you have an office, you have the option of closing your door instead.Turn over/cover PHI when a coworker approaches you to discuss something other than that PHI.

Don’t

leave documents containing PHI unattended in fax machines, printers, or copiers.

Check your fax machine frequently so documents are not left on the machine.

123Slide124

Safeguarding PHI

Disposal

How

should I dispose of confidential paper?

Shred or place all confidential paper in the designated confidential paper bins.How should I dispose of electronic media (floppy disk, CD, USB Drive, etc.)?Provide electronic media to the IS Department for proper disposal© Copyright HIPAA COW124Slide125

Facility

SecurityProtecting Our Patient’s Physical Security

How

can I help protect our facilities?

Wear your ID Badge at all times (helps identify you as an [Organization] employee/provider).Only let employees enter through employee entrances with you.Keep hallway doors that lead to patient care areas closed.Request vendors and contracted individuals to sign-in and obtain Vendor ID Badges when visiting a restricted area.© Copyright HIPAA COW125Slide126

What are Restricted Areas?

Restricted areas are those areas within our facilities where PHI and/or organizationally sensitive information is stored or utilizedReceptionist stations

Business office windows

HIM

DepartmentPatient care hallways/treatment areasOfficesStorage closets and cabinetsAccounting, Human Resources, Administration Offices, IS Department, etc.Employee meeting/rooms/kitchens in the departmentsAreas containing potential safety hazards (ex. medical imaging, lab, nuclear medicine, etc.

you see someone in a restricted area not wearing a badge, kindly ask “May I help you

?” Then escort

the individual out of the restricted area and to the

area

he/she is visiting.

126Slide127

Business Associate Agreements

127Slide128

Business Associate Agreements

If you initiate negotiations to contract with a company to perform, or assist in the performance of a function or activity involving the use or disclosure of PHI, please contact the [Organization Privacy Officer] to obtain a Business Associate Agreement (BAA).

Examples

of when to obtain a BAA with a company include:

Claims processing or administration, data analysis, processing or administration, utilization review, quality assurance, billing, benefit management, practice management, and repricing; and Legal, actuarial, accounting, consulting, data aggregation, management, administrative, accreditation, or financial services.© Copyright HIPAA COW128Slide129

Business Associates Include

Companies that “maintain” PHI on behalf of a Covered Entity (CE)

Data storage company

Patient safety organizations

Business Associates

(cont’d)Business Associates Also Include:Personal Health Record vendors

Subcontractors to Business Associates that create, receive, maintain or transmit PHI on behalf of the Business Associate.

130Slide131

Business Associates

(cont’d) Requirements

Limit

uses and disclosures of PHI to minimum

necessaryEnter into a BAA with their subcontractorsComply with the BAA and the same HIPAA; administrative, physical and technical safeguard rules as covered entities (CEs)Report to CE Breach of Unsecured

PHI

Comply

with Privacy Rule to extent

must carry out a CE’s obligation under Privacy

Rule

131Slide132

Other Confidentiality Agreements

When initiating a contract with a company to perform work for [organization] which will not

have direct access to PHI, request a Confidentiality Agreement be signed and forwarded to the [Organization Privacy Officer].

132Slide133

Section XII

HIPAA Violations and ComplaintsSlide134

HIPAA and Your Role

Remember, it is your responsibility, as a [Organization] employee or provider, to comply with all privacy and security laws, regulations, and [Organization’s] policies pertaining to them.Employees and providers suspected of violating a privacy or security law, regulation, or [Organization] policy are provided reasonable opportunity to explain their actions.

Violations of any law, regulation, and/or [Organization] policy will result in disciplinary action, up to and including termination, according to [Organization] HR Policy #.

134Slide135

HIPAA Violations

Three types

of violations:

IncidentalAccidentalIntentionalInsert [Organization’s] policy regarding types of violations and levels disciplinary action provided.How much is enough?

How much is too much?

135Slide136

Incidental Violations

If reasonable steps are taken to safeguard a patient’s information and a visitor happens to overhear or see PHI that you are using, you will not be liable for that disclosure.Incidental disclosures are going to happen (even in the best of

circumstances).

incidental disclosure is not a privacy incident and does not require documentation

136Slide137

Accidental Violations

Mistakes happen. If you mistakenly disclose PHI or provide confidential information to an unauthorized person or if you breach the security of confidential data, you must

Acknowledge the mistake and notify your supervisor and the Privacy Officer immediately.

Learn from the error and help revise procedures (when necessary) to prevent it from happening again.

Assist in correcting the error only as requested by your leader or the Privacy Officer. Don’t cover up or try to make it “right” by yourself.Accidental disclosures are privacy incidents and must be reported to your Privacy Officer immediately! Documentation of Accidental Disclosures is required.

137Slide138

Intentional Violations

If you ignore the rules and carelessly or deliberately use or disclose protected health or confidential information, you can expect:Disciplinary action, up to and including termination

Civil and/or criminal

charges

Examples of Intentional Violations of Privacy Include: Accessing PHI for purposes other than assigned job responsibilitiesAttempting to learn or use another person’s access informationIf you’re not sure about a use or disclosure, check with your Supervisor or the Privacy Officer© Copyright HIPAA COW

138Slide139

Reporting HIPAA Violations

If you are aware or suspicious of an accidental or intentional HIPAA violation, it is your responsibility to report it.

[Organization] may not intimidate, threaten, coerce, discriminate against, or take other retaliatory action against anyone who in good faith reports a violation (whistleblowing).

Refer to the [HIPAA Intranet page] for more examples of what to report.

It’s Important!

You Must Report HIPAA Violations

So they can be investigated, managed, and

documented

So they can be prevented from happening again in the futureSo damages can be kept to a minimumTo minimize your personal riskIn some instances, management may have to notify affected parties of lost, stolen, or compromised data

Incidental

disclosures need not be reported, but if you’re not sure, report them

anyway

140Slide141

Patient Complaints

All Privacy Complaints Must Be Reported

We Must

espond to Privacy and Security Complaints

141Slide142

How

Do I Report HIPAA

Privacy

Violations?Directly to your Supervisor, who in turn reports it to the [Organization’s] Privacy OfficerCall or email the Privacy OfficerComplete a HIPAA Incident Report form (#) which is located [on the HIPAA Intranet page]Email the internal “HIPAA Hotline” email

group

Note

: this is

not

anonymous as the sender will be

known

Leave a message on the HIPAA Hotline

[

insert

142Slide143

Same as for Privacy

Violations, except instead of reporting to the Privacy Officer, report to the [Organization’s] HIPAA Security OfficerYou may also call or email the

[Organization’s] Technical

Security Officer, Information Services Help Desk, or Director of Information

ServicesHow Do I ReportHIPAA Security Violations?

143Slide144

HIPAA Information

Want More Information About HIPAA Privacy and Security?

Check

out our website

at www.hipaacow.com

144Slide145

Comments or Questions?

Contact your Privacy

Officer at:

(phone)

(pager) (email)Contact your Security Officer at: (phone) (pager) (email)

Not sure which way to go?

145Slide146

Section XIII

Discussion SlidesSlide147

I Got the Fever!

And I Got Here First

Your daughter’s school just called. She has a fever and you need to pick her up immediately. You know she’ll need to see her pediatrician (who just happens to work down the hall) so you access her medical record to schedule an appointment quick before another patient gets the available time slot. Is this access permissible?

Does it make a difference if your daughter has a different last name than you?

I Know Something You Don’t Know!

You’re a Lab Technician. You just processed a positive blood alcohol test for a patient you later learned was your neighbor’s soon-to-be ex-husband. This information will be very useful in court to strengthen her case for full custody of the kids. Can you disclose the information to your neighbor?

148Slide149

I Was Just Concerned!

Your co-worker, Joan, hasn’t been at work the last 3 days and you’re starting to get worried about her. You consider her a friend and conclude she’d be hurt if you don’t call her. Y

ou don’t have her phone number. But it’s in the electronic medical record! You wait until your supervisor goes to lunch, log on and look up Joan’s phone number. Is this ok?

Consider This:

While looking up her phone number you notice she has a diagnosis of breast cancer on her problem list.© Copyright HIPAA COW149Slide150

I Just Needed a Gallon of Milk!

You’re a RN at the downtown clinic. This morning you saw 6-year old, Allison for a strep test. On the way home from work you you stop at Woodman’s for a few things. Walking through the Frozen Foods, you run into Allison’s mom, Sherry.

“I’m so glad I ran into you! Did you get the strep results yet? It would be great if I knew now so I could pick up the prescription tonight, get her started on the antibiotics and back to school sooner”. Can you disclose to Allison’s mom?

150Slide151

As The World Turns

You’re a CMA at the downtown clinic. You recently started dating the spouse of one of clinic patients and it’s gotten pretty serious. He has a teenage daughter being seen for mental health treatment at your west clinic and his wife comes in regularly to your clinic (she’s probably a hypochondriac) but you’re not usually the nurse for these visits. You’re very interested in tracking what’s going on with mom and daughter, not because you want to do anything with the information, you’re just plain curious. You have a routine now to look at their medical records every Tuesday at noon when your supervisor is in a meeting. Is this a good idea?

Consider This:

What if you are actually the nurse taking vital signs when his wife comes in so you have a legitimate right to access her record. Except you’re looking at it any time you want—you’ll never get caught since you do have a “legitimate” right to access.

I Have a Right to Know!

Mr. Albertson is on the phone. He states his wife was in the clinic yesterday for lab testing and he wants you to tell him the results of the urinalysis immediately. You explain that his wife has individual privacy rights and such information can be disclosed only to her. You suggest he talk directly to her. He is very angry! “I have a right to know since I pay the bills. I’m going to report you for a HIPAA violation.” Should you cave and tell him?

Consider This

: Upon review of Mrs. Albertson’s record, you see a signed authorization permitting the clinic to exchange PHI with Mr. Albertson regarding her care and treatment. Does this change your response?

No Harm No Foul?

The OB Department is crazy busy this morning. As a nurse you’re running from one crisis to another.

Around 11:00 am you finally get a breather and leave for a cup of coffee. While you’re usually diligent about securing your computer when you walk away, this time you were so distracted you forgot. Your computer is logged on to two patient records, one of whom is the wife of the hospital administrator who had a miscarriage. When you return from break, a receptionist is sitting at your desk intently reading the screen.

Will you confront her?

Self-report the incident to the Privacy Officer? Ignore her and walk away until she leaves. Make a deal with her, you won’t tell if she doesn’t

Consider This: Who is subject to disciplinary action in this case? You? The receptionist or both of you?

153Slide154

How Much is Too Much?

You are a coder at ABC Memorial Hospital. You’re reviewing a complex case for documentation to support a higher level of service. It’s a priority as part of the Coding Team to ethically make this determination and a commitment you take seriously. You’re going to have to conduct a detailed review of the medical record. This is time consuming and it becomes evident that you’re seeing a lot of confidential information unnecessary for the proper code assignment. Have you violated the minimum necessary policy?

Consider This

: The patient is also an employee at the hospital, someone with whom you’ve had a few disagreements and about whom you have engaged in gossip. You know better than to share this information with anyone but a week later she confronts you about a work problem and you accidentally say “Too bad, you probably just forgot to take your Prozac this morning.”

Maroon 5’s newest song is amazing---I could listen to it all day long!

Cool Stuff to Personalize My ComputerAre These Good

deas?

That screen saver with the bubbles? I love it and I want it!

I’m a gamer addicted to “Wild Robots of the World V2.” There’s no reason I can’t load it onto my work computer so I can play during breaks and lunch.

My sister’s wedding last weekend was just gorgeous and the pictures prove it. I was able to load all the pictures from the ceremony and the reception on my work computer. One’s even my home screen. So, my computer crashed when I was loading them. I booted and now they seem just fine.

Consider This:

I spend most of my life sitting in front of this computer. The least they can do is let me do stuff to enjoy it!

155Slide156

We Must Respect Each Other’s Jobs

As your employer, we appreciate that you want to personalize your workstation. We value your individuality. It’s one of the things that makes you a great employee!

You can feel free to bring framed pictures of your family and friends, posters and desk items to create a pleasant work environment.

However, your computer is a different story

Loading music, screen savers, game and photos can slow down our systems, including the effectiveness and quality of medical records and financial data

Unapproved tools such as software, downloads, CDs, or flash drives may damage or increase likelihood of unauthorized events such as hacking, viruses and Trojan Horses

Just as you don’t want another department to come into your office and start changing things around, the Information Services Department doesn’t want you to compromise the things they do to keep electronic systems effective and safe

Organizational policy is clear. You may not add such tools without written permission from the Information Services Department

156Slide157

How Do Privacy Violations Happen?

Assuming the auto lock would activate soon, the nurse did not lock her computer when she left the patient in an exam room. While waiting, the patient got bored with the old magazines in the room and looked at her electronic record. Not only did the patient see her prescription for Prozac and diagnosis of depression, but she also read her psychotherapy notes.

Discussion points:

What is [Organization Name]’s policy on locking computers?

Why are psychotherapy notes included in this patient’s EMR?What is [Organization Name]’s policy on workforce members accessing sensitive information?What is [Organization Name]’s policy for patients to request copies of their records?© Copyright HIPAA COW

157Slide158

How Do Privacy Violations Happen?

Katie, a billing department employee, saw her son’s girlfriend, Allison, in the hospital. Katie was concerned that Allison was ok so she looked at Allison’s medical record. Katie was upset when she saw that Allison was diagnosed with a heart murmur. Katie texted her son this information. When Katie got home, she learned that Allison read Katie’s text message and had already called the hospital to file a privacy complaint.

Discussion points:

Does it matter that Katie meant well?

What is [Organization Name]’s policy for accessing medical records?What is [Organization Name]’s policy for role-based access control?What is [Organization Name]’s policy for snooping discipline?© Copyright HIPAA COW

158Slide159

Calling All Privacy & Security Professionals!

Privacy & Security Professionals Must Keep the Pace:

Stay tuned in, ensure

nderstanding and be heard!Anticipate how privacy and security protections must change to accommodate technologyHow will audit trails work?Some Facts:Emerging electronic technology impacting privacy and security is a realityIt’s getter smarter and smarter & faster and fasterIt’s not just desktops and laptops—today we have tablets, iPads, iPhones, Androids, remote

monitoring of health conditions, HIE’s, eVisits, Work-at-Home, Apps, GPS, and cameras recording us shopping, driving, walking, banking, and grocery shopping

159Slide160

HIPAA COW

Privacy and Security Networking Groups

We are pleased to provide our peers and colleagues with this training module.

We hope you find it useful as you develop your organization’s privacy training.

Refer to the HIPAA COW website for additional privacy, security, and EDI reference materials http://hipaacow.org/home/home.aspx © Copyright HIPAA COW

160Slide161

Prepared by:

Reviewed by:

Content Changed:

Primary Author: Barbara J. Zabawa, JD, MPH, The Center for Health Law Equity, LLCContributing Authors: Karin Butikofer, Athletico Physical TherapyJulie Coleman, Group Health Cooperative of South Central Wisconsin

Chris Duprey,

Caris

Innovation

Cathy Hansen,

RHIA, Director, Health Information Services & Privacy Officer, St. Croix Regional Medical Center

Teresa

Hernandez,

HSHS

Mary Koehler, IT Security Regulatory Coordinator, ProHealth Care Information Technology

Meghan

O’Connor,

von Briesen & Roper, S.C.

Kathy

Schleis,

Bellin Health System

HIPAA COW Privacy & Security Networking Groups

This

document was updated to reflect changes required by the HITECH Act from 2009 and the subsequent rules that went into effect in 2013, as well as to reorganize and refresh the slides.

Current

Version:

4/8/15

Version HistorySlide162

Original Version: 3/31/09

Prepared by:

Reviewed by:

Primary Author: Holly Schlenvogt, MSH, ProHealth Care Medical Associates, Privacy OfficerContributing Authors: Cami Beaulieu, Red Cedar Medical Center, ROI Supervisor and Privacy AssistantJane Duerst Reid, RHIA, Clear Medical Solutions, HIM Consultant Linda Huenink, MS, RHIA, Wk Co. Dept. of Health & Human Services, Records Supervisor

Carla Jones, Senior Staff Attorney/Privacy Officer, Marshfield Clinic Legal Service

Kathy Johnson, Privacy & Compliance Officer, Wisconsin Dept. of Health Services

Melissa Meier, ProHealth Care Medical Associates, Corporate Compliance Coordinator

Kim

Pemble

, Executive Director, WI Health Information Exchange (WHIE)

LaVonne

Smith, Information Services Director, Tomah Memorial Hospital

HIPAA COW Privacy & Security Networking Groups

Version History (Cont’d.)

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