HIPAA Privacy and Security - PowerPoint Presentation

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HIPAA Privacy and Security

Annual Renewal Training For EmployeesCompliance is Everyone’s Job

For UA Health Care Components, Business Associates & Health Plans2018 v1

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What is HIPAA?

The Health Insurance Portability and Accountability Act (HIPAA) is federal legislation which addresses issues ranging from health insurance coverage to national standard identifiers for healthcare providers. The portions that are important for our purposes are those that deal with protecting the privacy (confidentiality) and security (safeguarding) of health data, which HIPAA calls Protected Health Information or PHI.

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What is Protected Health

Information? (PHI)Any information, transmitted or maintained in any medium, including demographic informationCreated/received by covered entity or business associateRelates to/describes past, present or future physical or mental health or condition; or past, present or future payment for provision of healthcare; and Can be used to identify the patient

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Types of Data Protected by

HIPAAWritten documentation and all paper recordsSpoken and verbal information including voice mail messagesElectronic databases and any electronic information, including research information, containing PHI stored on a computer, smart phone, memory card, USB drive, or other electronic devicePhotographic imagesAudio and Video recordings

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To De-Identify Patient Information You Must Remove All 18

IdentifiersNamesGeographic subdivisions smaller than state (address, city, county, zip)All elements of DATES (except year) including DOB, admission, discharge, death, ages over 89, dates indicative of ageTelephone, fax, SSN#s, VIN, license plate #sMed record #, account #, health plan beneficiary #Certificate/license #s

Email address, IP address, URLsBiometric identifiers, including finger & voice printsDevice identifiers and serial numbers Full face photographic and comparable imagesAny other unique identifying #, characteristic, or code

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UA HIPAA

SanctionsEmployees, students, and volunteers who do not follow HIPAA rules are subject to disciplinary action.UA sanctions depend on severity of violation, intent, pattern/practice of improper activity, etc., and might include:Dismissal from academic programTermination of employmentSuspension without payDenial of an annual raise or reduction in payCivil and/or criminal penalties including incarceration

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Notice of Health Information

PracticesExplains how the covered entity will use/disclose patient’s PHIExplains a patient’s rights and where to file a complaintIs offered to a patient at the time of the first visit (and patient should sign & date acknowledgement of receiving at time of first visit)Is posted on facility’s web page and in patient reception area

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TPO as Permitted Use

andDisclosure of PHIPHI may be used and disclosed to facilitate TPO, which means:For TreatmentFor PaymentFor certain healthcare Operations, such as quality improvement, credentialing, compliance, and patient/employee safety activities

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Authorizations and Patient’s Right to Access their PHI as Permitted Use and Disclosure of PHI

A covered entity may generally use and disclose PHI to a third party if it gets the patient’s signed HIPAA-valid authorizationHowever, a HIPAA authorization form should

not be used when a patient asks for a copy of their PHI for themselves or to be sent to a third party – in that case, use a Patient Request for Health Information Form

It is a HIPAA violation to use the wrong form in this circumstance (the regulations require different information on each form)

The fees that can be charged for a copy of a patient’s PHI or record differs based on whether the records are being released per an Authorization or a Patient’s Request

A covered entity can only charge a reasonable, cost-based amount when a patient requests the records – It is permissible to charge up to $6.50 for a flat fee for electronic copies (for labor, supplies and postage)

Only designated, HIPAA-trained personnel are permitted to approve disclosure of PHI per the person’s HIPAA-valid authorization or Patient Request for Health Information Form

For any questions concerning releases pursuant to a HIPAA authorization or Patient Request for Health Information Form, please contact your Privacy Officer

For a complete list of permitted uses and disclosures of PHI without the patient’s authorization, see your entity’s Notice of Health Information Practices

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Can Family/Friends Know

?Yes, but only PHI directly relevant to that person’s involvement with the patient’s healthcare or payment related to patient’s healthcare.And, only if the provider reasonably infers that the patient does not object.INTERNAL USE ONLY

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Minimum Necessary

StandardWhen HIPAA permits use or disclosure of PHI, a covered entity must use or disclose only the minimum necessary PHI required to accomplish the purpose of the use or disclosure.The only exceptions to the minimum necessary standard are those times when a covered entity is disclosing PHI for the following reasons:TreatmentPurposes for which an authorization is signedDisclosures required by lawSharing information to the patient about himself/herself

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Other Privacy

SafeguardsAvoid conversations involving PHI in public or common areas such as hallways or elevators.Keep documents containing PHI in locked cabinets or locked rooms when not in use.During work hours, place written materials in secure areas that are not in view or easily accessed by unauthorized persons.Do not leave materials containing PHI on desks or counters, in conference rooms, on fax machines/printers, or in public areas.

Do not remove PHI in any form from the designated work site unless authorized to do so by management.Never take unauthorized photographs in patient care areas including audio and video.

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Patient Rights Under HIPAA

The Notice of Health Information Practices outlines the patient’s following rights to:Restrict disclosure of PHI to health plan if patient pays out of pocket in full for the healthcare item/serviceLook at and obtain a copy of record/PHI or ePHI or request that a copy of their record be sent to their attorney, insurance company, or a third partyRemember, the patient should not have to fill out a HIPAA authorization for this purpose – a verbal request is fine, but should be documented. 

A patient’s request to direct PHI to another person must be in writing, signed by the individual and clearly identify the designated person and where to send the PHI (i.e., Patient Request for Health Information form)Remember that the only charge to a Patient exercising their right to a copy of the record is a reasonable, cost-based amount ($6.50 flat fee for electronic copy) Amend incorrect or misleading information in record

Receive an accounting of disclosures of PHI

Be notified of a breach of PHI

File a

complaint

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HIPAA Put New Requirements on

ResearchIf you work for a HIPAA-covered Health Care Provider, do not release PHI for research unless:The patient has signed a valid HIPAA authorization, orThe Institutional Review Board (IRB) at UA has approved a waiver of authorization; or The IRB agrees that an exception appliesInformation regarding HIPAA and Research is available through UA’s Office for Research Compliance.

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Business Associate (BA)

AgreementsAre required before a covered entity can contract with a third party individual or vendor (subcontractor) to perform activities or functions which may involve the use or disclosure of the covered entity’s PHILaw now requires BA to comply with certain Privacy and Security rules & subjects BA to HIPAA criminal and civil penalties.BA also subject to breach of contract claims BA Agreement must be approved in accordance with appropriate UA policies and procedures Individual employees are NOT authorized to sign contracts on behalf of UA.

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What is a Breach?

Breach is defined as the unauthorized acquisition, access, use, or disclosure of unsecured PHI which compromises the security or privacy of the information.Impermissible use or disclosure is presumed to be a breach unless the facility or business associate proves that there is a low probability that PHI has been compromised.INTERNAL USE ONLY

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What Constitutes a Breach

?A breach could result from many activities. Accessing more than the minimum necessaryFailing to log off when leaving a workstationUnauthorized access to PHISharing confidential information, including passwordsHaving patient-related conversations in public settingsImproper disposal of confidential materials in any formCopying or removing PHI from the appropriate

areaWhy?Curiosity…about a co-worker or friendLaziness…so shared sign-on to information systemsCompassion…the desire to help someoneGreed or malicious intent…for personal gain

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Risk Assessment

RequiredTo assess the probability that PHI has been compromised, we are required to consider:The nature and extent of PHI and likelihood of re-identification (credit card/SSN, etc.)Unauthorized person who used PHI or to whom disclosure was madeWhether PHI was actually acquired or viewedThe extent to which the risk of PHI has been mitigated (recipient destroyed it)

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Breach Notification

RegulationsIf it is determined that a breach of PHI occurred, then the covered entity must notify the affected individual (or next of kin) without unreasonable delay, but not later than 60 calendar days from discovering the breach.Time runs when incident

first known or reasonably should have been known (true for covered entity and business associate), NOT when it is determined that a breach occurred. Breach is treated as discovered when workforce member or other agent has knowledge of incident.That means an employee or volunteer must IMMEDIATELY report!Delay permissible in certain circumstances where law enforcement has requested a delay.

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Responsibility to Report

PromptlyWhen receiving a privacy complaint, learning of a suspected breach in privacy or security, or noticing something is “just not right,” we must work together.If you notice, hear, see, or witness any activity that you think might be a breach of privacy or security, please let your organization’s privacy and/or security officer know immediately. It is much better to investigate and discover no breach than to wait and later discover that something

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Security Standards – General

RulesHIPAA security standards ensure the confidentiality, integrity, and availability of PHI created, received, maintained, or transmitted electronically (PHI –Protected Health Information) by and with all facilities.Protect against any reasonably anticipated threats or hazards to the security or integrity or such information.

Protect against any reasonably anticipated uses or disclosures of such information that are not permitted.INTERNAL USE ONLY

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Rules for

AccessAccess to computer systems and information is based on your work duties and responsibilities.Access privileges are limited to only the minimum necessary information you need to do your work.Access to an information system does not automatically mean that you are authorized to view or use all the data in that system.

Different levels of access for personnel to PHI is intentional.If job duties change, clearance levels for access to PHI is re-evaluated.

Access is eliminated if employee is

terminated.

Accessing PHI for which you are not cleared or for which there is no job-related purpose will subject you to

sanctions.

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Rules for Protecting

InformationDo not allow unauthorized persons into restricted areas where access to PHI could occur.Arrange computer screens so they are not visible to unauthorized persons and/or patients; use security screens in areas accessible to public.Log in with password, log off prior to leaving work area, and do not leave computer unattended.Close files not in use/turn over paperwork containing PHI.

Do not duplicate, transmit, or store PHI without appropriate authorization.Storage of PHI on unencrypted removable devices (Disk/CD/DVD/Thumb Drives) is prohibited without prior authorization. Consider using UA Box.

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Encryption of

PHIElectronic protected health information must be encrypted when stored in any location outside the EHR including desktops, laptops, and other mobile devices (thumb drives, CDs, DVDs, smart phones, email, cloud storage devices (e.g. UA Box), etc.). Use of other mobile media for accessing and transporting PHI such as smart phones, iPads, Netbooks, thumb drives, CDs, DVDs, etc., presents a very high risk of exposureUse of personal computers or other personal electronic equipment (non-UA owned equipment) is not allowed to store protected health information. Any exceptions must be approved by senior leadership or in compliance with your entity's portable device guidelines. Due to a lack of infrastructure and control of delivery, the use of unencrypted text messaging of any protected health information is strongly discouraged. Text messaging of medical orders is prohibited

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Password

ManagementDo not allow coworkers to use your computer without first logging off your user account.Do not share passwords or reuse expired passwords.Do not use passwords that can be easily guessed (dictionary words, pets name, birthday, etc.).Should not be written down, but if writing down the password is required, must be stored in a secured location.

Should be changed if you suspect someone else knows it.Disable passwords or delete accounts when employees leave.Passwords:Should be minimum 8 characters longInclude 3 of 4 data types (upper/lower case, numeric, special characters)

Should be changed periodically

Good password scheme is critical for complex passwords – R0llt!de (don’t use this, just an example

)

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Protection from Malicious

SoftwareMalicious software can be thought of as any virus, worm, malware, adware, etc. As a result of an unauthorized infiltration, PHI and other data can be damaged or destroyed.Notify your supervisor, system support representative, and/or security officer immediately if you believe your computer has been compromised or infected with a virus—do not continue using computer until resolved.Managed anti virus and other security software is installed on all University computers and should not be

disabled.Any personal devices used for access to PHI must have appropriate anti virus software .Do not open e-mail or attachments from an unknown, suspicious, or untrustworthy source or if the subject line is questionable or unexpected—DELETE THEM IMMEDIATELY.

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Ransomware

Ransomware is malicious software that denies access to data, usually by encrypting the data with a private encryption key that is only provided once the ransom is paid.  Presence of ransomware (or any malware) on a covered entity’s or business associate’s computer systems is a security incident. Whether it results in an impermissible disclosure of PHI and/or a breach depends on the facts and circumstances of the attack.When ePHI

is encrypted due to a ransomware attack, a breach has occurred because the ePHI was acquired.Once the ransomware is detected, we must initiate our security incident response and reporting procedures.

If computer with encrypted data is powered on and the operating system loaded, the data is decrypted and breach notification may need to

occur.

Notification of a breach of unencrypted or decrypted data must occur unless there is a  “low probability the PHI has been compromised”

Maintaining frequent backups and ensuring ability to recover data from backups may show low probability (if no exfiltration of PHI

).

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Beware of Suspicious

EmailsBe very cautious of suspicious emails that request information such as email ID and password, or other personal information claiming that you need to verify an account, or you are out of disk space, or some other issue with your account. If they claim to come from the University check the following:From Address: Make sure the from address has ua.edu after the @URL Link: If you can see the URL in the message, make sure it has ua.edu before the first slash (/)

Hover trick: If you can’t see the URL, you can hover your mouse pointer over the link without clicking, and a box with the URL will appear. Check for ua.edu

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Use of

TechnologyUse of other mobile media for accessing and transporting PHI such as smart phones, iPads, Netbooks, thumb drives, CDs, DVDs, etc., presents a very high risk of exposure and requires appropriate authorization.Email, internet use, fax and telephones are to be used for UA business purposes (see UA policies). Fax of PHI should only be done when the recipient can be reliably identified; Verify fax number and recipient before transmitting.No PHI is permitted to leave facility in any format without prior

approval. Where technically feasible, email should be avoided when communicating unencrypted sensitive PHI - follow your organization’s email policy for PHI.No PHI is permitted on any social networking sites (Twitter, Facebook, etc.) without appropriate authorization.

No PHI is permitted on any texting or chat

platforms.

If

a situation requires use of email or text, appropriate encryption techniques must be used.

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Rules for Disposal of Computer

EquipmentOnly authorized employees should dispose of PHI in accordance with retention policies.Documents containing PHI or other sensitive information must be shredded when no longer needed. Shred immediately or place in securely locked boxes or rooms to await shredding.All questions concerning media reallocation and disposal should be directed to your HIPAA Security Officer; OIT systems representatives or your departmental IT support teams are responsible for sanitization and destruction methods.Media, such as CDs, disks, or thumb drives, containing PHI/sensitive information must be cleaned or sanitized before reallocating or

destroying.“Sanitize” means to eliminate confidential or sensitive information from computer/electronic media by either overwriting the data or magnetically erasing data from the media.If media are to be destroyed, then once they are sanitized, place them in specially marked secure containers for destruction.

NOTES: Deleting a file does not actually remove the data from the media. Formatting does not constitute sanitizing the

media.

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Reporting Security

IncidentsNotify your Security Officer of any unusual or suspicious incident.Security incidents include the following:Theft of or damage to equipmentUnauthorized use of a password

Unauthorized use of a systemViolations of standards or policyComputer hacking attemptsMalicious software Security Weaknesses

Breaches to patient, employee, or student privacy

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UA

ContactsKnow Your Security and Privacy OfficerUniversity-wide Privacy Officer: Jan ChaissonUniversity-wide Security Officer: Ashley EwingUniversity Medical Center Privacy Officer: Jan Chaisson

University Medical Center Security Officer: Amy SherwoodBrewer Porch Privacy/Security Officer: Warren WilliamsSpeech and Hearing Privacy/Security Officer: JoAnne PayneAutism Spectrum Disorders Clinic Privacy/Security

Officer:

JoAnne Payne

UA

Group Health

Plan/FSA

Privacy

Officer: Emily

Marbutt

UA Group Health

Plan/FSA

Security

Officer: Greg

Gaddis

Working on Womanhood Program (WOW) Privacy/Security

Officer: Jill

Beck

Center for Advanced Public Safety (CAPS) Privacy/Security

Officer: Vaughn

Poe

Institutional Review Board Compliance

Officer: Tanta Myles

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