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HIPAA Basic Trainingfor
Privacy and Information Security
Vanderbilt University Medical Center
VUMC HIPAA Website: www.mc.vanderbilt.edu/HIPAA
HIPAA Basic Training
Vanderbilt Credo“We treat others as we wish to be treated”
Vanderbilt Credo Behavior“I respect privacy and confidentiality”
What is HIPAA?
What Does HIPAA Do?Limits how we use and share patient information
Gives patients more control over their information
Protects the integrity, availability and confidentiality of patient information
Defines violation penalties
Health Insurance Portability and Accountability Act of 1996
What is Protected under HIPAA?
Individually identifiable health information: That is collected from an individual, or
That is created or received by A health care provider
Employer
Health insurer’s plan
This information can be in any form:
Written, verbal, or electronic
Information pertaining to HIV, alcohol and drug treatment, psychotherapy notes, etc.
have even more stringent protections.
What is Protected under HIPAA?
Patient Rights
ALL Patients have the right to:
Receive a Notice of Privacy Practices that describes how we use and share their information
Review and obtain copies of their medical and financial records
Request amendments to their medical record if they believe information is incorrect or missing.
HIPAA regulations provide individuals with certain rights that are reflected in VUMC
policy.
Sharing Patient Information
Treatment (physicians involved with care, family members involved in patient’s care, etc.)
Payment (insurance companies, other third parties)
Administrative functions (QI, financial analysis, educational or training activities
Other specific exceptions (required by law, Department of Public Health)
You must obtain patient authorization except in the following circumstances:
Protecting the Privacy of Patient Information
Only share patient information with other faculty and staff who need the information to do their job.
Avoid accessing a patient’s record unless you need to do so for your job or you have written permission from the patient.
You are not allowed to access the record of your co-worker, spouse, or family member unless there
is written authorization in the patient’s record.
Key Information Security Practices
Passwords & Electronic Signatures
Logging Off/Locking Computers
E-mailFiles
PasswordsWeb sites
Passwords and Electronic Signatures
DO choose ones that you can remember
DO remember that the longer they are, the better
DO use numbers, uppercase and lowercase letters, and special symbols to create them, where allowed
Some Do’s related to passwords and electronic signatures.
Some Don’ts related to passwords and electronic signatures.
DO NOT share them with anyone
DO NOT write them down where others can see them or store them where others can access them
DO NOT use words, names, or personal data others may guess, such as the name of your pet.
Passwords and Electronic Signatures
Logging Off Computers
Log Off OR\Lock the computer screen
If you need to walk away from a computer you are using, always:
E-mail sent over the Internet is generally unencrypted and not secure.
Find alternative ways to communicate confidential information
(e.g., encryption, MyHealthAtVanderbilt, password protected files, VPN)
Limit the amount of patient information.
Beware of E-mail Attachments!
Auditing
The Privacy Office conducts audits daily on the medical records of employees who come to the hospital to monitor for inappropriate access.
Audits are also conducted whenever a patient suspects that their medical record may have been inappropriately accessed.
Sanctions for Privacy and Information Security Violations
VUMC considers it a serious incident anytime that a privacy or security violation occurs.
HIPAA requires that we monitor information system activity which assists in identifying violations and that we document all incidents.
Disciplinary/corrective action ranges from training/counseling to termination.
What Should Be Reported?
Privacy and Security Violations:
Looking at someone else’s confidential data
Paperwork with patient information lying around unattended
Sharing passwords or electronic signatures or the use of another employee’s password or electronic signature
Privacy Office (936-3594) or e-mail [email protected]
Help Desk 343-HELP (343-4357)
Compliance Reporting Line (343-0135)
Always forward Patient privacy complaints to Patient Affairs (322-6154) or the Privacy Office.
Your manager
Contact One of the Following to Report Privacy & Information Security Incidents
The Bottom Line
Consider the patient’s perspective and give them control over how their information is used.
Avoid situations in which the patient would object to how their information was used or shared.
Implement appropriate security measures to maintain the integrity of patient data, ensure its availability, and keep it confidential.
Be familiar with Vanderbilt’s privacy & information security policies at: www.mc.vanderbilt.edu/HIPAA
Final Instructions
To complete the training you must print off the HIPAA Test and submit it to the manager in your department for filing in your personnel file.
Any questions related to this training may be submitted to the Privacy Office at [email protected] or call
936-3594.
