HIPAA

HIPAA

What

Why

Who

How

When

What Is HIPAA?

Health Insurance Portability & Accountability Act of 1996.

Why Do We Need HIPAA?

The purpose of HIPAA is toprotect confidential

healthcare information through

improved security andprivacy standards.

Who Must Comply With HIPAA?

Every employee of a healthcare facility or provider thathandles protected patienthealth information will have tocomply with HIPAA regulations.

What Must Be Kept Confidential?

PHI:Protected Health

Information

The HIPAA privacy rule defines the type of information that must be kept private by categorizing it as “Protected Health Information,” or PHI for short. Healthcare organizations must have policies in place

that maintain the privacy of PHI.

What is PHI?

Protected Health Information

PHI (Protected Health Information)

Health information is any information, (verbal,electronic, or written) thatrelates to a person’s physicalor mental health, or paymentinformation.

Examples of Personally Identifiable Information

NameSSNDriver’s licenseAddressTelephone numberMarital statusFinancial information

Parental statusGenderRaceReligionMedical ConditionTest ResultsIncome

Minimum Necessary

What can I access?Only information you “need to know”to do your job

Accessing, using, or disclosing PHI on a need to know basis to get your job done is an important concept under HIPAA known as “minimum necessary.” Working in a healthcare organization does not entitle a person to access any and all patient records in the organization. You can access only the information you need to know to get your job done.

Does the minimum necessary standard apply in every situation? No – the minimum necessary standard does not apply when accessing, using, or disclosing PHI for treatment of the individual. It also does not apply to the patient – they can have access to their protected health information.

Incidental Disclosure

The Privacy Rule does not saythat health information willnot be accidentally overheard. But everyone shouldmake every effort to prevent

thisfrom happening.

Examples of Incidental Disclosure

Calling a patient’s name in a waiting room

A sign-in sheet is ok as long as it does not list a reason for the visit

Examples of Verbal Risk

Discussing personal health information with a patient in awaiting room when there is risk ofothers overhearing the

conversation.

Examples of Verbal Risk

Personal health information should

not be discussed in public areas such

as elevators, hallways, parking lots,

or bathrooms.

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Examples of Verbal Risk

You should never discuss a patient’s

personal health information withfriends, family, or neighbors.

Examples of Visual Risks

Leaving documents that you know contain PHI inthe open, unprotectedand easily accessible byanyone

How Do I Know...

…when information is considered private?

-Did you learn it through your job?

-If yes, then it is considered private!

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Internal Security Violations

• Taking advantage of computer glitches that mistakenly allow access to a patient’s medical record

• Deliberately gaining access to patient data

• Sharing pass codes• Leaving documents with patient

information visible in an open area

How Do I Handle……An individual asking for access to

their record?• Individuals have a

right of access• Route requests to

appropriate department or staff

• Do not attempt to provide or get this information yourself

How Do I Handle…

…An individual’s request to change their medical record?• Individuals have the right to

amend or correct their record • Route requests to appropriate

department or staff• Do not attempt to handle

yourself

How Do I Handle…

• Tell them to call Directory information

• Do not attempt to answer yourself

…A family member or close friend asking about a patient?

How Do I Handle…

…Co-workers asking about a patient’s condition or treatment?• Route request to appropriate

department or staff• Do not attempt to provide

or get this informationyourself

Penalties

• If you break the rules, you can face civil and criminal penalties

• If found guilty you can be fined and/or sentenced to jail

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Civil Penalties

•$100 per wrong act •up to $25,000 per person, per year for each rule broken a

Criminal Penalties

• $50,000 & 1 year in jail if found guilty of telling protected health information

• $100,000 & 5 years in jail if found guilty of obtaining or disclosing protected health information under false pretenses

• $250,000 & 10 years in jail if found guilty of obtaining and disclosing PHI with intent to sell, transfer, or use for cash, personal gain, or malicious harm

“Privacy-friendly” Practices

•Abide by the Notice of Privacy Practice & Confidentiality

•Avoid discussing personal health information

•Keep health information out of public areas

“Privacy-friendly” Practices

•Secure records in all locations

•Respect an individuals’ right to privacy during treatments

HIPAA Security

HIPAA security applies to physical, technical and administrative safeguards that are put in place to protect the confidentiality of information.

PasswordsFile

Cabinets

ID Numbers Coded

information

Organizations should always access what resources need to be protected, determine the cost for protection and access the likelihood of loss or compromise.

Organizations should train all employees on day-to-day procedures that ensure the protection of information.

When complying with security standards…

Ways of Insuring that information is protected

• Faxes should never be left unattended or in places where unauthorized people can view them.

• Passwords should be changed regularly. Children’s names, pet’s names, spouse’s names and birthdates should never be used as passwords.

• Information on computer monitors should not be visible to unauthorized people.

• Files should always be closed and coded. Personal information should never be on a file’s cover.

What Can You Do?

• Be aware of patient information and how it is used or handled.

• Look for ways to insure the information is not available to unauthorized individuals.

• Shred when appropriate.

• Password protect your computer.

• Never leave files open on your desk or at the copier.

Organizations can prevent access the unauthorized data by implementing procedures at time of employee termination.

1. Change all combination locks

2. Removal of terminated employee for access lists

3. Removal of user account(s)

MCG Compliance/Privacy Officers

• Please report any violations to the MCG Privacy Officer at 721-2661, or call MCG’s Legal Office at 721-4018

Protect

&Serve