Title: HIPAA Privacy Keys to Success
1HIPAA PrivacyKeys to Success
2HIPAA and Its Purpose
- What is HIPAA?
- Health Insurance Portability and Accountability
Act of 1996 - Title II Administrative Simplification
- Its a federal law
- HIPAA is mandatory, penalties for failure to
comply
- Purpose
- Protect health insurance coverage, improve access
to healthcare - Reduce fraud and abuse
- Improve quality of healthcare in general
- Reduce healthcare administrative costs
(electronic transactions)
3HITECH and Its Purpose
- What is HITECH?
- Health Information Technology for Economic and
Clinical Health Act - Subtitle D of the American Recovery and
Reinvestment Act of 2009 (ARRA) - Its a federal law
- Purpose
- Makes massive changes to privacy and security
laws - Applies to covered entities and business
associates - Creates a nationwide electronic health record
- Increases penalties for privacy and security
violations
4Key HITECH Changes
- Breach Notification requirements
- AOD for treatment, payment, and healthcare
operations in electronic health record (EHR)
environment - Business Associate Agreements
- Restrictions
- Right to access
- Criminal provisions
- Penalties
- OCR Privacy Audits
- Copy charges for providing copies from EHR
- HIPAA preemption applies to new provisions
- Private cause of action
- Sharing of civil monetary penalties with harmed
individuals
5Civil Penalties for Non-compliance
Violation Category Each Violation All such violations of an identical provision in a calendar year
Did Not Know 100 - 50,000 1,500,000
Reasonable Cause 1,000 50,000 1,500,000
Willful Neglect Corrected 10,000 - 50,000 1,500,000
Willful Neglect Not Corrected 50,000 1,500,000
As of 2/17/09
6Criminal Penalties for Non-compliance
- For health plans, providers, clearinghouses and
business associates that knowingly and improperly
disclose information or obtain information under
false pretenses. These penalties can apply to
any person. - Penalties higher for actions designed to generate
monetary gain - up to 50,000 and one year in prison for
obtaining or disclosing protected health
information - up to 100,000 and up to five years in prison for
obtaining protected health information under
"false pretenses" - up to 250,000 and up to 10 years in prison for
obtaining or disclosing protected health
information with the intent to sell, transfer or
use it for commercial advantage, personal gain or
malicious harm
7Facility Privacy Official
- Your FPO is Cynthia Kean, HIM Director
- Responsible for
- Privacy Program
- Privacy Rights of patients
- Requests for Privacy Restrictions
- Facilitating the training and education of staff
8HIPAA Terminology
- HIPAA Health Insurance Portability and
Accountability Act - HITECH Health Information Technology for
Economic and Clinical Health Act - PHI Protected Health Information
- CE Covered Entity (Hospital)
- ACE Affiliated Covered Entity (Common
ownership) OHCA Organized Health Care
Arrangement (The hospital and medical staff will
be considered an Organized Health Care
Arrangement) - DRS Designated Record Set (medical record and
billing record) - AOD Accounting of Disclosures (patients right
to receive) - Directory Hospital census list used by
volunteers and operators with name and room
9How will HIPAA affect you?
- Coversheets with confidential statement need to
be used on all external faxes. - Screens will need to be placed out of public view
when possible - Patient charts will need to be placed in secure
area - PHI will need to be placed in Cintas containers
for disposal - Patient family members will give a passcode for
other than directory releases - Patient information should only be accessed if
there is a need to know
10How will HIPAA affect you?
- Registration will be giving out a Notice of
Privacy Practices brochure to every patient
concerning our patient privacy protection policy.
- Patients will be given the option to opt out
of our directory. - Patients have a right to a copy of their medical
record - Authorizations need to be obtained from patient
to release information for reasons other than for
treatment, payment or healthcare operations (TPO)
11What is Protected by HIPAA (PHI)?
- Name
- Address including street, city, county, zip code
and equivalent geocodes - Names of relatives
- Name of employers
- All elements of dates except year (i.e. DOB,
Admission, Discharge, Expiration, etc.) - Telephone numbers
- Fax Numbers
- Electronic e-mail addresses
- Social Security Number
- Medical record number
- Health plan beneficiary number
- Account number
- Certificate/license number
- Any vehicle or other device serial number
- Web Universal Resource Locator (URL)
- Internet Protocol (IP) address number
- Finger or voice prints
- Photographic images
- Any other unique identifying number,
characteristic, code
12What is a Covered Entity (CE)?
- Health plans, Health care clearinghouses, and
Health care providers that transmit
electronically for billing - Examples
- Hospitals
- Physician Practices
- Insurance companies
- Ambulance Transportation Services
- Hospice
- Home Health
13What does that mean to me?
- You can share information without patient
authorization as it relates to TPO - Other covered entities will request only minimum
necessary to perform their job - You may request the minimal information necessary
from them for reasons of TPO without patient
authorization - May need to verify the requestor according to
policy
14Disclosing PHI to Family Members and Friends Who
Call the Unit
- Patient will be assigned a four-digit passcode .
Knowledge of this passcode will allow
information, (PHI), to be shared with the family
member or friend - Distribution of passcode will be the
responsibility of the patient - Passcode may be changed during treatment
- Revocation and password change form must be
routed to FPO - Passcode will be last 4-digits of patient account
number
15Verification of Requestors
- Requestors via phone will need
- Patient SS, DOB and one of the following
- Account number, street address, MR, birth
certificate, insurance card or policy number - Scenarios
- Unknown physician calling from cell phone
- Family member or friend calling without passcode
16External Faxing Guidelines
- Limit when possible
- Verify fax number
- Utilize preset numbers when applicable
- Fax machine located in secure location
- ALWAYS use cover sheet with confidentiality
statement for transmittals - Highly sensitive information should not be faxed
(HIV status, abuse records, etc.)
17Patients Right to Access
- Forward to HIM for processing
- Must be able to provide access and/or hard copy
of record - If patient is in-house, HIM will manage access
process
18Patients Right to Amend
- Forward request to HIM for processing
- Right of patient to request amendment to records.
Request must be in writing - Cannot change or omit documentation already in
the medical record - If patient is in-house HIM will manage amendment
process
19Patients Right to Opt out of Directory
- Patient can opt out of directory at anytime but
will probably happen during admission process - You may not acknowledge the patient is in the
facility or give information about the patient to
friends, family or others who may inquire - Can still release information to family and
friends with 4-digit passcode as defined in the
Directory policy. - Forward any request for opt out to Registration
for processing
20Right to Privacy Restrictions
- Patients have the right to request a privacy
restriction of their PHI - NEVER agree to a restriction that a patient may
request - All requests must be made in writing and given to
the FPO to make a decision on - NO request is so small that it should not be
routed to the FPO
21Patient Privacy Complaints
- FPO must maintain complaint log in accordance
with the complaint process - ALL privacy complaints must be routed to the FPO
- Responses cannot be accompanied by retaliatory
actions by the hospital - Disposition of complaint must be consistent with
the facilitys Sanctions for Privacy Violations - Risk Management module of Meditech may be used
for complaint tracking
22Accounting of Disclosures (AOD)
- Right to an accounting of disclosures of
protected health information - An individual has a right to receive an
accounting of disclosures of protected health
information made by a covered entity in the six
years prior to the date on which the accounting
is requested, except for disclosures - For TPO
- To the patient
- For directory purposes
- To law enforcement or correctional institutions
- For national security
Additional requirements forthcoming as a result
of HITECH regulations
23How will Accounting of Disclosures (AOD) affect
me?
- You must enter information into the AOD for
- State mandated reporting
- Suspected Abuse Victims
- Certain Disease reporting such as STDs
- Brain Injury
- Organ and Tissue Donations
- Health Oversight Activities (JCAHO)
24Notice of Privacy Practices
- Patient will receive Notice upon each
registration - Outlines patient rights
- Right to access
- Right to amend
- Confidential Communication
- Right to Privacy Restriction
- Right to Opt out of Directory
25Sharing Information with Other Treatment Providers
- We can share information with physicians and
office staff, hospitals, or other treatment
facilities just as we do today - Need to verify the requestor according to policy
- Patient information (PHI) can be released for
reasons of treatment, payment or health care
operations
26Confidential Communications
- Request for use of alternate address or phone
number for future contact - Route any request for Confidential Communications
to Admissions - Should communicate only with alternate address
given
27Breach Notification
- HITECH provisions require the following
notifications when breaches (as defined in the
regulations) occur - To the patient
- To the Department of Health and Human Services
- To the media when the breach involves more than
500 individuals in the same state or jurisdiction
28Ensuring Security Compliance
- Ensure users log off terminals when not in use.
- PCs should have screen savers whenever
possible. - Computer screens should be positioned so
information (PHI) is not - readable by the public or other unauthorized
viewers - Printers should be positioned in protected
locations so that printed - information is not accessible or viewable by an
unauthorized - person.
- PHI must be properly disposed.
29Common Exposures on Nursing Units
- Discussions of patient information in public
places such as elevators, hallways and cafeterias - Printed or electronic information left in public
view (e.g., charts left on counters) - Discussing patient information on social
networking sites (e.g., Facebook, Twitter) - PHI in regular trash
- Records that are accessed without need to know in
order to perform job duties - Unauthorized individuals hearing patient
sensitive information such as diagnosis or
treatment
30Sanctions
- 3 levels of violations that require disciplinary
action - Accidental and/or due to lack of proper education
- Purposeful violation of privacy policy or an
unacceptable number of previous violations - Purposeful violation of privacy policy with
associated potential for patient harm - FPO to review facility sanctions policy examples
31Test Your Knowledge
- The FPO at JFK Medical Center is
- Gina Melby, CEO
- The President of the Medical Staff
- Cynthia Kean, HIM Director
- Jim Leamon, CFO
- Does the patient have the right to access or
obtain a copy their medical record? - Yes
- No
- Can a patient amend their record?
- Yes
- No
- What is protected by HIPAA (PHI-Protected Health
Information)?
32Test Your Knowledge
- What right is NOT provided under HIPAA?
- Right to Opt out of the dictionary
- Right to not pay the bill
- Right to amend
- Right to request Confidential Communication
- 6. Under HITECH when a breach occurs the
following must be notified, EXCEPT - The Department of Health and Human Services
- The media when more than 500 individuals reside
in the same state or jurisdiction - The patients next of kin
- The patient
- One of the purposes of HITECH is to create an
electronic health record - True
- False
-
33To Test Your Knowledge
- Patients have the right to request a privacy
restriction of their PHI. This request must
always be forwarded to the - Admitting Physician
- The FPO
- The Chief Nursing Officer
- The Quality Director
- Criminal penalties for non-compliance can apply
to any person - True
- False
- Examples of exposure would be
- discussions of a patients diagnosis in the
elevator - PHI in the trashcan
- sharing PHI without an authorization when one is
required - sharing of passwords