1. HIPAA/HITECH Training (Clinical Non - Patient Care Areas)
HIPAA Job Specific Education

2. Objectives Participants will be able to:
Describe an overview of HIPAA and HITECH privacy key definitions and principles
Describe how HIPAA and HITECH affect job duties
List tips and guidance for applying privacy requirements
This course is designed to
Provide an overview of HIPAA and HITECH privacy key definitions and principles
Describe how HIPAA and HITECH affect job duties
Give tips and guidance for applying privacy requirements

3. HIPAA 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 (patient’s right to receive)
Directory: Hospital census list used by volunteers and operators with name and room

4. Hospitals are required by law to maintain the privacy of patients’ health information.
It is everyone's responsibility to ensure patient information is properly protected and safeguarded!

5. Facility Privacy Official (FPO)
What is a FPO?
The FPO is the “go-to” person for any
Potential patient privacy issues
Questions on patient privacy matters
Patient privacy complaints
FPO for OU Medical Center Systems is Joan Crall
FPO for OUMC-Edmond is Wanda Price
FPO or Facility Privacy Official oversees the facility’s patient privacy program and is the “go-to” person for
Any potential patient privacy issues
Questions on patient privacy matters
Patient privacy complaints.
FPO also ensures work force members are properly trained.

6. HIPAA Definition & Purpose
What is HIPAA?
The Health Insurance Portability and Accountability Act (HIPAA) was enacted by Congress in 1996. The HIPAA Privacy Rule provides federal protections for personal health information held by covered entities and gives patients an array of rights with respect to that information.
Federal Law.
What is the purpose of the law?
Guarantee privacy and security of health information
Protect health insurance coverage, improve access to healthcare
Reduce fraud, abuse and administrative health care cost
Improve quality of healthcare in general
The Health Insurance Portability and Accountability Act (HIPAA) was enacted by Congress in 1996. The HIPAA Privacy Rule provides federal protections for personal health information held by covered entities and gives patients an array of rights with respect to that information.
The purpose of the law:
-Guarantee privacy and security of health information
-Protect health insurance coverage and improve access to health care
-Reduce fraud, abuse and administrative health care costs

7. HITECH Definition & Purpose
What is HITECH?
The Health Information Technology for Economic and Clinical Health Act (HITECH) was signed into law by the President on February 17, It is the part of the American Recovery and Reinvestment Act of 2009.
It is a Federal Law.
HITECH Act strengthens those patient privacy protections of HIPAA and places additional requirements on the healthcare community.
What is the purpose of the law?
Makes massive changes to existing privacy and security laws
Increases penalties for privacy and security violations
Creates a nationwide electronic health record
The Health Information Technology for Economic and Clinical Health Act or also called HITECH was signed into law by the President on February 17, It is the part of the American Recovery and Reinvestment Act of 2009.
The purpose of the law:
- The HITECH Act makes massive changes to existing privacy and security laws, particularly the Administrative Simplification provisions of the HIPAA and its implementing regulations. In addition to changing existing HIPAA regulations, HITECH also rolls out sweeping new federal privacy and security laws.
- Increases penalties for privacy and security violations
- Creates a nationwide electronic health record
HITECH Act strengthens those patient privacy protections of HIPAA and places additional requirements on the healthcare community.
( It is also important to note that individual states may have specific privacy laws that is more stringent than the federal privacy laws. In such case, the state law must be followed.)

8. Let’s look at some of the details of these changes.
HITECH Changes
While there are many changes as a result of HITECH, some of the more substantial changes include:
Requirements for notification when certain breaches of protected health information (PHI) occur
Strengthened criminal provisions
Additional audit capabilities by the Office of Civil Rights
Changes to the patient's right to access his or her health information
Let’s look at some of the details of these changes.
While there are many changes as a result of HITECH, some of the more substantial changes include
Strengthened criminal provisions
Requirements for notification when certain breaches of protected health information (PHI) occur
Additional audit capabilities by the Office of civil rights
Changes to the patient's right to access his or her health information
In the next few slides, we'll discuss some of these changes in detail.

9. Breach Notification
A breach is a security incident in which sensitive, protected or confidential data is copied, transmitted, viewed, stolen or used by an individual unauthorized to do so.
Certain breaches of protected health information can result in potential significant risk of harm to the patient and now require notification to:
The patient
The Department of Health and Human Services
And in some situations, the media
An unauthorized acquisition, use, access, or disclosure of unsecured PHI that poses a significant risk of financial, reputational, psychological and or emotional harm to the patient is considered a HITECH breach.
We required by HITECH to notify the patient, the Department of Health and human Services and in some cases the media when these breaches occur.

10. Civil Monetary 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
Willful Neglect – Corrected
$10,000-$50,000
Willful Neglect – Not Corrected
$50,000
There are four categories of violations:
- Did not know
- Reasonable cause
- Willful neglect that has been corrected
- Willful neglect that has not been corrected.
Each category has a range of civil monetary penalties associated with the type and that penalty can reach up to 1.5 million.
Privacy violations can result in large fines from facilities and work force members that are non-compliant. it is everyone's responsibility to ensure patient information is properly protected and safeguarded.
* As of 2/17/2009

11. Criminal Penalties for Non-Compliance
For health plans, providers, employees, clearinghouses and business associates that knowingly and improperly disclose information or obtain information under false pretenses can be assess penalties. These penalties can also apply to any “person”.
up to $50,000 and one year in prison for obtaining or disclosing protected health information (PHI)
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
Penalties are higher for actions designed to generate monetary gain.

12. What is Protected Health Information (PHI)?
PHI is the information pertaining to healthcare that contains any of these identifiers. People often believe that if the patient's name is removed then the information is not PHI. That is not true. There are many types of patient identifying information.
Name
Address including street, county, zip code and equivalent geocodes
Name of relatives
Name of employers
All elements of dates except year (DOB, admission/ discharge, expiration, etc. )
Telephone numbers
Fax numbers
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 address (IP)
Finger or voice prints
Photographic images
Any other unique identifying number, characteristic or code
PHI is the information pertaining to healthcare that contains any of these identifiers. People often believe that if the patient's name is removed then the information is no PHI. That is not true. As you can see from this list there are many other data elements that make information identifiable.

13. How will HIPAA affect you?
Coversheets with confidential statement need to be used on all faxes.
Screens will need to be placed out of public view and screensavers in use
Patients will identify who their information can be discussed with, including family.
All PHI will need to be placed in Shred-It containers (e.g., dietary slips)
Patient information should only be accessed if there is a need to know and only the minimum necessary used
Adhere to all Information Security Policies and Standards.

14. Minimum Necessary
Only workforce members with a legitimate “NEED TO KNOW” may access, use or disclose PHI
- Regardless of the extent of the access provided
Only the minimum amount of PHI necessary may be used to accomplish the intended purpose of the access, use or disclosure
Workforce members CANNOT access their own record
- Contact HIM/medical records to request access
Only workforce members with a legitimate “NEED TO KNOW” may access, use or disclose PHI regardless of the extent of the access provided.
Workforce members must make reasonable efforts to limit PHI to the minimum necessary to accomplish the intended purpose of the use, disclosure, or request.
Workforce members cannot access his/her own record; A workforce member should contact HIM/medical record to request his/her own PHI.

15. Notice of Privacy Practices (NOPP)
The patient receives NOPP at each registration.
Patient privacy rights are outlined in the NOPP:
Right to Access
Right to Amend
Confidential Communication
Right to Restrict
Right to Opt out of the Directory
Right to Request an Accounting Disclosure
Each patient receives Notice of Privacy Practices or NOPP at each registration. NOPP outlines the following information about patient’s Privacy Rights:
Right to Access
Right to Amend
Confidential Communication
Right to Restrict
Right to Opt out of the Directory
Right to Request an Accounting Disclosure
The next slides will show these in detail.

16. Right 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. Always refer the individual to the FPO
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

17. Accounting of Disclosures (AOD)
An individual has a right to receive an AOD of protected health information made by a covered entity for up to 6 years:
Medical & Billing records
All required state reporting
Births and Deaths
Tumor Registry reporting
Domestic/Child Abuse suspect reporting
Very complex to implement
Due to HITECH, additional requirements are forthcoming

18. Patient Privacy Complaints
ALL privacy complaints must be routed to the FPO
FPO maintains complaint log in accordance with the complaint process
No retaliatory actions can be taken
Disposition of the complaint must be consistent with the facility’s Sanctions for Privacy Violations
The Meditech Risk Management module may be used for complaint tracking
For More Information Review:
Policy #: Patient Privacy – Privacy Complaint Process

19. Examples of Exposure Lack of knowledge regarding permitted uses of PHI
Discussions of patient information in public places such as elevators, hallways and cafeterias
Inappropriate control or use of patient lists with PHI
PHI in regular trash
Records that are accessed without need to know in order to perform job duties

20. Examples of Exposure Cont.
Sharing passwords
Using business agents without contracts and appropriate Business Associate Agreements
Sharing PHI without an authorization when one is required
Failure to act proactively to prevent, detect, or correct privacy or security breaches
Discussing patient information on social networking sites (e.g., Facebook, Twitter)

21. For More Information Review:
Sanctions
There is a sanctions policy to address privacy and information security violations
Types of violations can include:
Negligent (accidental or inadvertent)
Intentional (purposeful)
For specific information on sanctions policy contact FPO and/or review the facility’s policy
For More Information Review:
Policy #: Patient Privacy – Sanctions for Privacy and Information Security Violations

22. Patient Privacy Policies and Forms on the Intranet

23. Test Your Knowledge Do you know who your FPO is?
What kinds of privacy rights does the patient have?
Can a patient amend their record?
Do you know who to refer patient privacy questions or complaints to?
What is an Accounting of Disclosures?
When can you access, use or disclose the patient’s PHI?
Where do you dispose of patient information?

24. The following are the policies related to the HIPAA/HITECH
The following are the policies related to the HIPAA/HITECH. Review them further as needed:
20-01: Patient Privacy – Community Clergy Access to Patient Listings Under HIPAA Privacy Standards
20-02: Patient Privacy – Designated Record Sets 
20-03: Patient Privacy – Determination of, and Uses and Disclosures of De-Identified Information
20-04: Patient Privacy – Authorization for Uses and Disclosures of PHI
20-05: Patient Privacy – Hybrid Entity
20-06: Patient Privacy – Limited Data Set and Data Use Agreement 
20-07: Patient Privacy – Marketing Under the HIPAA Privacy Standards/HITECH
20-08: Patient Privacy – Patient’s Right to Opt Out of Being Listed in Facility Directory 
20-09: Patient Privacy – Privacy Complaint Process
20-10: Patient Privacy – Sanctions for Privacy and Information Security Violations 

25. Policy and Procedure Cont.
20-11: Patient Privacy – Uses and Disclosures for Which an Authorization or Opportunity to Agree or Object is not Required
20-12: Patient Privacy – Uses and Disclosures of Patient Health Information to Other Treatment Providers Under the HIPAA Privacy Standards 
20-13: Uses and Disclosures of Patient Health Information to Patients’ Family Members or Friends for Patient Care Purposes
20-14: Patient Privacy – Uses and Disclosures Required by Law
20-15: Patient Privacy – Verification of External Requestors HIPAA and PHI
20-16: Patient Privacy – Electronic Incident Response
20-17: Patient Privacy – Confidential Patient Status
20-19: Patient Privacy – Photographing, Video Recording, Audio Recording, and Other Imaging of Patients, Visitors, and Workforce Members
20-20: Patients’ Right to Access

26. Thank you for your attention and for protecting our patient’s PHI
Thank you for your attention and for protecting our patient’s PHI. Every patient, every time!