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UNIVERSITY OF ALABAMA V2013.1 HIPAA Privacy and Security Training For Employees Compliance is Everyones Job 1 INTERNAL USE ONLY For UA Health Care Components,

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Presentation on theme: "UNIVERSITY OF ALABAMA V2013.1 HIPAA Privacy and Security Training For Employees Compliance is Everyones Job 1 INTERNAL USE ONLY For UA Health Care Components,"— Presentation transcript:

1 UNIVERSITY OF ALABAMA V HIPAA Privacy and Security Training For Employees Compliance is Everyones Job 1 INTERNAL USE ONLY For UA Health Care Components, Business Associates & Health Plans

2 INTERNAL USE ONLY 2 Topics to Cover General HIPAA Privacy and Security Overview HIPAA Privacy HIPAA Breach Notification Rules and Procedures HIPAA Security

3 INTERNAL USE ONLY 3 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.

4 INTERNAL USE ONLY 4 Applicability of HIPAA to UA HIPAA Applies to: University Medical Center Brewer-Porch Children's Center The Speech & Hearing Center Autism Spectrum Disorders Clinic Departments that have signed Business Associate Agreements Group Health Insurance/Flexible Spending Plan/EAP/Wellbama Program UA Administrative Departments supporting the above entities (like Legal Office, Auditing, Financial Affairs, Risk Management, OIT, UA Privacy/Security Officer, etc.) Research involving PHI from a HIPAA-covered entity Does not apply to Psychology Clinic, Student Health Center/Pharmacy, ODS records, Counseling Center, WRC, Athletic Dept health records

5 INTERNAL USE ONLY 5 What is Protected Health Information (PHI) Any information, transmitted or maintained in any medium, including demographic information; Created/received by covered entity or business associate; Relates 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

6 INTERNAL USE ONLY 6 Types of Data Protected by HIPAA Written documentation and all paper records Spoken and verbal information including voice mail messages Electronic databases and any electronic information, including research information, containing PHI stored on a computer, smart phone, memory card, USB drive, or other electronic device Photographic images Audio and Video recordings

7 INTERNAL USE ONLY 7 To De-Identify Patient Information You Must Remove All 18 Identifiers: Names Geographic 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 age Telephone, fax, SSN#s, VIN, license plate #s Med record #, account #, health plan beneficiary # Certificate/license #s address, IP address, URLs Biometric identifiers, including finger & voice prints Device identifiers and serial numbers Full face photographic and comparable images Any other unique identifying #, characteristic, or code

8 INTERNAL USE ONLY 8 Question Photographs are considered PHI. a)True b)False

9 INTERNAL USE ONLY 9 Correct Answer a: Photographs as well as video and audio recordings are protected under HIPAA regulations.

10 INTERNAL USE ONLY 10 Department of Justice-Imposed Criminal Penalties for Employee Wrongfully Accessing or Disclosing PHI: Fines up to $50,000 and up to 1 Year in Prison Obtaining PHI Under False Pretenses: Fines up to $100,000 and up to 5 Years in Prison Wrongfully Using PHI for a Commercial Activity: Fines up to $250,000 and up to 10 Years in Prison HIPAA criminal and civil fines and penalties can be enforced against INDIVIDUALS as well as covered entities and Business Associates who obtain or disclose PHI without authorization

11 INTERNAL USE ONLY 11 Federal-Imposed Civil Penalties Violation CategoryEach Violation All Identical Violations per Calendar Year Did Not Know $100 - $50,000$1,500,000 Reasonable Cause $ $50,000$1,500,000 Willful Neglect- Corrected $10,000 - $50,000$1,500,000 Willful Neglect-Not Corrected$50,000$1,500,000

12 INTERNAL USE ONLY 12 Federal-Imposed Civil Penalties HHS is now required to investigate and impose civil penalties where violations are due to willful neglect Federal government has six (6) years from occurrence of violation to initiate civil penalty action State attorneys general can pursue civil cases against INDIVIDUALS who violate the HIPAA privacy and security regulations Civil penalties now apply to Business Associates

13 INTERNAL USE ONLY 13 Breach and Sanction Information Breach Notifications: September 2009 – March 2013: 556 reports involving a breach of over 500 individuals Over 64,000 reports involving under 500 individuals Top types of large breaches – Theft – Unauthorized access/disclosure – Loss Top locations for large breaches – Laptops – Paper records – Desktop computers – Portable electronic device

14 INTERNAL USE ONLY 14 Breach and Sanction Information Stolen Laptop Stanford University Lucile Packard Childrens Hospital (2013) – An unencrypted laptop containing medical information on pediatric patients was stolen from a secured access room – Laptop was older model with damaged screen; it was not being used in normal day-to-day operations – Laptop contained patient names, ages, medical records, surgical procedures, and names and telephone numbers of various physicians – This HIPPA breach affected over 13,000 patients – If the laptop had been encrypted, the PHI would not have been exposed and this would not have been a breach

15 INTERNAL USE ONLY 15 Breach and Sanction Information Business Associates Laptop Stolen Howard University Hospital (2012) – Notified 34,503 patients of a HIPPA breach when a password-protected but unencrypted laptop with patient files was stolen from a contractors vehicle (Howard Universitys Business Associate) – Note: Howard Univ. had to notify: not its contractor – Stolen records had patients names, addresses, SSNs and diagnosis-related information – If the laptop had been encrypted, the PHI would not have been exposed and this would not have been a breach

16 INTERNAL USE ONLY 16 Breach and Sanction Information Theft of a Portable Electronic Device Georgetown University Hospital (2010) – Notified 2,416 patients that their PHI (names, DOB, clinical information) had been compromised – Employee inappropriately ed PHI to an offsite research office (not HIPAA-covered entity) in violation of the review preparatory to research protocol – Research office stored the ePHI on external hard drive that was later stolen – Employee given verbal warning & counseling – Hospital stopped transmitting PHI to research office & undertook review of all research affiliations involving PHI of its patients to confirm that appropriate documentation and procedures were in place

17 INTERNAL USE ONLY 17 Breach and Sanction Information Firewall Security Breach Idaho State University (2013) – Paid $400,000 to U.S. Dept. of Health and Human Services to resolve HIPPA violations – Breach of unsecured electronic PHI of 17,500 patients at ISUs Pocatello Family Medicine Clinic: occurred because firewall was disabled – ISUs risk analyses and assessments were incomplete, and ISU inadequately identified potential risks and other system vulnerabilities – ISU did not apply proper security measures and policies to address risks to electronic PHI and did not engage in routine review of the information systems in place with these protections in place, ISU likely could have detected the firewall breach sooner

18 INTERNAL USE ONLY 18 Breach and Sanction Information Improper Disposal of Paper PHI CVS Pharmacy, Inc (2009) & Rite Aid (2010) – CVS paid $2.25 million to U.S. Dept. of Health and Human Services to resolve HIPPA violations & implement detailed Corrective Action Plan to ensure that its workforce members appropriately dispose of PHI, such as labels from prescription bottles and old prescriptions – Rite Aid paid $1 million to HHS & developed Corrective Action Plan to resolve similar violation: throwing out old prescriptions and labeled pill bottles in industrial dumpsters that were accessible to the public – Corrective Action Plan: revise & distribute policies and procedures re: disposal of PHI; sanction workers who do not follow them; train workforce members on new requirements; conduct internal monitoring; and engage a qualified, independent third- party assessor to conduct compliance reviews and render reports to HHS

19 INTERNAL USE ONLY 19 Breach and Sanction Information Employee Misconduct: Terminations University of Miami (2012) – Two university employees were terminated for inappropriately accessing 64,846 patients face sheets (patients names, DOB, insurance policy numbers, partial & full Social Security numbers, and clinical information) University of California at Los Angeles Health System (UCLAHS) (2011) – Paid HHS $865,500 to resolve complaints of intentional unauthorized access to/use/disclosure of PHI – Two celebrity patients alleged employees reviewed their medical records without authorization – Employees had repeatedly been caught and fired for looking at records of celebrities (Brittney Spears, Farrah Fawcett)

20 INTERNAL USE ONLY 20 Breach and Sanction Information Employee Misconduct – Criminal Charges University of Pittsburgh Medical Center Shadyside Hospital (2010) – 8,000 patient records were compromised – Breach stemmed from employees unauthorized access to and theft of several paper records with names & financial data, which employee eventually destroyed – Employee terminated. Facing criminal prosecution with penalties of 80 years in prison or $4.7 million fine or both

21 INTERNAL USE ONLY 21 Breach and Sanction Information Employee Misconduct: Probation & Jail Time 2008: 25-year-old LPN working at Northeast Arkansas Clinic inappropriately accessed a patients PHI & shared it with her husband, who immediately called the patient & threatened to use PHI against him in upcoming legal proceeding – LPN fired. Indicted for wrongful disclosure of PHI for personal gain and malicious harm – LPN faced maximum of 10 years in prison, fine of no more than $250,000 or both, and term of supervised release of not more than 3 years – LPN sentenced to 2 years probation & 100 hours community service – Arkansas State Board of Nursing: suspend or revoke license 2010: Licensed cardiothoracic surgeon working at UCLA School of Medicine as a researcher looked at employee and patient medical records he was not authorized to view – Pled guilty to four misdemeanor charges. Prosecutor asked for 90 days in jail and fine of $500, because he had received formal training on HIPAA violations, unlawfully accessed records after hours & was terminated. – Sentenced to four months in federal prison and $2,000 fine – First HIPAA violation resulting in incarceration

22 INTERNAL USE ONLY 22 UA HIPAA Sanctions Employees, 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 program – Termination of employment – Suspension without pay – Denial of an annual raise or reduction in pay Civil and/or criminal penalties including incarceration

23 INTERNAL USE ONLY 23 Question A University of Alabama employee who violates HIPAA Policies can have their employment terminated. a)True b)False

24 INTERNAL USE ONLY 24 Correct Answer a: True: The University of Alabama is legally obligated to enforce HIPAA Policies. Employees who violate policy will be subject to sanctions, which can included termination of employment. The nature of the sanction is determined by the severity of the policy breach.

25 INTERNAL USE ONLY 25 Authorization as Permitted Use and Disclosure of PHI A covered entity can generally use and disclose PHI for any purpose if it gets the persons signed HIPAA- valid authorization Only designated, HIPAA-trained personnel are permitted to approve disclosure of PHI per the persons HIPAA-valid authorization For any questions concerning authorization, please contact your Privacy Officer For a complete list of permitted uses and disclosures of PHI without the patients authorization, see your entitys Notice of Health Information Practices

26 INTERNAL USE ONLY 26 TPO as Permitted Use and Disclosure of PHI PHI may be used and disclosed to facilitate TPO, which means: For Treatment For Payment For certain healthcare Operations, such as quality improvement, credentialing, compliance, and patient/employee safety activities

27 INTERNAL USE ONLY 27 Can Family/Friends Know? Yes, but only PHI directly relevant to that persons involvement with the patients healthcare or payment related to patients healthcare And, only if the provider reasonably infers that the patient does not object

28 INTERNAL USE ONLY 28 What About Deceased Patients? Family/friends involved in care can receive information related to care or payments, unless inconsistent with patients prior expressed preferences Records of person deceased for more than 50 years is no longer protected under HIPAA

29 INTERNAL USE ONLY 29 What About Immunization Records to Schools? Okay to disclose proof of immunization to School where state or other law requires School to have information prior to admitting student Need oral agreement (phone/ ) documented in patients medical record

30 INTERNAL USE ONLY 30 Use or Disclosure of PHI for Fundraising Permissible to give to business associate or related foundation – Demographic information – Dates health care provided for fundraising, but only if included in Notice of Health Information Practices & patient is given chance to opt out

31 INTERNAL USE ONLY 31 Minimum Necessary Standard When 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: – Treatment – Purposes for which an authorization is signed – Disclosures required by law – Sharing information to the patient about himself/herself

32 INTERNAL USE ONLY 32 What HIPAA Did Not Change: Family and friends can still pick up prescriptions for sick people Physicians and Nurses do not have to whisper State laws still govern the disclosure of minors health information to parents (a minor is under the age of 19 in Alabama)

33 INTERNAL USE ONLY 33 Question Jenny, a pediatric nurse, needs to report lab results to the mother of a 3 year old child who is sitting in the waiting room. She sticks her head in the waiting room door and says, Good news. The lab results are normal. Is this a privacy breach? a)Yes b)No

34 INTERNAL USE ONLY 34 Correct Answer a: Yes, unless no one else was in the waiting room. The nurse should have asked the mother to step out into the hallway or taken other steps to minimize the risk that someone would overhear the conversation.

35 INTERNAL USE ONLY 35 Other Privacy Safeguards Avoid 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

36 INTERNAL USE ONLY 36 Notice of Health Information Practices Explains how the covered entity will use/disclose patients PHI Explains a patients rights and where to file a complaint Is 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 facilitys web page and in patient reception area

37 INTERNAL USE ONLY 37 Patient Rights Under HIPAA The Notice of Health Information Practices outlines the patients following rights to: Restrict disclosure of PHI to health plan if patient pays out of pocket in full for the healthcare item/service Look at and obtain a copy of record/PHI or ePHI Amend incorrect or misleading information in record Receive an accounting of disclosures of PHI Be notified of a breach of PHI File a complaint

38 INTERNAL USE ONLY 38 Question TPO stands for a)Therapy, patient, outcome b)Treatment, payment, operation c)Training, participation, organization

39 INTERNAL USE ONLY 39 Correct Answer b: Treatment, payment, operation. Once the Acknowledgement of Health Information Practices has been signed by the patient, PHI can be disclosed as necessary to complete treatment, bill for services, and manage healthcare operations.

40 INTERNAL USE ONLY 40 Question PHI can never be released for any reason except TPO (treatment, payment, operations). a)True b)False

41 INTERNAL USE ONLY 41 Correct Answer b: False. PHI can be released for reasons other than TPO if additional release forms have been signed by the patient or as permitted by law. Your entitys Notice of Health Information Practices describes additional circumstances in which release of PHI is permitted.

42 INTERNAL USE ONLY 42 Question Charlie works at a medical center and is responsible for entering billing data into the computer system. He looks at his mother-in-laws medical records, because he is concerned that she has not been fully honest with her family about some recent health problems. Since he has been HIPAA trained, is this a breach of privacy? a)Yes b)No

43 INTERNAL USE ONLY 43 Correct Answer a: Yes. Although Charlie has been HIPAA trained, his access is based on the minimum necessary requirement to complete his job. He does not need to access health records to enter billing data. Unless his mother-in-law has given permission, in writing on a HIPAA-valid authorization, for him to access her records, this action was a violation of Privacy Policies.

44 INTERNAL USE ONLY 44 Business Associate (BA) Agreements Are 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 entitys PHI Law 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.

45 INTERNAL USE ONLY 45 HIPAA Put New Requirements on Research If you work for a HIPAA-covered Health Care Provider, do not release PHI for research unless: – The patient has signed a valid HIPAA authorization, or – The Institutional Review Board (IRB) at UA has approved a waiver of authorization; or – The IRB agrees that an exception applies Information regarding HIPAA and Research is available through UAs Office for Research Compliance.

46 46 Breach Notification HIPAA requires that we notify affected individuals and federal officials when a breach or potential breach of privacy has occurred The following slides discuss: – The types of breaches requiring patient notification and those that are exempt – Time in which the notification must occur – Responsibility of employee to report any incident INTERNAL USE ONLY

47 47 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

48 48 Risk Assessment Required To 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 made Whether PHI was actually acquired or viewed The extent to which the risk of PHI has been mitigated (recipient destroyed it) INTERNAL USE ONLY

49 49 Exceptions When Breach Notification Not Required Unintentional acquisition, access, or use of PHI by an employee or individual acting under the authority of a covered entity or business associate if made in good faith or within course and scope of employment Inadvertent disclosure of PHI from one person authorized to access PHI at a covered entity or business associate to another person authorized to access PHI at the covered entity or business associate Unauthorized disclosures in which an unauthorized person to whom PHI is disclosed would not reasonably have been able to retain the information INTERNAL USE ONLY

50 50 Home Free – No Notification Required Home free methods under which breaches involving the misuse, loss, or inappropriate disclosure of paper or electronic data would indicate no harm done, and therefore, no patient notification: PHI is encrypted in both storage (servers, desktops, laptops, thumb drives, tablets, etc.) and in transit (https: or SSL encryption while accessing electronically). PHI has been properly disposed (paper is shredded with an appropriate shredder, pulped or incinerated; electronic storage devices such as hard drives, thumb drives, CD/DVD, etc., are properly erased with a DoD-approved data erasure process). INTERNAL USE ONLY

51 51 Encryption Security Rules require Covered Entity/Business Associate to consider implementing encryption as a method for safeguarding Electronic Protected Health Information (PHI) If you encrypt, then patient notification is not required in event of breach

52 52 What Constitutes a Breach? A breach could result from many activities. Some examples are – Accessing more than the minimum necessary – Failing to log off when leaving a workstation – Unauthorized access to PHI – Sharing confidential information, including passwords – Having patient-related conversations in public settings – Improper disposal of confidential materials in any form – Copying or removing PHI from the appropriate area Why? – Curiosity…about a co-worker or friend – Laziness…so shared sign-on to information systems – Compassion…the desire to help someone – Greed or malicious intent…for personal gain INTERNAL USE ONLY

53 53 Question Bill, a billing employee, receives and opens an containing PHI which a nurse, Nancy, mistakenly sent to Bill. Bill notices that he is not the intended recipient, alerts Nancy to the misdirected , and deletes it. Was this a breach of PHI that requires notification to the patient? a)Yes b)No INTERNAL USE ONLY

54 54 Correct Answer b: No. Bill unintentionally accessed PHI that he was not authorized to access. However, he opened the within the scope of his job for the covered entity. He did not further use or disclose the PHI. This was not a breach of PHI as long as Bill did not further use or disclose the information accessed in a manner not permitted by the Privacy Rule. INTERNAL USE ONLY

55 55 Question Rhonda is a receptionist for a covered entity, and, due to her work responsibilities, she is authorized to access PHI. Rhonda decides to look through patient files to learn about a friends last visit to the doctor. Does Rhondas action constitute a breach requiring notification to the patient? a)Yes b)No INTERNAL USE ONLY

56 56 Correct Answer a: Yes. Rhonda accessed PHI without a work- related need to know. This access was not unintentional, done in good faith, or within the scope of her job for the covered entity. The patient will be notified of Rhondas review of her files.

57 57 Question Rob, a research assistant, wanted to get ahead on some statistical work, so he copied the information from 240 research participants to his thumb drive. The information included PHI, and the thumb drive was not encrypted. On his way home to continue his work, he stopped by the store to get some snacks. When he returned to his car, he found it had been broken into. Missing were his GPS, dozens of CDs, and his book bag containing the thumb drive. Does this event constitute a breach requiring patient notification? a)Yes b)No INTERNAL USE ONLY

58 58 Correct Answer a: Yes. Unsecured PHI was stolen because the thumb drive was unencrypted. Actually, Rob violated many UA policies: – Removed confidential information from the unit without approval – Used his personal portable computing device for UA business without senior management approval – Copied confidential information to a portable computing device without senior management approval – Used a portable computing device that was not encrypted INTERNAL USE ONLY

59 59 Breach Notification Regulations If 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 INTERNAL USE ONLY

60 60 Notification for Breaches Greater than 500 All breaches requiring patient notification must be reported to HHS no later than 60 days after the end of the calendar year (by March 1) If more than 500 individuals are affected, additional requirements include: Immediate notification of the Department of Health and Human Services to post on their website Notification of major media outlets in covered entity area Posting on covered entity website home page for 90 days INTERNAL USE ONLY

61 61 Responsibility to Report Promptly When 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 organizations 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 DID happen INTERNAL USE ONLY

62 62 Question If you suspect that there has been a breach of HIPAA Policies in your UA workplace, you should report your suspicions to a)University Police b)University Office of Legal Counsel c)HIPAA Privacy or Security Officer assigned to your workplace

63 INTERNAL USE ONLY 63 Correct Answer c: The HIPAA Privacy or Security Officer for your workplace should be notified of any possible breach of HIPAA Policies. The employee who reports such suspicions is protected from any repercussions for making his/her concerns known to the HIPAA Officer.

64 INTERNAL USE ONLY 64 Security Standards – General Rules HIPAA 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

65 INTERNAL USE ONLY 65 Rules for Access Access 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

66 INTERNAL USE ONLY 66 Question Once employees have completed HIPAA training, their access to PHI is a)Unlimited b)Based on work duties and responsibilities c)Limited to the minimum necessary information to complete required work d)Both B and C

67 INTERNAL USE ONLY 67 Correct Answer d: Access to PHI is based on need-to-know which is determined by the employees duties and responsibilities. The employee should only access the minimum PHI necessary to complete the required task.

68 INTERNAL USE ONLY 68 Rules for Protecting Information Do 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

69 INTERNAL USE ONLY 69 Encryption of PHI Encryption is generally necessary to protect information outside of the Electronic Medical Records (EMR) system 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 exposure and requires appropriate authorization Use of any personally owned laptops, desktops or other mobile devices (non-UA equipment) for accessing PHI requires appropriate authorization Help UA avoid costly patient notification process by encrypting devices!

70 INTERNAL USE ONLY 70 Password Management Do 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 long – Include 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 (dont use this, just an example)

71 INTERNAL USE ONLY 71 Question Is it acceptable to share your computer password with your fellow employees if they have received HIPAA training. a)Yes b)No

72 INTERNAL USE ONLY 72 Correct Answer b: No. You should not share your computer password.

73 INTERNAL USE ONLY 73 Protection from Malicious Software Malicious 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 virusdo 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 or attachments from an unknown, suspicious, or untrustworthy source or if the subject line is questionable or unexpectedDELETE THEM IMMEDIATELY

74 INTERNAL USE ONLY 74 Beware of Suspicious s Be very cautious of suspicious s that request information such as 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 after sign – URL Link: If you can see the URL in the message, make sure it has before the first slash (/) – Hover trick: If you cant see the URL, you can hover your mouse pointer over the link WITHOUT CLICKING and a box with the URL will appear. Check for

75 INTERNAL USE ONLY 75 Rules for Disposal of Computer Equipment Only 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 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

76 INTERNAL USE ONLY 76 Use of Technology 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 exposure and requires appropriate authorization , 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, should be avoided when communicating unencrypted sensitive PHI - follow your organizations policy for PHI No PHI is permitted on any social networking sites (Twitter, Facebook, MySpace, etc.) No PHI is permitted on any texting or chat platforms (AOL, MSN, cell phones)

77 INTERNAL USE ONLY 77 Question Your office computer is being replaced. You should a)Delete all files that might contain sensitive information b)Have the computer sent to surplus for secure storage c)Contact your HIPAA Security Officer to initiate steps to sanitize the computer

78 INTERNAL USE ONLY 78 Correct Answer c: Contact your HIPAA Security Officer. Deleting files from a hard drive will not permanently remove the files from the computer. Computers should not be taken to surplus until they have been sanitized. Not all used computers go to surplus. Some are reassigned for further use.

79 INTERNAL USE ONLY 79 Facility Access Controls Help to monitor the controls we have for Facility Access – Sign-in Visitors and Vendors (as required) – Insure that locks, card access, or any other physical access controls are working as expected Report any problems or possible problems to your security officer

80 INTERNAL USE ONLY 80 Reporting Security Incidents Notify your Security Officer of any unusual or suspicious incident Security incidents include the following: – Theft of or damage to equipment – Unauthorized use of a password – Unauthorized use of a system – Violations of standards or policy – Computer hacking attempts – Malicious software – Security Weaknesses – Breaches to patient, employee, or student privacy

81 INTERNAL USE ONLY 81 UA Contacts Know Your Security and Privacy Officer: – Medical Center Privacy/Security Officer is Jan Chaisson – Brewer Porch Privacy/Security Officer is Warren Williams – Speech and Hearing Privacy/Security Officer is Becca Brooks – Autism Spectrum Disorders Clinic Privacy/Security Officer is Kelly McKinnon – UA Group Health Plan/FSA Privacy/Security Officer is Emily Marbutt – WellBAMA Program Privacy/Security Officer is Rebecca Kelly – Working on Womanhood Program (WOW) Privacy/Security Officer is Karan Singley – Center for Advanced Public Safety (CAPS) Privacy Officer is Laura Culp, Security Officer is Terry Lee – Institutional Review Board Compliance Officer is Tanta Myles – University-wide Privacy Officer: Jan Chaisson – University-wide Security Officer: Ashley Ewing

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