Presentation on theme: "Alliance for Clinical Education (ACE) HIPPA Training Sept 2012"— Presentation transcript:
1Alliance for Clinical Education (ACE) HIPPA Training Sept 2012
2ObjectivesDescribe the HIPPA Privacy rules and regulations Identify patients’ rights and your role in protecting them Discuss your responsibilities under HIPPA – related policies and procedures Explain the penalties for non-compliance
3Protecting Patient Privacy IS EVERYONE’S RESPONSIBILITY
4Your Responsibilities Respect the patient’s right to privacyKnow the facility’s privacy policiesBe sensitive
5DefinitionsHIPPA – the Health Insurance Portability and Accountability Act of A federal law that specifies the types of measures required to protect the security and privacy of personally identifiable health information.Patient Confidentiality – keeping information about a patient’s health care private. The information is shared only with those who need to know in order to perform their duties on behalf of the patient.
6Definitions continued… Protected Health Information (PHI) – medical information that can be traced to, or identified with, a particular patient. PHI is information created or received by a health care organization that relates to the past, present, or future health or condition of an individual.Transaction – the exchange of information between two parties to carry out financial or administrative activities related to health care.
7HIPPAWhat is it?“Patients have the right to have health information kept private and secure”**HIPPA is mandatory, there are penalties for failure to comply
8Covered Information Confidentiality and Privacy All protected, identifiable health information (PHI) must be considered and treated as confidential and all patients have the right to request restrictions on who will see their PHI.SecurityEstablishes the requirements for ensuring the confidentiality, availability and integrity of PHI
9Patients have the Right to: Expect privacy and freedom from intrusions or disturbances regarding his/her personal affairs.Expect that all communications and records concerning his/her care will be treated as confidential. Information will be shared only with those who need to know the information to perform their duties on behalf of the patient.Review the records pertaining to his/her medical care.
11Confidential? How do I know? Did you learn the information through caring for your patient?If yes, then consider it confidential
12Understanding PHI (Protected Health Information) Is created by a health care providerIs information that there is a reasonable basis to believe it could be used to identify the patientRelates to past, present or future physical or mental condition of an individual; provision of healthcare or for payment of care provided to an individualIs transmitted or maintained in any form (electronic, paper or oral representation)
13Privacy Protected Elements Health information is considered individually identifiable if any of the following are present:Certificate/license numberAny vehicle or other device serial numberWeb Universal Resource Locator (URL)Internet Protocol (IP) address numberFinger or voice printsPhotographic imagesAny other unique identifying number, characteristic, code that could be used to identify the patientName Full address Names of relatives Name of employers Birth date Telephone numbers Fax numbers Electronic addresses Social security number Medical record number Health plan beneficiary number Account number
14Patients Right to Receive Notice of Privacy Practices Items required to be included in the Notice:How medical information is used and disclosed by an organizationHow to access and obtain a copy of their medical recordsA summary of patient rights and facility responsibilities under HIPPAHow to file a complaint and contact information for filing a complaint
15Facilities Notice of Privacy Practices The patient has the right to receive a Notice of Privacy Practices:Must provide the notice at the first encounter with the patientMust attempt to obtain written acknowledgement of receipt of the Notice of Privacy Practices
16Minimum Necessary HIPPA Requirement: Identify members of the work group who need access to confidential informationIdentify what information can be accessedLimit accessWHAT GROUP DO YOU BELONG TO?Complete Access:Clinical departmentsHealth Information ManagementStudents & Clinical Instructors: limited to assigned patients onlyLimited Access:Admissions/Business OfficeNo Access:Departments or individuals whose job does not require any handling of PHI (Food Services, Environmental Services/Housekeeping)
17Discussions of PHIStaff will discuss patient information to share information and the treatment plan. Every effort should be made to protect the privacy of the patient by minimizing risk that others can overhear the conversation. The discussion of PHI should never occur in public areas such as the cafeteria or elevators. Discussions can occur at the nursing station and with a patient in a treatment area.
18Minimum NecessaryWhat can I access as a student or clinical instructor?Only the information you “NEED TO KNOW” to care for assigned patient(s)DO NOT access information when you are not assigning or student is not caring for that patient any longer or for any patients you not assigned to care for
19Patient Right to Access Patients have the right to:Access or inspect their health recordObtain a copy of their health record from the healthcare providerReasonable fees may be charged for copyingAccess and copying for as long as the information is retainedFacility must act on request for access no later than 10 days after receipt (Colorado Law)Students: Refer requests for access to the facility staff
20Patients Right to Request Privacy Restrictions The patient has the right to request an organization restrict the use and disclosure (release) of their protected health informationCan request restriction in use of information for treatment, payment or healthcare operation purposes (TPO)Organization is not required to agree with the request for restrictionsRequests must be made in writingNo staff level individual should accept any requested restrictionsStudents: Refer requests for restrictions to the facility staff
21Patients Right to Amend Patients have the right to request an amendment to their PHIAmend is defined as the right to add/revise information with which s/he disagrees. The original information is not removed from the record but the amended/corrected information is added to the record.Students: Refer requests for amendments to the facility staff
22As a Student How do I Handle…. An individual asking for access to their record?Students: Refer requests for access to the facility staffThe staff will follow-up per specific facility policy
23Disclosure ??? What is it???The release, transfer, access or divulging of PHI (protected health information) to an outside person or entityStudents do not participate in this process
24Disclosure can occur without the patient’s consent under the following conditions: When required by law For public health activities to control disease, injury or disability For disaster relief In cases of abuse and neglect For coroners, funeral directors and organ donation For legal proceedings For worker’s compensation In cases of communicable diseases
25Student Responsibilities In a patient room or exam roomKnock before entering roomIdentify yourself as a studentClose door after entering the room if okay with patientAsk visitors to leave the room unless patient requests otherwiseSpeak softly if roommate presentIn a clinic or office settingSign in sheets should contain minimal amount of PHIStreet address or reason for visit should not be on sign in sheets
26Student Responsibilities cont… At the Nurses’ StationDo not leave patient information, e.g. flow sheets, charts, sticky notes, lab reports or x-rays out in the open where others may view. When finished working on it, put it back where it belongsShred all documents with PHI, do not put in garbage, do not take them homeWhen at the nurses’ station, speak softly when discussing PHI. It is best to use a private area to discuss the patient
27Student Responsibilities cont… At the ComputerHave screen facing away from the public so it is not visible to patients, visitor and other unauthorized personsAlways log off when leaving the computerChange the password on your computer if required by clinical facilityDo not share your log-in information or password with anyone else. You are responsible for what is done under your log-in
28Student Responsibilities cont… UsingAlways use protected, encrypted to communicate with your faculty and clinical instructorsNever use PHI in attachments or in the itself for the following reasonscan easily be sent to the wrong person, either on purpose or by accidentdoes not ensure privacy of information transmitted
29Student Responsibilities cont… Do not post PHI or discuss patients you have met on web-based chat rooms (My Space, Facebook)Do not take photos of patientsDo not photocopy medical recordsAt the FaxStudents do not use the fax machine during the clinical experience
30Student Responsibilities cont… Using an InterpreterWhen interpreter services are needed, follow clinical agency practiceIn PublicNever mention a patient’s PHI in public as people are often watching and listening, as you never know who knows the patientNever carry, review, discuss or disclose a patient’s chart or PHI in a public place
31ScenariosFollowing are scenarios to help you think through privacy related situations in the clinical facilities After reading each scenario, think how you would answer the question before going to the next slide Scenario answers follow each scenario
32Scenario #1One of your fellow students who had lab work done recently, called you from home and asked you to look up her lab results on the computer and give her the results. Do you look up your fellow students lab results?
33Scenario #1 AnswerNo. Since you are not providing treatment to your fellow student, you are not permitted to look up her lab results and provide them to her. She needs to get this information from her doctor This applies to your own records as well
34Scenario #2You see your fellow student reading through a patient's medical record. She is not providing treatment for this patient. What do you do?
35Scenario #2 AnswerTell your clinical instructor. He/she will follow-up with the student. The clinical instructor then needs to notify the facility privacy officer of this action
36Scenario #3Your sister’s close friend is having surgery at the organization where you are doing a clinical rotation. She asks you to find out what you can about the friend’s condition. Should you call and ask around to the nurses you know? Should you look up the friend’s medical record?
37Scenario #3 AnswerNo. Even if you and your sister have the best intentions you have no right to look at private information about her friend’s health. Suggest to your sister that she call the facility or visit the information desk. If the patient has agreed to have her information available, hospital staff will assist her in obtaining information on her friend. Do not seek out confidential patient information unless you need it to do your job. When you happen to hear confidential information, do not repeat it to anyone. Looking at patient records for any non business reason is cause for disciplinary action and can have possible legal consequences.
38Scenario #4You are called to work in a patient's room to perform a routine job. You knock on the door and are invited in. You see that a nurse is in the room discussing the patient’s condition or medication. What should you do?
39Scenario #4 AnswerIf you must do the job immediately to properly care for the patient, ask whether you can interrupt. If the job can wait, explain that you are there to perform a routine job and will return in minutes. This protects the patient’s privacy by allowing him/her to openly discuss his/her condition without being overheard Some patients may say that it is acceptable for you to stay in the room during the conversation. But remember that a patient may not feel comfortable sharing everything about his/her symptoms or medical history while you are in the room. They also might not feel comfortable asking you to leave. It would be best for you to come back later.
40Scenario #5You are working the ER when you see that a neighbor has arrived for treatment after a car crash. You hear someone saying he will be taken to surgery soon. Your neighbor’s wife works in another part of the hospital. Should you notify her that her husband is in the ER?
41Scenario #5 AnswerNo. Tell the nursing staff that you know the patient and his wife. Tell them that if they need to locate her, you can help. When patients are in the hospital, they have the right to decide who should know that they are there. Your neighbor has a right to privacy and may not want to notify his family of the accident. If he is conscious, the ER staff will allow him to decide whom to notify that he is there. If he is unconscious, the doctors and nurses will use their professional judgment about whether to notify his wife. Leave the decision up to the ER staff. They will let you know whether they need your help to find the patients wife.
42Scenario #6You are in the nurses’ station where the patient’s medical records are located in the chart rack. You spot the name of a close friend. Should you stop by her room?
43Scenario #6 AnswerNo. if you learned of your friend’s stay only by seeing the name on a medical record on the chart rack, you should not go to her room. You should inform your clinical instructor of your relationship with her so that you are not assigned to care for her. If you find out from the patient or her family member that she is a patient there, feel free to visit her after your shift.
44Scenario #7You are walking by a trashcan and notice a pile of photocopied records has been laid on top of the trash. How should you handle this?
45Scenario #7 AnswerDon’t just take the records to a shredder or locked disposal container yourself. Gather the records and take them to your Clinical instructor. He or she will report it to the Manager of the unit who will investigate the incident and report it to the organization’s privacy officer.
46Scenario #8A woman provides the name of a patient and asks for information. What can you tell her?
47Scenario #8 AnswerRefer the woman to the information desk Check the facility directory. If the patient is listed in thedirectory, you can tell the woman the patient’s location. If the patient has requested that his name not be included in the directory, you can not give out any information about them to anyone or even acknowledge that they are here, regardless of the person’s relationship to the patient.
48Scenario #9At the nurses’ station, you are approached by someone asking to see a patient record. What do you do?
49Scenario #9 AnswerRefer to agency staff for clarification of identification and appropriateness of request.
51Patient’s Right to File a Complaint The patient has the right to file a complaint if s/he believes privacy rights have been violated**Organization must provide contact information for filing a complaint
52Doing Your PartAccess confidential information ONLY if you need it to care for your patient.Protect your computer passwordsUnderstand the facility’s privacy policiesReport problems to the facility staff
53As a Student Patient identification Cannot use patients’ initials Need to assign a number to the patient for identificationCare plansAny notes with PHI gathered must be shredded after the assigned shiftThe use of PDAs or pocket PCs to RECORD patient information is not allowed
54Penalties……. Both criminal and civil penalties for: Failure to comply with HIPPA requirementsKnowingly or wrongfully disclosing or receiving individually identifiable health informationObtaining information under false pretensesObtaining information with intent to:Sell or transfer itUse it for commercial advantageUse it for personal gainUse it for malicious harmFines as high as $250,000 and prison sentence of up to 10 years
55Family Educational Rights and Privacy Act FERPA refers to confidentiality in regards to students. Your information is also to be kept confidential and accessed only by those who need to know.FERPA generally prohibits the improper disclosure of personally identifiable information derived from education records.
56References HIPPA Programs from: Arapahoe Community College Craig HospitalCenturaHCA-HealthONEDenver HealthPresbyterian St. Luke’sRegis University