1. Health Insurance Portability & Accountability Act “HIPAA” To every patient, every time, we will provide the care that we would want for our own loved ones. Health, healing and hope.

2. The Privacy Rule Protects information known as PROTECTED HEALTH INFORMATION (PHI) that exists in written, oral and electronic formats.

3. Examples of PHI Name Date of Birth Fax Number Account Number Web Universal Resource Locator (URL) Street Address Electronic mail address Certificate/License Number License Plate Number City Discharge Date Social Security Number Vehicle and Serial Number Device Identifier and Serial Number Precinct Date of Death Medical Record Number Internet Protocol Number Full Face Photographic Images Zip Code Telephone Number Health Plan Beneficiary Number Biometrics Identifiers (i.e. finger prints) Any other Unique Identifying Number, Characteristic, or Code

4. The Privacy Rule Limits the way in which members of the GBMC workforce may use and disclose (release) PHI. GBMC workforce must have a job-related reason to use or disclose PHI. Requires that all GBMC workforce use only the minimum amount of PHI necessary to get the job done. This is what HIPAA defines as the MINIMUM NECESSARY standard. “Workforce” means employees, volunteers, trainees, and other persons who conduct work for GBMC and are under the direct control of GBMC, whether or not they are paid by GBMC.

5. The Privacy Rule Provides patients with certain rights – these rights are commonly referred to as the PATIENT PRIVACY RIGHTS. These rights are communicated to the patient in the Notice of Privacy Practices. If a patient wishes to exercise any of these Patient Privacy Rights (which are outlined on the next slide), they must do so in writing. You should contact Medical Records Correspondence Department (443-849-2274) for the correct forms.

6. The Patient Privacy Rights Right to access PHI. Right to request an amendment to PHI. Right to request restrictions on how PHI is used for treatment, payment, and healthcare operations. Right to receive confidential communications. Right to request an accounting of disclosures. Right to complain to the Department of Health and Human Services’ Office for Civil Rights.

7. HIPAA Privacy The Notice of Privacy Practices The Notice is a useful tool not only for you but also for the patient. The NOPP: * describes how GBMC may use a patient’s PHI * provides a clear and concise description of the patient’s rights * discusses how a patient may opt-out of the facility directory * discusses how the medical staff may interact with the patient’s family

8. The Privacy Rule Requires that GBMC provide a way for patients and workforce to REPORT PRIVACY CONCERNS or ask privacy questions. Reporting Privacy Concerns Stacey McGreevy, GBMC Privacy 443-849-4325 Officer HIPAA GroupWise Resource To send an email, type in HIPAA the “To” field 1-800-299-7991 The Business Ethics Line is now the Privacy Hotline too The Compliance Home Page GBMC Infoweb is your source for HIPAA information

9. Privacy Compliance Tips Keep all PHI locked and secured when you are away from your work area. Do not include any patient identifiers in the subject line of an email. Do not discuss PHI in public or common areas. Make sure to check the fax number for accuracy before sending a fax that contains PHI. All faxes must include a completed GBMC standard fax cover sheet (see fax policy for limited exceptions). If a fax is sent to the wrong recipient in error, you must complete the Accounting of Disclosures log located on the Compliance page of the InfoWeb and send it to Medical Records. Sign-in sheets are allowed as long as we continue to follow the standard protocols that have always been in place at GBMC. Sign-in sheets should be limited to patient name and appointment time.

10. The Security Rule Requires administrative, physical, and technical safeguards be implemented to address the confidentiality, integrity, and availability of ELECTRONIC PROTECTED HEALTH INFORMATION (ePHI). Security of patient information is EVERYONE’S job! We owe it to our patients! Electronic Protected Health Information

11. The Security Rule Requires GBMC provide each computer system user with a unique user identity. You user identity is the combination of your user ID and your password – do not share or write down your password where it can be easily retrieved by someone other than you. Your user identity is what is used to monitor your activity on the system (s). Do not leave yourself signed onto a computer and then walk away without signing off. You are responsible for any activity that occurs under your user identity. Your user identity appears on audit reports which are frequently monitored. User Identity

12. Security Compliance Tips Do not store electronic patient health information (ePHI) on your local drive (C:). If you use mobile media devices such as laptops and USB drives, make sure they are encrypted. Avoid emailing PHI but if it is necessary, be sure to encrypt the email by typing the word “SECURE” as the first word in the subject line of the email. If you believe the PHI in paper or electronic form has been used or released in an unauthorized manner, contact the Privacy Office at 443-849-4325.

13. Protecting Your Password In order to protect against unauthorized access to our computers, GBMC has taken appropriate steps to monitor all activity on the network to ensure that people are not trying to break-in to those systems. However, as a user of a GBMC system, it is important that you also take measures to ensure that people cannot access GBMC systems – that is partly accomplished through password management. Password management includes selecting a strong password, protecting your password, as well as frequently changing your password. Password Management

14. Examples of How to Create a Strong Password 1.Mix upper and lowercase characters ○ 3bLINdmice ○ 5gOLDenrings ○ 4cALLingbirdS 2.Replace letters with numbers ○ Replace “E” with “3” ■ “Sp3cial” or “3l3gant” 3.Combine two words by using a special character ○ Roof^Top ○ Sugar$Daddy ○ B@ttercup! 4.Use the first letter from each word of a phrase from a song ○ “Oops! I did it again” becomes “O!idia” In general, passwords should have a minimum length of 6 characters but each application may have other requirements/limitations. Password Management