1. HIPAA Privacy & Security EVMS Health Services 2004 Training

2. Privacy & Security Privacy –what should be protected Security –how to protect it

3. Privacy What should be protected? Any health information that can be used to identify the patient

4. Patient Identifiers Name Date of Birth Date of Visit Social Security # Postal Address (even zip) Telephone/Fax # Medical record/Chart # Email Address/URL Account # Photographs

5. Privacy Ways to protect patient information: –Turn computer screens inward –Keep patient schedules covered –Talk quietly – don’t use patient’s name –Shred documents –Verify identity before disclosure –Use security controls

6. Security Is a process not a product Examples of Security Controls –Set automatic log offs after 20 minutes –Use screensavers w/ password features –Virus protection software –Log-on trails

7. Security Weakest link in security is people why? Don’t see it as important Laziness Averse to technology Don’t know controls are there

8. People Controls - management/leadership Don’t assign system passwords until employees have Privacy Training Tell staff how to safeguard work areas Store confidential information on network drive – not hard drive Don’t ever share passwords

9. People Controls Monitor Behavior  Are staff logging off computers?  Are they accessing information not needed for their job?  Is sensitive information removed whenever possible (minimum necessary rule?)  Are fax cover sheets used?  Are recycling bins used?

10. People Controls Monitor Actions  Is the Privacy Notice prominently displayed?  Are new patients being asked to initial/sign the privacy notice acknowledgement?  Are accidental disclosures logged in the patient’s disclosure log?  Are privacy complaints being forwarded to the privacy office?

11. Fax Transmittals - controls Always use a fax cover sheet that lets the recipient know who to contact “just in case” there is a transmission error – If you make a mistake, the “unauthorized” disclosure must be logged in the patient’s medical record.

12. Disclosure Log - in the medical record We are required by law to “log” the following types of disclosures: Public health Social Services Law enforcement Unauthorized (or accidental) disclosures

13. Data bases #1 Risk area Do it right Get patient authorization (even for prospective research) Protect data w/ security controls Limit access Don’t store on portable devices Update data fields

14. EVMS Privacy & Security Manuals It is your responsibility to follow the EVMS HIPAA Privacy & Security Policy & Procedures Each manager is required to review the Privacy & Security procedures with staff Privacy Policy & Procedures: http://hsmail.evms.edu/compliance/compliance web/ http://hsmail.evms.edu/compliance/compliance web/ Security Policy & Procedures: http://info.evms.edu/bfis/postdocs/itac_1/hipaa_ /policies_/bov20030710secu/default.htm

15. Mini Quiz Someone is caught accessing the PHI of a co-worker. How do you handle this situation?  Report person to supervisor/Privacy Office  Tell person that she can get fired, but don’t report to Privacy Office  Find out what person was looking at so you can report it (click mouse for answer) Report person to supervisor/Privacy Office immediately

16. Mini Quiz What are some ways to protect patient information?  Turn computer screens inward  Keep schedules covered up  Talk quietly, without using the patient’s name  All of the above (click mouse for answer) All of the above

17. Mini Quiz You use an electronic device to store/use health information. How do you protect the information?  Log off system when not in use  Store information on password protected network drive  Keep portable devices on you or locked up at all time  All of the above (click mouse for answer) All of the above

18. Mini Quiz The following are patient identifiers: A) Date of birth B) Date of office visit C) Strep throat diagnosis D) A & C E) A & B (click mouse for answer) E) A & B

19. Mini Quiz A patient does not want to be contacted by EVMS for fundraising purposes. What should be done? A) remove patient’s address & telephone # from IDX B) ask patient to complete an opt-out fundraising form & forward to Privacy Office C) call the EVMS Institutional Advancement office for advice (click mouse for answer) Answer is B!

20. Mini Quiz Are you allowed to share passwords?  It is ok to give passwords to nurses, but no one else  IDX passwords can be shared but not electronic medical record passwords  No one is allowed to share passwords – ever (click mouse for answer) No one is allowed to share passwords!

21. Privacy - questions/concerns Contact the Privacy Office: