1. For UA Health Care Components, Business Associates & Health Plans
HIPAA Privacy and Security Annual Renewal Training For Employees Compliance is Everyone’s Job
For UA Health Care Components, Business Associates & Health Plans
INTERNAL USE ONLY

2. 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.
INTERNAL USE ONLY

3. 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
INTERNAL USE ONLY

4. 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
INTERNAL USE ONLY

5. 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
INTERNAL USE ONLY

6. 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
INTERNAL USE ONLY

7. Notice of Health Information Practices
Explains how the covered entity will use/disclose patient’s PHI
Explains a patient’s 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 facility’s web page and in patient reception area
INTERNAL USE ONLY

8. 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
INTERNAL USE ONLY

9. Authorization as Permitted Use and Disclosure of PHI
A covered entity can generally use and disclose PHI for any purpose if it gets the person’s signed HIPAA-valid authorization
Only designated, HIPAA-trained personnel are permitted to approve disclosure of PHI per the person’s 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 patient’s authorization, see your entity’s Notice of Health Information Practices
INTERNAL USE ONLY

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

11. 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
INTERNAL USE ONLY

12. 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
INTERNAL USE ONLY

13. Patient Rights Under HIPAA
The Notice of Health Information Practices outlines the patient’s 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
INTERNAL USE ONLY

14. 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 UA’s Office for Research Compliance.
INTERNAL USE ONLY

15. 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 entity’s 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.
INTERNAL USE ONLY

16. 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

17. 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

18. 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

19. 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

20. 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 organization’s 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

21. 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
INTERNAL USE ONLY

22. 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
INTERNAL USE ONLY

23. 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
INTERNAL USE ONLY

24. 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 following University policy that requires encryption
INTERNAL USE ONLY

25. 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 (don’t use this, just an example)
INTERNAL USE ONLY

26. 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 virus—do 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 unexpected—DELETE THEM IMMEDIATELY
INTERNAL USE ONLY

27. Ransomware
Ransomware is malicious software that denies access to data, usually by encrypting the data with a private encryption key that is only provided once the ransom is paid 
Presence of ransomware (or any malware) on a covered entity’s or business associate’s computer systems is a security incident
Whether it results in an impermissible disclosure of PHI and/or a breach depends on the facts and circumstances of the attack
When ePHI is encrypted due to a ransomware attack, a breach has occurred because the ePHI was acquired
Once the ransomware is detected, we must initiate our security incident and response and reporting procedures
If computer with encrypted data is powered on and the operating system loaded, the data is decrypted and breach notification may need to occur
Notification of a breach of unencrypted or decrypted data must occur unless there is a  “low probability the PHI has been compromised”
Maintaining frequent backups and ensuring ability to recover data from backups may show low probability (if no exfiltration of PHI)
INTERNAL USE ONLY

28. Beware of Suspicious Emails
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 ua.edu after sign
URL Link: If you can see the URL in the message, make sure it has ua.edu before the first slash (/)
Hover trick: If you can’t see the URL, you can “hover” your mouse pointer over the link WITHOUT CLICKING and a box with the URL will appear. Check for ua.edu
INTERNAL USE ONLY

29. 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 organization’s policy for PHI
No PHI is permitted on any social networking sites (Twitter, Facebook, MySpace, etc.) without appropriate authorization
No PHI is permitted on any texting or chat platforms (AOL, MSN, cell phones)
If a situation requires use of or text, appropriate encryption techniques must be used.
INTERNAL USE ONLY

30. 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 or your departmental IT support teams 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
INTERNAL USE ONLY

31. 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
INTERNAL USE ONLY

32. UA Contacts Know Your Security and Privacy Officer:
University-wide Privacy Officer: Jan Chaisson
University-wide Security Officer: Ashley Ewing
University Medical Center Privacy Officer is Jan Chaisson
University Medical Center Security Officer is Amy Sherwood
Brewer Porch Privacy/Security Officer is Warren Williams
Speech and Hearing Privacy/Security Officer is JoAnne Payne
Autism Spectrum Disorders Clinic Privacy/Security Officer is Sarah Ryan
UA Group Health Plan/FSA Privacy Officer is Emily Marbutt
UA Group Health Plan/FSA Security Officer is Greg Gaddis
WellBAMA Program Privacy/Security Officer is Heather Clayton
Working on Womanhood Program (WOW) Privacy/Security Officer is Jill Beck
Center for Advanced Public Safety (CAPS) Privacy/Security Officer is Vaughn Poe
Institutional Review Board Compliance Officer is Tanta Myles
College of Education Alabama Medicaid Agency Project Privacy/Security Officer: Rick Houser
INTERNAL USE ONLY