1. HIPAA Job Specific Education1 HIPAA Privacy Keys to Success Updated January 2010

2. HIPAA Job Specific Education2 HIPAA and Its Purpose What is HIPAA?  Health Insurance Portability and Accountability Act of 1996  Title II – Administrative Simplification  It’s a federal law  HIPAA is mandatory, penalties for failure to comply Purpose:  Protect health insurance coverage, improve access to healthcare  Reduce fraud and abuse  Improve quality of healthcare in general  Reduce healthcare administrative costs (electronic transactions)

3. HIPAA Job Specific Education3 HITECH and Its Purpose What is HITECH?  Health Information Technology for Economic and Clinical Health Act  Subtitle D of the American Recovery and Reinvestment Act of 2009 (ARRA)  It’s a federal law Purpose:  Makes massive changes to privacy and security laws  Applies to covered entities and business associates  Creates a nationwide electronic health record  Increases penalties for privacy and security violations

4. Key HITECH Changes –Breach Notification requirements –AOD for treatment, payment, and healthcare operations in electronic health record (EHR) environment –Business Associate Agreements –Restrictions –Right to access –Criminal provisions –Penalties –OCR Privacy Audits –Copy charges for providing copies from EHR –HIPAA preemption applies to new provisions –Private cause of action –Sharing of civil monetary penalties with harmed individuals HIPAA Job Specific Education4

5. 5 Civil Penalties for Non- compliance* Violation CategoryEach ViolationAll such violations of an identical provision in a calendar year Did Not Know$100 - $50,000$1,500,000 Reasonable Cause$1,000 – $50,000$1,500,000 Willful Neglect – Corrected$10,000 - $50,000$1,500,000 Willful Neglect – Not Corrected$50,000$1,500,000 *As of 2/17/09

6. HIPAA Job Specific Education6 Criminal Penalties for Non-compliance For health plans, providers, clearinghouses and business associates that knowingly and improperly disclose information or obtain information under false pretenses. These penalties can apply to any “person”. Penalties higher for actions designed to generate monetary gain  up to $50,000 and one year in prison for obtaining or disclosing protected health information  up to $100,000 and up to five years in prison for obtaining protected health information under "false pretenses"  up to $250,000 and up to 10 years in prison for obtaining or disclosing protected health information with the intent to sell, transfer or use it for commercial advantage, personal gain or malicious harm

7. HIPAA Job Specific Education7 Facility Privacy Official Your FPO is Cynthia Kean, HIM Director Responsible for: –Privacy Program –Privacy Rights of patients –Requests for Privacy Restrictions –Facilitating the training and education of staff

8. HIPAA Job Specific Education8 HIPAA Terminology HIPAA: Health Insurance Portability and Accountability Act HITECH: Health Information Technology for Economic and Clinical Health Act PHI: Protected Health Information CE: Covered Entity (Hospital) ACE: Affiliated Covered Entity (Common ownership) OHCA: Organized Health Care Arrangement (The hospital and medical staff will be considered an Organized Health Care Arrangement) DRS: Designated Record Set (medical record and billing record) AOD: Accounting of Disclosures (patient’s right to receive) Directory: Hospital census list used by volunteers and operators with name and room

9. HIPAA Job Specific Education9 How will HIPAA affect you? Coversheets with confidential statement need to be used on all external faxes. Screens will need to be placed out of public view when possible Patient charts will need to be placed in secure area PHI will need to be placed in Cintas containers for disposal Patient family members will give a passcode for other than directory releases Patient information should only be accessed if there is a need to know

10. HIPAA Job Specific Education10 How will HIPAA affect you? Registration will be giving out a Notice of Privacy Practices brochure to every patient concerning our patient privacy protection policy. Patients will be given the option to “opt out” of our directory. Patients have a right to a copy of their medical record Authorizations need to be obtained from patient to release information for reasons other than for treatment, payment or healthcare operations (TPO)

11. HIPAA Job Specific Education11 What is Protected by HIPAA (PHI)? Name Address including street, city, county, zip code and equivalent geocodes Names of relatives Name of employers All elements of dates except year (i.e. DOB, Admission, Discharge, Expiration, etc.) Telephone numbers Fax Numbers Electronic e-mail addresses Social Security Number Medical record number Health plan beneficiary number Account number Certificate/license number Any vehicle or other device serial number Web Universal Resource Locator (URL) Internet Protocol (IP) address number Finger or voice prints Photographic images Any other unique identifying number, characteristic, code

12. HIPAA Job Specific Education12 What is a Covered Entity (CE)? Health plans, Health care clearinghouses, and Health care providers that transmit electronically for billing –Examples Hospitals Physician Practices Insurance companies Ambulance Transportation Services Hospice Home Health

13. HIPAA Job Specific Education13 What does that mean to me? You can share information without patient authorization as it relates to TPO Other covered entities will request only minimum necessary to perform their job You may request the minimal information necessary from them for reasons of TPO without patient authorization May need to verify the requestor according to policy

14. HIPAA Job Specific Education14 Disclosing PHI to Family Members and Friends Who Call the Unit Patient will be assigned a four-digit passcode. Knowledge of this passcode will allow information, (PHI), to be shared with the family member or friend Distribution of passcode will be the responsibility of the patient Passcode may be changed during treatment –Revocation and password change form must be routed to FPO Passcode will be last 4-digits of patient account number

15. HIPAA Job Specific Education15 Verification of Requestors Requestors via phone will need: –Patient SS#, DOB and one of the following: –Account number, street address, MR#, birth certificate, insurance card or policy number –Scenarios Unknown physician calling from cell phone Family member or friend calling without passcode

16. HIPAA Job Specific Education16 External Faxing Guidelines Limit when possible Verify fax number Utilize preset numbers when applicable Fax machine located in secure location ALWAYS use cover sheet with confidentiality statement for transmittals Highly sensitive information should not be faxed (HIV status, abuse records, etc.)

17. HIPAA Job Specific Education17 Patient’s Right to Access Forward to HIM for processing Must be able to provide access and/or hard copy of record If patient is in-house, HIM will manage access process

18. HIPAA Job Specific Education18 Patient’s Right to Amend Forward request to HIM for processing Right of patient to request amendment to records. Request must be in writing Cannot change or omit documentation already in the medical record If patient is in-house HIM will manage amendment process

19. HIPAA Job Specific Education19 Patient’s Right to Opt out of Directory Patient can opt out of directory at anytime but will probably happen during admission process You may not acknowledge the patient is in the facility or give information about the patient to friends, family or others who may inquire Can still release information to family and friends with 4-digit passcode as defined in the Directory policy. Forward any request for opt out to Registration for processing

20. HIPAA Job Specific Education20 Right to Privacy Restrictions Patients have the right to request a privacy restriction of their PHI NEVER agree to a restriction that a patient may request All requests must be made in writing and given to the FPO to make a decision on NO request is so small that it should not be routed to the FPO

21. HIPAA Job Specific Education21 Patient Privacy Complaints FPO must maintain complaint log in accordance with the complaint process ALL privacy complaints must be routed to the FPO Responses cannot be accompanied by retaliatory actions by the hospital Disposition of complaint must be consistent with the facility’s Sanctions for Privacy Violations Risk Management module of Meditech may be used for complaint tracking

22. HIPAA Job Specific Education22 Accounting of Disclosures (AOD) Right to an accounting of disclosures of protected health information An individual has a right to receive an accounting of disclosures of protected health information made by a covered entity in the six years prior to the date on which the accounting is requested, except for disclosures: –For TPO –To the patient –For directory purposes –To law enforcement or correctional institutions – For national security Additional requirements forthcoming as a result of HITECH regulations

23. HIPAA Job Specific Education23 How will Accounting of Disclosures (AOD) affect me? You must enter information into the AOD for: –State mandated reporting Suspected Abuse Victims Certain Disease reporting such as STDs Brain Injury –Organ and Tissue Donations –Health Oversight Activities (JCAHO)

24. HIPAA Job Specific Education24 Notice of Privacy Practices Patient will receive Notice upon each registration Outlines patient rights –Right to access –Right to amend –Confidential Communication –Right to Privacy Restriction –Right to Opt out of Directory

25. HIPAA Job Specific Education25 Sharing Information with Other Treatment Providers We can share information with physicians and office staff, hospitals, or other treatment facilities just as we do today Need to verify the requestor according to policy Patient information (PHI) can be released for reasons of treatment, payment or health care operations

26. HIPAA Job Specific Education26 Confidential Communications Request for use of alternate address or phone number for future contact Route any request for Confidential Communications to Admissions Should communicate only with alternate address given

27. Breach Notification HITECH provisions require the following notifications when breaches (as defined in the regulations) occur: –To the patient –To the Department of Health and Human Services –To the media when the breach involves more than 500 individuals in the same state or jurisdiction HIPAA Job Specific Education27

28. HIPAA Job Specific Education28 Ensuring Security Compliance Ensure users log off terminals when not in use. PC’s should have screen savers whenever possible. Computer screens should be positioned so information (PHI) is not readable by the public or other unauthorized viewers Printers should be positioned in protected locations so that printed information is not accessible or viewable by an unauthorized person. PHI must be properly disposed.

29. HIPAA Job Specific Education29 Common Exposures on Nursing Units Discussions of patient information in public places such as elevators, hallways and cafeterias Printed or electronic information left in public view (e.g., charts left on counters) Discussing patient information on social networking sites (e.g., Facebook, Twitter) PHI in regular trash Records that are accessed without need to know in order to perform job duties Unauthorized individuals hearing patient sensitive information such as diagnosis or treatment

30. HIPAA Job Specific Education30 Sanctions 3 levels of violations that require disciplinary action –Accidental and/or due to lack of proper education –Purposeful violation of privacy policy or an unacceptable number of previous violations –Purposeful violation of privacy policy with associated potential for patient harm FPO to review facility sanctions policy examples

31. HIPAA Job Specific Education31 Test Your Knowledge 1.The FPO at JFK Medical Center is: a)Gina Melby, CEO b)The President of the Medical Staff c)Cynthia Kean, HIM Director d)Jim Leamon, CFO 2.Does the patient have the right to access or obtain a copy their medical record? a)Yes b)No 3.Can a patient amend their record? a)Yes b)No 4.What is protected by HIPAA (PHI-Protected Health Information)? a)Telephone number b)Names of relatives c)Photos d)All the above Where do you dispose of patient information?

32. Test Your Knowledge 5.What right is NOT provided under HIPAA? a)Right to Opt out of the dictionary b)Right to not pay the bill c)Right to amend d)Right to request Confidential Communication 6. Under HITECH when a breach occurs the following must be notified, EXCEPT: a)The Department of Health and Human Services b)The media when more than 500 individuals reside in the same state or jurisdiction c)The patients next of kin d)The patient 7.One of the purposes of HITECH is to create an electronic health record a)True b)False HIPAA Job Specific Education32

33. To Test Your Knowledge 8.Patients have the right to request a privacy restriction of their PHI. This request must always be forwarded to the : a) Admitting Physician b) The FPO c) The Chief Nursing Officer d) The Quality Director 9. Criminal penalties for non-compliance can apply to any person a)True b)False 10.Examples of exposure would be a)discussions of a patients diagnosis in the elevator b)PHI in the trashcan c)sharing PHI without an authorization when one is required d)sharing of passwords e)All of the above HIPAA Job Specific Education33