2.  Has been a federal privacy regulation since 2003. Covers
privacy and security of health information.
 Reviewed in annual education
 Taught in new employee orientation
 The facility Security Officer is Michael Boudreaux
 The facility Privacy Officer is Alane Bryan

3.  Does not replace HIPAA—it gives it TEETH!
 Requires a breach notification policy
 Encourages EHR adoption
 Provides strict data protection regulations for more
secure patient privacy

4. Violation Type Each Violation Repeat Violations/Yr.
Did not know $100 - $50,000 $1.5 million
Reasonable Cause $1,000 - $50,000 $1.5 million
Willful Neglect – Corrected $10,000 - $50,000 $1.5 million
Willful Neglect – Not
Corrected
$50,000 $1.5 million
•Healthcare organizations or providers may be held liable
for violations.
•Individual employees may be prosecuted or may be sued
for civil penalties.

5.  Must notify individuals and HHS and, in some cases the media, of
any substantiated breaches within 60 days.
 Breaches affecting 500 or more patients will be posted to the
HHS.gov website.
 Four factors are used to determine if low to high probability of PHI
is compromise:
1. The nature and extent of the PHI involved in the incident
 Is the PHI sensitive information i.e. Social Security Numbers, or
infectious disease test results
2. The unauthorized recipient of the PHI
 Is another physician receiving the PHI?
3. Whether the PHI was actually acquired or viewed
4. The extent to which the risk to the PHI has been mitigated
 Was it immediately destroyed?

6.  Mass General
 California Breaches
 BCBS of TN Breach
 Individual Prosecution
 Personal Gain

7. Stolen laptops/computers
Lost CDs
ID theft/Social Security Numbers
Medicare Fraud
Access to EMR with no job-related need

8. Using Social Networking to talk about patients
Discussing PHI with employees or family who do not
have a job-related need
Looking at EMR out of concern or curiosity
Telling others that a patient was “in” for treatment
Discussing progress or prognosis in front of family
without permission

9. Using chart to get information to use against patient in
lawsuit or divorce
Looking in minor child’s EMR
Taking a peek for “educational purposes”
Starting conversations with “Don’t tell anyone I told
you this, but…”
Sharing computer access/passwords

10.  Treatment, Payment, Operations
 Some law enforcement exceptions
 Public health reporting
 When in doubt, get a Signed Release
 Disclose “minimal necessary” amount of PHI

11.  Patients/family members requesting patient
information AFTER DISCHARGE should be referred
to the HIM Department
 If a patient requests information during an admission,
make sure the report is FINAL before giving the
information to the patient or to their designee
(document the designee). We do not release
information unless it is in a FINAL status.
 Discuss patient information as quietly as possible

12.  Try not to say the patient’s name repeatedly
 Make sure paper containing PHI makes it to a shred bin
 Shred bins should be dumped in large bins each day
 Use fax cover sheets with the confidentiality clause
 Do not leave messages with too much information
 Wear your employee ID badge at all times
 Do not take pictures in patient care areas. Patients ,
their names, or their family members may be visible
without you realizing it. It is not worth the risk!!

13.  Use workstations for intended purposes
 No gaming, no unauthorized downloading of files,
personal emails are subject to access by P&S Surgical
Hospital
 Log-off or lock your computer when you are not using
it
 Make sure others cannot view your computer screen

14.  Keep passwords secure
 Use your own individual password
 Avoid sharing passwords
 Trigger encryption for emails containing PHI being
sent outside the organization
 If photos must be taken of a patient, use a P&S camera
or device; NEVER use your personal camera or smart
phone

15.  Never share proprietary or confidential information in
blogs or on social media sites
 Report potential breaches, inappropriate disclosures,
or otherwise suspect behavior to your direct
supervisor, the Privacy Officer, the Security Officer, or
the Corporate Compliance Officer

16.  End of presentation