1. Upholding
Confidentiality
It is your ethical responsibility
Theresa Tapley
MHA690: Health Care Capstone
Ashford University
Dr. David Cole
April 23, 2013

2. Objectives
 Understanding of HIPAA
 Ethical Responsibility to keep each and
every patient’s PHI confidential
 Patient Privacy Rule and Security Rules
 Identification of what PHI is
 Ways to protect PHI
 Tips for electronic confidentiality
protections
 Consequences if confidentiality or PHI
mishandlement

3. What is Health Insurance Portability and
Accountability Act (HIPAA)?
 HIPPA is a federal law that gives an
individual the right of protection of their
personal health information (PHI).
 PHI includes all medical and personal
information and must be protected
whether communication is
verbal, written, or electronic.
(U.S. Department HHS, 2012)

4. Forms of Sensitive Information
Sensitive Information exists in various forms
Printed Spoken Electronic
It is the responsibility of every employee to
protect the privacy and security of sensitive information
in ALL forms

5. What Information is Considered Confidential
and must be Protected?
 Personal billing information
 All medical records
 Conversations between
physician and other
medical staff regarding a
patient
 Information about a
patient within their
Insurance carrier’s
database

6. Patient Privacy Rule Rights
 The right to see and obtain a copy of
their health record
 The right to have corrections added to
their personal health record
 The right to receive notice about how
their health information will be used or
shared for certain purposes
 The right to get a report of when and
why their health information was shared
 The right to file a complaint with the
provider or health insurer
 The right to file a complaint with the U. S.
Government

7. Personal Health Information
How to keep it confidential
 Never leave medical
records where others can
gain access to them
 PHI should be guarded and
kept confidential, shared
only with healthcare
providers involved in their
healthcare
 PHI is confidential and
should not be viewed on
paper or on computer by
unauthorized staff

8. Ways to Protect Confidentiality of PHI
 PHI should only be shared with other healthcare
professionals directly involved in an individual’s
care
 Records are kept locked and only people with a
need to see information about patients have
access to them
 Employees who use computerized patient records
to not leave their computers logged in to the
patient information system while they are not at
their workstations. Computer screens containing
patient information are turned away from the view
of the public or people passing by.

9. More Ways to Protect Confidentiality of PHI
 Posted or written patient information maintained in
work areas such as nurses’ stations or front desk is
kept covered from the public.
 Discussions about patient care are kept private to
reduce the likelihood that those who do not need
to know will overhear.
 Electronic records are kept secure, and the facility
monitors who gains access to records to ensure
that they are being used appropriately.
 Paper records are always shredded or placed in
closed receptacles for delivery to a company that
destroys records for the facility. They must never
be left in the garbage.

10. Understanding the Security Rule
 Specifies a series of administrative, physical, and technical
safeguards for covered entities to use to assure the
confidentiality, integrity, and availability of electronic
protected health information
 The Security Rule defines “confidentiality” to mean that e-PHI is
not available or disclosed to unauthorized persons. The Security
Rule's confidentiality requirements support the Privacy Rule's
prohibitions against improper uses and disclosures of PHI
 The Security rule also promotes the two additional goals of
maintaining the integrity and availability of e-PHI
 Designation of a security official who is responsible for
developing and implement its security policies and procedures

11. Electronic confidentiality protections
 Keep passwords and
other security
features that restrict
access to your
computer private
 Never share
password access or
log in to the health
information system
using a borrowed
credential

12. More steps for protecting
electronic information
 Point computer screen away from the public
 Never walk away from your computer with
PHI up and in view of a passerby
 Never remove computer equipment, disks, or
software unless instructed to do so by your
supervisor
 Never send confidential patient information in
an e-mail unless it is encrypted
 Always double-check the address line of an
email before you send it.

13. Penalties for Breaches
Breaches of the HIPAA Privacy and Security Rules have
serious ramifications for all involved. In addition to
sanctions imposed by this organization, such breaches
may result in civil and criminal penalties.
Statutory and regulatory penalties for breaches may
include:
Civil: $50,000 per incident, up to $1.5 million per calendar
year for violations that are not corrected
Criminal: $50,000 to $250,000 in fines and up to 10 years in
prison
In addition, institutions that fail to correct a HIPAA violation
may be fined up to $50,000 per violation.

14. Best Practice Reminders
 DO keep computer sign-on codes and passwords secret, and DO NOT allow unauthorized
 persons access to your computer. Also, use locked screensavers for added privacy.
 DO keep notes, files, memory sticks, and computers in a secure place, and be careful to NOT
 leave them in open areas outside your workplace, such as a library, cafeteria, or airport.
 DO NOT place PHI or PII on a mobile device without required approval. DO encrypt mobile
 devices that contain PHI or PII.
 DO hold discussions of PHI in private areas and for job-related reasons only. Also, be aware of
 places where others might overhear conversations, such as in reception areas.
 DO make certain when mailing documents that no sensitive information is shown on postcards or
 through envelope windows, and that envelopes are closed securely.
 DO NOT use unsealed campus mail envelopes when sending sensitive information to another
 employee.
 DO follow procedures for the proper disposal of sensitive information, such as shredding
 documents or using locked recycling drop boxes.
 When sending an e-mail, DO NOT include PHI or other sensitive information such as Social
 Security numbers, unless you have the proper written approval to store the information and
 encrypted your computer or e-mail.
(UNC, 2013)

15. References
HIPAA (n.d.) HIPAA training handbook for the healthcare staff: An
introduction to confidentiality and privacy under HIPAA. Retrieved from
website: http://www.regalmed.com/pdfs/HIPAA_Handbook.pdf
Kongstvedt, P.R. (2007). Essentials of managed health care (5th ed.). MA:
Jones and Bartlett Publishers.
U.S. Department of Health & Human Services (2012). Health Information
Privacy. Retrieved form U.S. Department of Health and Human Services
website:
http://www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/ind
ex.html
University of North Carolina (UNC) (2013). HIPAA, privacy, & security.
Retrieved from website:
http://www.unc.edu/hipaa/Annual%20HIPAA%20Training%20current.p
df