This document provides an overview of HIPAA privacy and security training for employees at a covered entity. It discusses key topics including what constitutes protected health information (PHI) under HIPAA, how PHI can be used and disclosed, minimum necessary standards, security safeguards, breach notification requirements, and penalties for noncompliance. Employees are informed that strict compliance with HIPAA privacy and security policies is required to protect patient information.

1. HIPAA Privacy and Security Training For EmployeesCompliance is Everyone’s Job 1 INTERNAL USE ONLY

3. HIPAA Privacy

4. ARRA of 2009: HIPAA Breach Notification Rules and Procedures

5. HIPAA Security

8. Brewer-Porch Children's Center

9. The Speech & Hearing Center

10. Autism Clinic

11. Departments that have signed Business Associate Agreements

12. Group Health Insurance/Flexible Spending Plan/EAP

13. UA Administrative Departments supporting the above entities (like Legal Office, Auditing, Financial Affairs, Risk Management, OIT, UA Privacy/Security Officer, etc.)

14. Research involving PHI from a HIPAA covered entityDoes not apply to Psychology Clinic, Student Health Center/Pharmacy, ODS records, Counseling Center, WRC, Athletic Dept health records

15. INTERNAL USE ONLY 5 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

16. INTERNAL USE ONLY 6 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

17. INTERNAL USE ONLY 7 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 Email 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

19. Minimum per violation: $100 (each name in a data set can be a violation); Maximum per calendar year: $25,000

20. Tier B: Violations due to reasonable cause, but not willful neglect:

21. Minimum per violation: $1,000; Maximum per calendar year: $50,000

22. Tier C: Violations due to willful neglect that organization corrected:

23. Minimum per violation: $10,000; Maximum per calendar year: $250,000

24. Tier D: Violations due to willful neglect that organization did not correct

25. Minimum per violation: $50,000; Maximum per calendar year: $1.5 Million

26. HHS is now required to investigate and impose civil penalties where violations are due to willful neglect

27. Feds have 6 yrs from occurrence to initiate civil penalty action

28. State attorneys general can pursue civil cases against INDIVIDUALS who violate the HIPAA privacy and security regulations

30. INTERNAL USE ONLY 11 UA HIPAA Sanctions Employees who do not follow Privacy and Security Policies and related workplace rules and policies are subject to disciplinary action, up to and including dismissal Type of sanction depends on severity of violation, intent, pattern/practice of improper activity, etc.

31. INTERNAL USE ONLY 12 HIPAA Permitted Uses and Disclosures of PHI A covered entity can always 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 a complete list of permitted uses and disclosures of PHI, see your entity’s notice of health information practices

32. INTERNAL USE ONLY 13 HIPAA Permitted Uses and Disclosures of PHI The HIPAA Privacy Rule states that PHI may be used and disclosed to facilitate treatment, payment, and healthcare operations (TPO) which means: PHI may be disclosed to other providers for treatment PHI may be disclosed to other covered entities for payment PHI may be disclosed to other covered entities that have a relationship with the patient for certain healthcare operations such as quality improvement, credentialing, and compliance PHI may be disclosed to individuals involved in a patient’s care or payment for care unless the patient objects

33. INTERNAL USE ONLY 14 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

34. INTERNAL USE ONLY 15 What HIPAA Did Not Change: Family and friends can still pick up prescriptions for sick people Physicians and Nurses do not have to whisper State laws still govern the disclosure of minor’s health information to parents. (a minor is under the age of 19 in Alabama)

35. INTERNAL USE ONLY 16 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, 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 photographs in patient care areas

36. INTERNAL USE ONLY 17 Required Forms and Documents Used at UA Notice of Health Information Practices Acknowledgement of Receipt of Notice Confidentiality Statement Authorization for Use or Disclosure of Information Accounting of Disclosures Documentation Business Associate Agreements Fax Coversheet Data Use Agreement

37. INTERNAL USE ONLY 18 Business Associate Agreements Are required before a covered entity can contract with a third party individual or vendor (subcontractor) to perform activities or functions which will involve the use or disclosure of the covered entity’s PHI Binds the third party individual or vendor to the HIPAA regulations when performing the contracted services. Must be approved in accordance with appropriate UA policies and procedures Individual employees are NOT authorized to sign contracts on behalf of UA

38. INTERNAL USE ONLY 19 HIPAA Put New Requirements on Research: If you work for a Health Care Provider under HIPAA, do not release PHI for research unless: The patient has signed a valid HIPAA authorization, or The 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 Office of Research Compliance – Director is Tanta Myles

40. 21 First Federal Definition of Breach ARRA provides the first federal definition of a Breach: The unauthorized acquisition, access, use, or disclosure of unsecured PHI which compromises the security or privacy of the information Exceptions: Unintentional acquisition, access, or use of PHI by an employee or individual acting under the authority of a covered entity Inadvertent disclosure of PHI from one person authorized to access PHI at a covered entity to another person authorized to access PHI at the covered entity Unauthorized disclosures in which an unauthorized person to whom PHI is disclosed would not reasonably have been able to retain the information INTERNAL USE ONLY

42. Therefore, for breaches involving the misuse, loss, or inappropriate disclosure of paper or electronic data, there are some “home free” methods under which the loss would indicate no harm done:

43. Paper-secured by use of crosscut shredder (or destroyed)

44. Electronic data-encrypted data files and/or transmissionsINTERNAL USE ONLY

45. INTERNAL USE ONLY 23 Encryption Security Rules require Covered Entity/Business Associate to consider implementing encryption as a method for safeguarding Electronic Protected Health Information (EPHI) If you choose to encrypt, then not required to notify in event of breach

46. 24 What Constitutes a Breach? A breach could result from many activities. Some examples are 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/ePHI 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

47. 25 Example 1 Bill, a billing employee, receives and opens an email containing PHI which a nurse, Nancy, mistakenly sent to Bill. Bill notices that he is not the intended recipient, alerts Nancy to the misdirected email, and deletes it. Was this a breach of PHI? INTERNAL USE ONLY

48. 26 And the answer is… No. Bill unintentionally accessed PHI that he was not authorized to access. However, he opened the email within the scope of his job for the covered entity. He did not further use or disclose the PHI. This was not a breach of PHI as long as Bill did not further use or disclose the information accessed in a manner not permitted by the Privacy Rule INTERNAL USE ONLY

49. 27 Example 2 Rhonda is a receptionist for a covered entity, and, due to her work responsibilities, she is not authorized to access PHI. Rhonda decides to look through patient files to learn about a friend’s last visit to the doctor. Does Rhonda’s action constitute a breach? INTERNAL USE ONLY

50. 28 The answer is… Yes. Rhonda accessed PHI without a work-related need to know. This access was not unintentional, done in good faith, or within the scope of her job for the covered entity. INTERNAL USE ONLY

51. 29 One more example… Rob, a research assistant, wanted to get ahead on some statistical work, so he copied the information from 240 research participants to his thumb drive. The information included PHI, and the thumb drive was not encrypted. On his way home to continue his work, he stopped by the store to get some snacks. When he returned to his car, he found it had been broken into. Missing were his GPS, dozens of CDs, and his book bag containing the thumb drive. Does this event constitute a breach? INTERNAL USE ONLY

52. 30 The answer is… Yes. Unsecured PHI was stolen because the thumb drive was unencrypted. Actually, Rob violated many UA policies: Removed confidential information from the unit without approval Used his personal portable computing device for UA business without senior management approval Copied confidential information to a portable computing device without senior management approval Used a portable computing device that was not encrypted INTERNAL USE ONLY

54. Immediate notification of the Department of Health and Human Services to post on their website

55. Notify major media outlets in covered entity area

56. Post on covered entity website home page for 90 daysINTERNAL USE ONLY

58. Immediately; cooperatively; efficiently; carefully; and confidentially

59. 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

60. It is much better to investigate and discover no breach than to wait and later discover that something DID happenINTERNAL USE ONLY

61. INTERNAL USE ONLY 33 Security Standards – General Rules HIPAA security standards ensure the confidentiality, integrity, and availability of PHI created, received, maintained, or transmitted electronically (ePHI – Electronic 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

63. Access privileges are limited to only the minimum necessary information you need to do your work

64. Access to an information system does not automatically mean that you are authorized to view or use all the data in that system

65. Different levels of access for personnel to ePHI is intentional

66. If job duties change, clearance levels for access to ePHI is re-evaluated

67. Access is eliminated if employee is terminated

69. INTERNAL USE ONLY 36 Encryption of ePHI Encryption is generally necessary to protect information outside of the Electronic Medical Records (EMR) system Use of other mobile media for accessing and transporting ePHI such as smart phones, iPads, Netbooks, thumb drives, CDs, DVDs, etc., presents a very high risk of exposure and requires Use of any personally owned laptops, desktops or other mobile devices (non-UA equipment) for accessing ePHI requires appropriate authorization

71. Do not share passwords or reuse expired passwords

72. Use passwords that cannot be easily guessed (B’day, pets, kids)

73. Choose new passwords when they must be reset

74. Do not write down passwords that could provide access to ePHI

75. Change password if you suspect anyone else knows it

76. Change passwords or delete accounts when employees are transferred or terminated

77. Pick good passwords – Recommendations for good passwords:

78. 8 characters long

79. 3 of 4 data types – Upper, Lower, Numeric and Special Character

80. Change periodically

82. INTERNAL USE ONLY 39 Use of Technology Use of other mobile media for accessing and transporting ePHI such as smart phones, iPads, Netbooks, thumb drives, CDs, DVDs, etc., presents a very high risk of exposure and requires appropriate authorization Email, 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 ePHI is permitted to leave facility in any format without prior approval Where technically feasible, email should be avoided when communicating unencrypted sensitive PHI - follow your organization’s email policy for ePHI No ePHI is permitted on any social networking sites (Twitter, Facebook, MySpace, etc.) No ePHI is permitted on any texting or chat platforms (AOL, MSN, cell phones)

83. INTERNAL USE ONLY 40 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 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 NOTE: Deleting a file does not actually remove the data from the media. Formatting does not constitute sanitizing the media

84. INTERNAL USE ONLY 41 Facility Access Controls Help to monitor the controls we have for Facility Access Sign-in Visitors and Vendors (as required) Insure that locks, card access, or any other physical access controls are working as expected Report any problems or possible problems to your security officer

86. Security incidents include the following:

87. Theft of or damage to equipment

88. Unauthorized use of a password

89. Unauthorized use of a system

90. Violations of standards or policy

91. Computer hacking attempts

92. Malicious software

93. Security Weaknesses