Health Insurance Portability & Accountability Act (HIPAA) April 2005: Health Insurance Portability & Accountability Act (HIPAA) April 2005
Overview of Privacy & the new Security Standards: Overview of Privacy & the new Security Standards
Agenda: Agenda Review HIPAA Privacy Standards
Introduce HIPAA Security Standards
What the Security Standards require
What it means to the way you work
Examples of how things will be different
Legislation: Legislation Federal Law: HIPAA Privacy & Security
Standards mandate protection and
safeguards for access, use and
disclosure of PHI and/or ePHI with
sanctions for violations.
Pertinent Law : Pertinent Law Security Breach Notification (SB 1386): requirement to notify California residents if their electronically held personal information may have been acquired by an unauthorized person
Security Breach Notification (SB 1386): Security Breach Notification (SB 1386) Personal information includes:
Individual’s first name or initial and last
name in combination with one or more of
the following:
Social Security Number
Driver’s License Number
Account number, credit card or debit card number with security or access code
What is HIPAA?: What is HIPAA? HIPAA is a federal law enacted to:
Ensure the privacy of an individual’s protected health information (PHI)
Provide security for electronic and physical exchange of PHI
Provide for individual rights regarding PHI.
HIPAA is Federal Law that requires HIPAA-Covered Entities to:: HIPAA is Federal Law that requires HIPAA-Covered Entities to: Protect the privacy and security of an individual’s
Protected Health Information (PHI):
health information created, stored or maintained by a health care provider, health plan, health care clearinghouse; and
relates to the past, present or future physical or mental health or condition of the individual, the provision of health care to the individual or the payment for the provisions of health care; and
identifies the individual.
Personal Identifiers under HIPAA include:: Personal Identifiers under HIPAA include: Name, all types of addresses including email, URL, home
Identifying numbers, including Social Security, medical records, insurance numbers, account numbers
Full facial photos
Dates, including birth date, dates of admission and discharge, or death
Personal identifiers coupled with a broad range of health, health care or health care payment information creates PHI
Why it affects your work at UC: Why it affects your work at UC UC health plans are Covered Entities;
UC, on behalf of employees, may use or access PHI;
As an employee, you need to understand how HIPAA and other laws allow you to use, access, or disclose a member’s health information.
Who or what are HIPAA “Covered Entities”?: Who or what are HIPAA “Covered Entities”? HIPAA's regulations directly cover three basic
groups of individual or corporate entities:
health care providers, health plans, and
health care clearinghouses.
Health Care Provider means a provider of medical or health services, and entities who furnishes, bills, or is paid for health care in the normal course of business
Health Plan means any individual or group that provides or pays for the cost of medical care, including employee benefit plans
Healthcare Clearinghouse means an entity that either processes or facilitates the processing of health information, e.g., billing service
UC as a “Covered Entity?”: UC as a “Covered Entity?” UC’s Group Health Plans
Self-Funded plans – UC is the covered entity
Subject to all HIPAA Rules
Insured Plans – UC is not the covered entity
When participating in the administration of the plan (e.g., assisting employees with health claim issues, fielding healthcare complaints, and assisting with claim payment resolution)
but, UC has certain obligations under HIPAA
To be safe & for consistency, treat individually-identifiable health information as PHI
UC has various roles: UC has various roles PLAN ADMINSTRATOR/PLAN SPONSOR ROLE Some 'covered' activities under HIPAA are:
handling of a member complaint
resolving a claim payment with a carrier
assisting a member with a health claim issue
EMPLOYER ROLE Some 'non-covered' activities not subject to HIPAA are: - facilitating enrollment into the health plans - verifying eligibility - when a staff member reports an absence - performing Family Medical Leave Act (FMLA) functions
Slide14: HIPAA is on you!
Understand your individual responsibility: Understand your individual responsibility Always maintain a separation between your covered and non-covered activities and know what additional state or federal laws apply to the privacy of an individual’s health information
Never disclose PHI to other non-covered entities (UC or third parties) without Authorization or unless required or permitted by law
Always apply the Minimum Necessary Standard to uses and disclosures of PHI
90/10 Rule
Minimum Necessary Standard : Minimum Necessary Standard Use or disclose only the minimum PHI that you need to know to do your job
A Covered Entity should have in place procedures that limit access according to job class
Limit access, use or disclosure of PHI by others to the minimum amount necessary to accomplish the intended purpose
“Think Twice” Rule:
Is it reasonable?
Is it necessary?
HIPAA Security Standards: HIPAA Security Standards The Security Standards require information security, confidentiality, integrity, and availability of electronic Protected Health Information (ePHI)
What are the Security Rule General Requirements? : What are the Security Rule General Requirements? Ensure the confidentiality, integrity and availability of all electronic protected health information (ePHI) that the covered entity creates, receives, maintains, or transmits.
Protect against reasonably anticipated threats or hazards to the security or integrity of ePHI, e.g., hackers, viruses, data back-ups
Protect against unauthorized disclosures
Train workforce members (“awareness of good computing practices”) Compliance required by April 20, 2005
What this means to You: What this means to You “Information Security” means to ensure the confidentiality, integrity, and availability of information through safeguards.
“Confidentiality” – that information will not be disclosed to unauthorized individuals or processes
“Integrity” – the condition of data or information that has not been altered or destroyed in an unauthorized manner. Data from one system is consistently and accurately transferred to other systems.
“Availability” – the property that data or information is accessible and useable upon demand by an authorized person.
Definition of “ePHI”: Definition of “ePHI” ePHI or electronic Protected Health Information is patient/member health information which is computer based, e.g., created, received, stored or maintained, processed and/or transmitted in electronic media.
Electronic media includes computers, laptops, disks, memory stick, PDAs, servers, networks, dial-up modems, Email, web-sites, e-fax.
Why do I need to learn about Security – “Isn’t this just a Systems Problem?”: Good Security Standards follow the “90 / 10” Rule:
10% of security safeguards are technical
90% of security safeguards rely on the computer user (“YOU”) to adhere to good computing practices
Example: The lock on the door is the 10%. You remembering to lock, check to see if it is closed, ensuring others do not prop the door open, keeping control of keys is the 90%. 10% security is worthless without YOU! Why do I need to learn about Security – “Isn’t this just a Systems Problem?”
Culture Change is Coming: Culture Change is Coming The way we at Human Resources & Benefits do business will change
Your work will be impacted as new paths are found
Easiest Solution: Easiest Solution Don’t do it!
Slide24: So what do we do and why are we doing it?
Workstation Security: Workstation Security “Workstations” include any
electronic computing device, for
example, a laptop or desktop
computer, plus electronic media
stored in its immediate environment
(e.g., diskettes, CDs, e-fax).
Workstation Controls: Workstation Controls Lock-up when you leave your desk! – Offices, files, workstations, sensitive papers and PDAs, laptops, mobile devices / media.
Lock your workstation (Cntrl+Alt+Del and Lock Computer) – Windows XP, Windows 2000
Do not leave sensitive information on printers, fax machines or copiers.
Workstation Controls: Workstation Controls Automatic Screen Savers: Set to 15 minutes with password protection.
Shut down before leaving your workstation unattended or leaving work.
This will prevent other individuals from accessing information under your User-ID and limit access by unauthorized users.
Unique User Log-In / User Access Controls/ Passwords: Unique User Log-In / User Access Controls/ Passwords Access Controls:
Users are assigned a unique “User ID” for log-in purposes
Each individual user’s access to ePHI system(s) is appropriate and authorized
Unauthorized access to ePHI by former employees is prevented by terminating access
Follow procedures to terminate accounts in a timely manner
Your Account Is Only As Secure As Its Password: Your Account Is Only As Secure As Its Password Change your password often (at least once every 180 days)
Don't let others watch you log in
Don’t write your password on a post-it note
Don’t attach it to your video monitor or under the keyboard
Slide30: Password Construction It can’t be obvious or exist in a dictionary.
Every word in a dictionary can be tried within minutes.
Don’t use a password that has any obvious significance to you.
Slide31:
Pick a sentence that reminds you of
the password. For example: If my car makes it through 2 semesters, I'll be lucky (imcmit2s,Ibl)
Only Bill Gates could afford this $70.00 textbook (oBGcat$7t)
Just what I need, another dumb thing to remember! (Jw1n,adttr!)
Slide32: We share offices, equipment and ideas, but...
Do not share your password with anyone, anytime!
Password Management Do not use the same password for critical services at work as you do for personal use.
This is what the Systems staff does for you:: This is what the Systems staff does for you: Uses an Internet firewall
Uses up-to-date anti-virus software
Installs computer software updates & patches
Does automated back-ups & storage for TSM users only In addition you should routinely backup all important data and documents
Cleans devices/media before recycling or destroying
If you want to reuse or recycle zip disks or diskettes send them to BENHUR.
If you need to destroy CDs send them to BENHUR
BENHUR will overwrite or clean a workstation before releasing for re-use or discarding
Automated Data Backup & Storage Tool = TSM: Automated Data Backup & Storage Tool = TSM Systems staff controls backup for critical data for those with TSM (Tivoli Storage Management)**
If you don’t have TSM, you will need to backup your computer manually
Contact your supervisor to determine if you have sensitive & critical data, and need TSM
Supervisors may download forms from http://hr-iss.ucop.edu/op/access/ **You should manually backup your computer periodically even if you have TSM
Device and Media: Device and Media
Security for USB Flash Drives & Other Storage Devices: Security for USB Flash Drives & Other Storage Devices Flash Drives are devices which pack big data in tiny packages, e.g., 256MB, 512MB, 1GB.
HR/Benefits strongly recommends that these devices not be used to house sensitive & critical data
If these devices must be used, all files must be password protected.
Delete temporary ePHI files from local drives & portable media too!
Security for PDAs (Personal Digital Assistants): Security for PDAs (Personal Digital Assistants) PDA or Personal Digital Assistants are personal organizer tools, e.g., calendar, address book, phone numbers, productivity tools, and can contain databases of information and data files with ePHI. PDAs are at risk for loss or theft.
HR/Benefits strongly recommends that these devices not be used to house sensitive & critical data
Examples: Palm Pilot; HP;
Treo; Compaq iPAQ
Remote Access: Remote Access The following minimum standards are required for remote access by personal home computer. More stringent standards may apply in individual units.
Minimum security standards that you are required to have:
Software security patches up-to-date
Anti-virus software running and up-to-date
Turn-off unnecessary services & programs
Physical security safeguards to prevent unauthorized access
HR/Benefits strongly recommends that your personal home computer not be used to house sensitive & critical data
Apply these same standards to all portable devices.
Email Security: Email Security Email is like a “postcard”. Email may potentially be viewed in transit by many individuals, since it may pass through several switches enroute to its final destination (e.g., forwarded, misdirected or never received). Although the risks to a single piece of email are small given the volume of email traffic, emails containing ePHI need a higher level of security.
New Email Policy: New Email Policy Use the Minimum Necessary Standard
Do not send ePHI outside the department (scrub an email before replying to members and others)
Destroy the original email containing PHI as soon as it is not needed
New Email Policy: New Email Policy Response to a member sending an email with unnecessary medical information:
We have received your email requesting ____________.
We are working (have worked) on a resolution of your issue (and the status is______________). For your protection, due to HIPAA and other privacy requirements, we may delete your initial email or the unnecessary personal medical information contained in your email, because we did not require it to address your problem. It is the policy of the University to use only the minimum necessary information to resolve our plan members’ issues.
New Email Policy: New Email Policy TO: Customer.service@ucop.edu
From: AnxiousAnnie@sbc.net
Subject: I need an Operation
Dear Vice President Judy Boyette:
I retired from the University in 1998 after thirty-five years at UC Berkeley. I have always been with Health Net for my medical plan, and have had no problems with them until recently. They even took care of my treatment with Dr. Freud for severe anxiety disorder after my husband died in 1995. But now they have cancelled my coverage.
I have been seeing my doctor recently for back pain and back aches, which he has diagnosed as degenerative disc disease of the lower lumbar. He thinks I will need an operation in the next few months. The Percodan prescription he gave me for pain over the last few months is no longer working. I need surgery soon and can’t get it without my medical coverage.
Please help me.
Anxious Annie
New Email Policy: New Email Policy To: AnxiousAnnie@sbc.net
From: Customer.service@ucop.edu
Subject: Your Health Net coverage
Dear Annie:
We have received your email requesting reinstatement of your Health Net medical coverage. We are working on a resolution of your issue. You should hear from us in the next few days.
For your protection, due to HIPAA and other privacy requirements, we may delete your initial email or the unnecessary personal medical information contained in your email, because we did not require it to address your problem. It is the policy of the University to use only the minimum necessary information to resolve our plan members’ issues.
UC Employee
New Email Policy: New Email Policy If you must send PHI to someone, this is what you should do:
Use the alternate delivery method of:
phone,
dedicated fax machine,
dedicated carrier line, or
hardcopy.
New Email Policy: New Email Policy This is also acceptable for sending PHI
Send an email with the PHI in an attached password protected Word document.
Call the recipients and give them the password over the phone, or send a separate email with the password.
World Wide Web: World Wide Web
On the Wire Universal Access…: On the Wire Universal Access… Estimated 500 million people with Internet access
All of them can communicate with your connected computer
Any of them can “rattle” the door to your computer to see if it’s locked
Opportunities for Abuse: Opportunities for Abuse
To break into a safe, the safe cracker needs to know something about safes
To break into your computer, the computer cracker only needs to know where to download a program
Use of UC’s Internet: Use of UC’s Internet UC's Electronic Communications Policy governs use of its computing resources, web-sites, and networks.
Appropriate use of UC's electronic resources must be in accordance with the University principles of academic freedom and privacy.
Protection of UC's electronic resources requires that everyone use responsible practices when accessing online resources.
Be suspicious of accessing sites offering questionable content. These often result in spam or the release of viruses.
Be careful about providing personal, sensitive or confidential information to an Internet site or to web-based surveys that are not from trusted sources.
http://www.ucop.edu/ucophome/policies/ec/brochure.pdf
90/10 Rule: 90/10 Rule Information ownership rests with you.
System ownership rests with systems staff, systems managers and executive staff
Your Responsibility to Adhere to UC-Information Security Policies: Your Responsibility to Adhere to UC-Information Security Policies Users of electronic information resources are responsible for familiarizing themselves with and complying with all University policies, procedures and standards relating to information security.
Users are responsible for appropriate handling of electronic information resources (e.g., ePHI data)
Safeguards: Your Responsibility: Safeguards: Your Responsibility Protect your computer systems from unauthorized use and damage by using:
Common sense
Simple rules
Technology
Remember – By protecting yourself, you're also doing your part to protect UC and our members’ data and information systems.
Security Incidents and ePHI (HIPAA Security Rule): Security Incidents and ePHI (HIPAA Security Rule) Security Incident defined:
“The attempted or successful or improper instance of unauthorized access to, or use of information, or mis-use of information, disclosure, modification, or destruction of information or interference with system operations in an information system.”
Another Security Breach Law SB 1386: Another Security Breach Law SB 1386 “Security breach” per UC Information Security policy (IS-3) is when a California resident’s unencrypted personal information is reasonably believed to have been acquired by an unauthorized person. Personal Identifiable information means:
Name + SSN + Drivers License +
Financial Account /Credit Card Information
Good faith acquisition of personal information by a University employee or agent for University purposes does not constitute a security breach, provided the personal information is not used or subject to further unauthorized disclosure.
Examples of Security Breach: Examples of Security Breach UC Berkeley library data base hacked
UC Berkeley laptop stolen
UCSF accounting department test server compromised
UCLA laptop with blood bank information stolen
UCSD student database hacked
Report Security Incidents: Report Security Incidents You are responsible for:
Reporting and responding to security incidents and security breaches.
Reporting security incidents & breaches to:
HIPAA Privacy Liaison & HR/B IT Security Officer: Eva Devincenzi
Or,
HR/B Security Coordinator: Stephanie Rosh
What are the Consequences for Security Violations?: What are the Consequences for Security Violations? Risk to integrity of sensitive & critical information, e.g., data corruption or destruction
Risk to security of personal information, e.g., identity theft
Loss of valuable business information
Loss of confidentiality, integrity & availability of data (and time) due to poor or untested disaster data recovery plan
What are the Consequences for Security Violations?: What are the Consequences for Security Violations? Embarrassment, bad publicity, media coverage, news reports
Loss of members’, employees’, and public trust
Costly reporting requirements for SB 1386 issues
Internal disciplinary action(s), termination of employment
Penalties, prosecution and potential for sanctions/lawsuits
Sanctions for Violators: Sanctions for Violators Employees who violate UC policies and procedures regarding privacy/security of confidential, restricted, and/or protected health information or ePHI are subject to corrective and disciplinary actions according to existing policies.
Want to Learn More? References & Resources: Want to Learn More? References & Resources UC Systemwide HIPAA Website (http://www.universityofcalifornia.edu/hipaa/)
ISS Website (http://hr-iss.ucop.edu)
Exchange (under Benefits Information/HIPAA folder)
UC Information Security Policy
(http://www.ucop.edu/ucophome/policies/bsfb/bfbis.html)
Guidelines for HIPAA Security Rule Compliance, University of California (On Exchange under Benefits Information/HIPAAfolder/HIPAA policies.doc)
Summary: Summary Review of HIPAA Privacy Standards
Introduce HIPAA Security Standards
What the Security Standards require
What it means to the way you work
Examples of how things will be different Effective April 20, 2005
You are finished: You are finished If you have questions about HR/B HIPAA compliance or procedures, email your questions to the HIPAA Privacy Liaison for HR/B & HR/B IT Security Officer -
Eva.Devincenzi@ucop.edu
If you have no questions, complete the Certification form in these materials (see next page) and send to Information Systems Support.
Security Awareness Training HR/B CERTIFICATE: Security Awareness Training HR/B CERTIFICATE Security Awareness Training Module completed by:
Print Name: First: ___________Last: _________
Date of Training: _________
Unit: ___________ Phone # ______________
___________________________
Signature
Print this page out, complete it, and return it to Eva Devincenzi at HR/Benefits, Information Systems Support.
Slide64: This completes your HIPAA Security Training