HIPAA Training

HIPAA: Privacy/Info Security :

HIPAA: Privacy/Info Security Jeff Jones HIPAA Privacy Officer HIPAA Information Security Officer KY Region

Instructions:

Instructions As part of required work for your program, you are asked to complete the following HIPAA Training. Please view the presentation and complete the test at the end. Check your own answers. Print out the completion page and sign and date it. Only this page is to be turned into your instructor. This presentation was created with the collaboration of Lourdes Hospital.

What you should know…:

Protected Health Information (PHI) Disclosure & Use Authorization Form Minimum Necessary Patient Notice Privacy Officer Security Awareness Security Training Information Security Officer Security Mistakes Penalties What you should know… Discussion Topics

What Does HIPAA Do?:

What Does HIPAA Do? Imposes new restrictions on the use and disclosure of PHI Gives patients greater access to their medical records Gives patients greater protection of their medical records

What is PHI?:

What is PHI? Protected Health Information: Individually Identifiable Health Information (IIHI) relating to the past, present or future health condition of the individual and is transmitted or maintained in any form (electronically, orally or on paper). Examples: Name, address, dates of service, date of birth, social security number, etc.

What is Disclosure & Use?:

What is Disclosure & Use? Use : Shared, examined, applied or analyzed within an entity that holds the information. Disclosure : Released, transferred, or made accessible to anyone outside the entity holding the information.

When can PHI be Used/Disclosed?:

When can PHI be Used/Disclosed? PHI can be use or disclosed for: T reatment, P ayment, Healthcare O perations With authorization from the individual Disclosure to the patient Incidental uses

When is Authorization Required?:

When is Authorization Required? Generally speaking, for uses other than: T reatment P ayment Hospital O perations

What is an Authorization Form?:

What is an Authorization Form? An authorization is a written document, signed by the patient, that specifically allows the covered entity to disclose PHI with patient’s permission.

When is Authorization Not Required?:

When is Authorization Not Required? To maintain a patient directory To inform family members of patient location, general condition, or death Public health activities Coroners, medical examiners, funeral directors, organ donations To avert a serious threat to health and safety

What is “Minimum Necessary”?:

What is “Minimum Necessary”? Make sure the least amount of health information is shared to accomplish the task Identify those who regularly access PHI and the types of PHI necessary for proper TPO of the patient

What is the Notice of Privacy Practices?:

What is the Notice of Privacy Practices ? The Patient Notice is a required document that outlines the common uses of PHI. Must contain patient’s rights and the covered entity’s legal duties Must be made available in print Must be displayed at the site of service and posted on a web site

Security Awareness What is it?:

Security Awareness What is it? Recognizing what types of security issues may arise in the workplace, and Knowing what actions to take in the event of a security breach.

Security Awareness/Training:

Security Awareness/Training The HIPAA Security Rule requires that everyone in the workforce is trained Members of the workforce include volunteers!!!

What’s a person to do?:

What’s a person to do? Always Report Anything Unusual Notify your supervisor if you suspect a security incident Never share your user ID or password with anyone

Top 10 Workplace Security Mistakes:

Top 10 Workplace Security Mistakes 1. Hidden under the keyboard – Keeping a computer password on a yellow post-it note 2. I’ll do it my way – Not listening to or following security procedures 3. On, gone, not locked – Walking away from the computer, leaving it unlocked or not turned off 4. Gee, what’s in this attachment – Unknown email attachments can cripple by carrying viruses 5. Weak passwords – Passwords based on information easily accessible to others

Top 10 Workplace Security Mistakes:

Top 10 Workplace Security Mistakes 6. Loose lips – Talking in public about things you shouldn’t 7. Laptops with legs – Laptops left unsecured and unattended are vulnerable to theft 8. Law enforcement – Managers and supervisors need to ensure ongoing compliance 9. The threat within – Statistically, most security breaches originate inside the organization 10. Update now – Security updates don’t do any good unless they are loaded on your computer

How do we comply?:

How do we comply? HIPAA requires that we assign a “Privacy Officer” and “Information Security Officer” This person will be responsible for overseeing all privacy policies and procedures. This person will be the contact person for receiving complaints Institute a training program for Volunteers

What if we don’t comply?:

What if we don’t comply? Civil penalties from $100 to $25,000 Criminal penalties up to $250,000 and 10 years in prison

Summary:

Remember: It’s all about protecting patient’s right to privacy and security Put yourself in the patient’s place Summary

Test Your Knowledge:

Test Your Knowledge True or False 1. It is ok if I discuss a patient with my spouse, he or she won’t tell anyone. True or False 2. It is not a breach of HIPAA if you check on your neighbor’s condition who was admitted to ICU because she is like family to you without authorization from the patient. True or False

Slide 22:

3. HIPAA was designed to provide the public with any and all health information on a patient without proper authorization. True or False 4. Patients can be verbally notified of their privacy rights according to HIPAA. Written notification is not necessary. True or False

Slide 23:

5. The HIPAA Security Rule requires that everyone in the workforce is trained. True or False Answers: 1.F 2.F 3.F 4.F 5.T

Please print out this page and sign & date it, then turn it into your instructor.:

Please print out this page and sign & date it, then turn it into your instructor. Health Insurance Portability & Accountability Act – Instruction Session I completed the instruction session on the Health Insurance Portability & Accountability Act (HIPAA) on ______________________. I understand the privacy and confidentiality policies of the clinical facilities I will be attending for my clinical experiences. I know the condition information terminology, the policies regarding “privacy patients” and the disclosure of protected information. I also know the “safeguards” to confidentiality and the penalties for violation of HIPAA. Signature___________________________Date____________________