HIPAA Privacy Keys to Success

1
HIPAA PrivacyKeys to Success

• Updated January 2010

2
HIPAA and Its Purpose

• What is HIPAA?
• Health Insurance Portability and Accountability
  Act of 1996
• Title II Administrative Simplification
• Its a federal law
• HIPAA is mandatory, penalties for failure to
  comply

• Purpose
• Protect health insurance coverage, improve access
  to healthcare
• Reduce fraud and abuse
• Improve quality of healthcare in general
• Reduce healthcare administrative costs
  (electronic transactions)

3
HITECH and Its Purpose

• What is HITECH?
• Health Information Technology for Economic and
  Clinical Health Act
• Subtitle D of the American Recovery and
  Reinvestment Act of 2009 (ARRA)
• Its a federal law

• Purpose
• Makes massive changes to privacy and security
  laws
• Applies to covered entities and business
  associates
• Creates a nationwide electronic health record
• Increases penalties for privacy and security
  violations

4
Key HITECH Changes

• Breach Notification requirements
• AOD for treatment, payment, and healthcare
  operations in electronic health record (EHR)
  environment
• Business Associate Agreements
• Restrictions
• Right to access

• Criminal provisions
• Penalties
• OCR Privacy Audits
• Copy charges for providing copies from EHR
• HIPAA preemption applies to new provisions
• Private cause of action
• Sharing of civil monetary penalties with harmed
  individuals

5
Civil Penalties for Non-compliance
Violation Category Each Violation All such violations of an identical provision in a calendar year
Did Not Know 100 - 50,000 1,500,000
Reasonable Cause 1,000 50,000 1,500,000
Willful Neglect Corrected 10,000 - 50,000 1,500,000
Willful Neglect Not Corrected 50,000 1,500,000
As of 2/17/09
6
Criminal Penalties for Non-compliance

• For health plans, providers, clearinghouses and
  business associates that knowingly and improperly
  disclose information or obtain information under
  false pretenses. These penalties can apply to
  any person.
• Penalties higher for actions designed to generate
  monetary gain
• up to 50,000 and one year in prison for
  obtaining or disclosing protected health
  information
• up to 100,000 and up to five years in prison for
  obtaining protected health information under
  "false pretenses"
• up to 250,000 and up to 10 years in prison for
  obtaining or disclosing protected health
  information with the intent to sell, transfer or
  use it for commercial advantage, personal gain or
  malicious harm

7
Facility Privacy Official

• Your FPO is Cynthia Kean, HIM Director
• Responsible for
• Privacy Program
• Privacy Rights of patients
• Requests for Privacy Restrictions
• Facilitating the training and education of staff

8
HIPAA Terminology

• HIPAA Health Insurance Portability and
  Accountability Act
• HITECH Health Information Technology for
  Economic and Clinical Health Act
• PHI Protected Health Information
• CE Covered Entity (Hospital)
• ACE Affiliated Covered Entity (Common
  ownership) OHCA Organized Health Care
  Arrangement (The hospital and medical staff will
  be considered an Organized Health Care
  Arrangement)
• DRS Designated Record Set (medical record and
  billing record)
• AOD Accounting of Disclosures (patients right
  to receive)
• Directory Hospital census list used by
  volunteers and operators with name and room

9
How will HIPAA affect you?

• Coversheets with confidential statement need to
  be used on all external faxes.
• Screens will need to be placed out of public view
  when possible
• Patient charts will need to be placed in secure
  area
• PHI will need to be placed in Cintas containers
  for disposal
• Patient family members will give a passcode for
  other than directory releases
• Patient information should only be accessed if
  there is a need to know

10
How will HIPAA affect you?

• Registration will be giving out a Notice of
  Privacy Practices brochure to every patient
  concerning our patient privacy protection policy.
  
• Patients will be given the option to opt out
  of our directory.
• Patients have a right to a copy of their medical
  record
• Authorizations need to be obtained from patient
  to release information for reasons other than for
  treatment, payment or healthcare operations (TPO)

11
What is Protected by HIPAA (PHI)?

• Name
• Address including street, city, county, zip code
  and equivalent geocodes
• Names of relatives
• Name of employers
• All elements of dates except year (i.e. DOB,
  Admission, Discharge, Expiration, etc.)
• Telephone numbers
• Fax Numbers
• Electronic e-mail addresses
• Social Security Number
• Medical record number

• Health plan beneficiary number
• Account number
• Certificate/license number
• Any vehicle or other device serial number
• Web Universal Resource Locator (URL)
• Internet Protocol (IP) address number
• Finger or voice prints
• Photographic images
• Any other unique identifying number,
  characteristic, code

12
What is a Covered Entity (CE)?

• Health plans, Health care clearinghouses, and
  Health care providers that transmit
  electronically for billing
• Examples
• Hospitals
• Physician Practices
• Insurance companies
• Ambulance Transportation Services
• Hospice
• Home Health

13
What does that mean to me?

• You can share information without patient
  authorization as it relates to TPO
• Other covered entities will request only minimum
  necessary to perform their job
• You may request the minimal information necessary
  from them for reasons of TPO without patient
  authorization
• May need to verify the requestor according to
  policy

14
Disclosing PHI to Family Members and Friends Who
Call the Unit

• Patient will be assigned a four-digit passcode .
  Knowledge of this passcode will allow
  information, (PHI), to be shared with the family
  member or friend
• Distribution of passcode will be the
  responsibility of the patient
• Passcode may be changed during treatment
• Revocation and password change form must be
  routed to FPO
• Passcode will be last 4-digits of patient account
  number

15
Verification of Requestors

• Requestors via phone will need
• Patient SS, DOB and one of the following
• Account number, street address, MR, birth
  certificate, insurance card or policy number
• Scenarios
• Unknown physician calling from cell phone
• Family member or friend calling without passcode

16
External Faxing Guidelines

• Limit when possible
• Verify fax number
• Utilize preset numbers when applicable
• Fax machine located in secure location
• ALWAYS use cover sheet with confidentiality
  statement for transmittals
• Highly sensitive information should not be faxed
  (HIV status, abuse records, etc.)

17
Patients Right to Access

• Forward to HIM for processing
• Must be able to provide access and/or hard copy
  of record
• If patient is in-house, HIM will manage access
  process

18
Patients Right to Amend

• Forward request to HIM for processing
• Right of patient to request amendment to records.
  Request must be in writing
• Cannot change or omit documentation already in
  the medical record
• If patient is in-house HIM will manage amendment
  process

19
Patients Right to Opt out of Directory

• Patient can opt out of directory at anytime but
  will probably happen during admission process
• You may not acknowledge the patient is in the
  facility or give information about the patient to
  friends, family or others who may inquire
• Can still release information to family and
  friends with 4-digit passcode as defined in the
  Directory policy.
• Forward any request for opt out to Registration
  for processing

20
Right to Privacy Restrictions

• Patients have the right to request a privacy
  restriction of their PHI
• NEVER agree to a restriction that a patient may
  request
• All requests must be made in writing and given to
  the FPO to make a decision on
• NO request is so small that it should not be
  routed to the FPO

21
Patient Privacy Complaints

• FPO must maintain complaint log in accordance
  with the complaint process
• ALL privacy complaints must be routed to the FPO
• Responses cannot be accompanied by retaliatory
  actions by the hospital
• Disposition of complaint must be consistent with
  the facilitys Sanctions for Privacy Violations
• Risk Management module of Meditech may be used
  for complaint tracking

22
Accounting of Disclosures (AOD)

• Right to an accounting of disclosures of
  protected health information
• An individual has a right to receive an
  accounting of disclosures of protected health
  information made by a covered entity in the six
  years prior to the date on which the accounting
  is requested, except for disclosures
• For TPO
• To the patient
• For directory purposes
• To law enforcement or correctional institutions
• For national security

Additional requirements forthcoming as a result
of HITECH regulations
23
How will Accounting of Disclosures (AOD) affect
me?

• You must enter information into the AOD for
• State mandated reporting
• Suspected Abuse Victims
• Certain Disease reporting such as STDs
• Brain Injury
• Organ and Tissue Donations
• Health Oversight Activities (JCAHO)

24
Notice of Privacy Practices

• Patient will receive Notice upon each
  registration
• Outlines patient rights
• Right to access
• Right to amend
• Confidential Communication
• Right to Privacy Restriction
• Right to Opt out of Directory

25
Sharing Information with Other Treatment Providers

• We can share information with physicians and
  office staff, hospitals, or other treatment
  facilities just as we do today
• Need to verify the requestor according to policy
• Patient information (PHI) can be released for
  reasons of treatment, payment or health care
  operations

26
Confidential Communications

• Request for use of alternate address or phone
  number for future contact
• Route any request for Confidential Communications
  to Admissions
• Should communicate only with alternate address
  given

27
Breach Notification

• HITECH provisions require the following
  notifications when breaches (as defined in the
  regulations) occur
• To the patient
• To the Department of Health and Human Services
• To the media when the breach involves more than
  500 individuals in the same state or jurisdiction

28
Ensuring Security Compliance

• Ensure users log off terminals when not in use.
• PCs should have screen savers whenever
  possible.
• Computer screens should be positioned so
  information (PHI) is not
• readable by the public or other unauthorized
  viewers
• Printers should be positioned in protected
  locations so that printed
• information is not accessible or viewable by an
  unauthorized
• person.
• PHI must be properly disposed.

29
Common Exposures on Nursing Units

• Discussions of patient information in public
  places such as elevators, hallways and cafeterias
• Printed or electronic information left in public
  view (e.g., charts left on counters)
• Discussing patient information on social
  networking sites (e.g., Facebook, Twitter)
• PHI in regular trash
• Records that are accessed without need to know in
  order to perform job duties
• Unauthorized individuals hearing patient
  sensitive information such as diagnosis or
  treatment

30
Sanctions

• 3 levels of violations that require disciplinary
  action
• Accidental and/or due to lack of proper education
• Purposeful violation of privacy policy or an
  unacceptable number of previous violations
• Purposeful violation of privacy policy with
  associated potential for patient harm
• FPO to review facility sanctions policy examples

31
Test Your Knowledge

• The FPO at JFK Medical Center is
• Gina Melby, CEO
• The President of the Medical Staff
• Cynthia Kean, HIM Director
• Jim Leamon, CFO
• Does the patient have the right to access or
  obtain a copy their medical record?
• Yes
• No
• Can a patient amend their record?
• Yes
• No
• What is protected by HIPAA (PHI-Protected Health
  Information)?

32
Test Your Knowledge

• What right is NOT provided under HIPAA?
• Right to Opt out of the dictionary
• Right to not pay the bill
• Right to amend
• Right to request Confidential Communication
• 6. Under HITECH when a breach occurs the
  following must be notified, EXCEPT
• The Department of Health and Human Services
• The media when more than 500 individuals reside
  in the same state or jurisdiction
• The patients next of kin
• The patient
• One of the purposes of HITECH is to create an
  electronic health record
• True
• False

33
To Test Your Knowledge

• Patients have the right to request a privacy
  restriction of their PHI. This request must
  always be forwarded to the
• Admitting Physician
• The FPO
• The Chief Nursing Officer
• The Quality Director
• Criminal penalties for non-compliance can apply
  to any person
• True
• False
• Examples of exposure would be
• discussions of a patients diagnosis in the
  elevator
• PHI in the trashcan
• sharing PHI without an authorization when one is
  required
• sharing of passwords