HIPAA Privacy and Security Initial Training For Employees Compliance is Everyone’s Job

1. HIPAA Privacy and Security Initial Training For EmployeesCompliance is Everyone’s Job For UA Health Care Components, Business Associates & Health Plans INTERNAL USE ONLY

2. Topics to Cover • General HIPAA Privacy and Security Overview • HIPAA Privacy • HIPAA Breach Notification Rules and Procedures • HIPAA Security INTERNAL USE ONLY

3. What is HIPAA? The Health Insurance Portability and Accountability Act (HIPAA) is federal legislation which addresses issues ranging from health insurance coverage to national standard identifiers for healthcare providers. The portions that are important for our purposes are those that deal with protecting the privacy (confidentiality) and security (safeguarding) of health data, which HIPAA calls Protected Health Information or PHI. INTERNAL USE ONLY

4. Applicability of HIPAA to UA • HIPAA Applies to: • University Medical Center • Brewer-Porch Children's Center • The Speech & Hearing Center • Autism Spectrum Disorders Clinic • Departments that have signed Business Associate Agreements • Group Health Insurance/Flexible Spending Plan/Wellbama Program • UA Administrative Departments supporting the above entities (like Legal Office, Auditing, Financial Affairs, Risk Management, OIT, UA Privacy/Security Officer, etc.) • Research involving PHI from a HIPAA-covered entity • Does not apply to Psychology Clinic, Student Health Center/Pharmacy, ODS records, Counseling Center, WRC, Athletic Dept health records 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 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 recordings 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 INTERNAL USE ONLY

8. Department of Justice-Imposed Criminal Penalties for Employee • Wrongfully Accessing or Disclosing PHI: Fines up to $50,000 and up to 1 Year in Prison • Obtaining PHI Under False Pretenses: Fines up to $100,000 and up to 5 Years in Prison • Wrongfully Using PHI for a Commercial Activity: Fines up to $250,000 and up to 10 Years in Prison • HIPAA criminal and civil fines and penalties can be enforced against INDIVIDUALS as well as covered entities and Business Associates who obtain or disclose PHI without authorization INTERNAL USE ONLY

9. Federal-Imposed Civil Penalties INTERNAL USE ONLY

10. Federal-Imposed Civil Penalties • HHS is now required to investigate and impose civil penalties where violations are due to willful neglect • Federal government has six (6) years from occurrence of violation to initiate civil penalty action • State attorneys general can pursue civil cases against INDIVIDUALS who violate the HIPAA privacy and security regulations • Civil penalties now apply to Business Associates INTERNAL USE ONLY

11. Breach and Sanction Information Breach Notifications: September 2009 – March 2013: • 556 reports involving a breach of over 500 individuals • Over 64,000 reports involving under 500 individuals • Top types of large breaches • Theft • Unauthorized access/disclosure • Loss • Top locations for large breaches • Laptops • Paper records • Desktop computers • Portable electronic device INTERNAL USE ONLY

12. Breach and Sanction Information Stolen Laptop • Stanford University Lucile Packard Children’s Hospital (2013) • An unencrypted laptop containing medical information on pediatric patients was stolen from a secured access room • Laptop was older model with damaged screen; it was not being used in normal day-to-day operations • Laptop contained patient names, ages, medical records, surgical procedures, and names and telephone numbers of various physicians • This HIPPA breach affected over 13,000 patients • If the laptop had been encrypted, the PHI would not have been exposed and this would not have been a breach INTERNAL USE ONLY

13. Breach and Sanction Information Theft of a Portable Electronic Device • Georgetown University Hospital (2010) • Notified 2,416 patients that their PHI (names, DOB, clinical information) had been compromised • Employee inappropriately emailed PHI to an offsite research office (not HIPAA-covered entity) in violation of the review preparatory to research protocol • Research office stored the ePHI on external hard drive that was later stolen • Employee given verbal warning & counseling • Hospital stopped transmitting PHI to research office & undertook review of all research affiliations involving PHI of its patients to confirm that appropriate documentation and procedures were in place INTERNAL USE ONLY

14. Breach and Sanction Information Employee Misconduct: Terminations • University of Miami (2012) • Two university employees were terminated for inappropriately accessing 64,846 patients’ “face sheets” (patients’ names, DOB, insurance policy numbers, partial & full Social Security numbers, and clinical information) • University of California at Los Angeles Health System (UCLAHS) (2011) • Paid HHS $865,500 to resolve complaints of intentional unauthorized access to/use/disclosure of PHI • Two celebrity patients alleged employees reviewed their medical records without authorization • Employees had repeatedly been caught and firedfor looking at records of celebrities (Brittney Spears, Farrah Fawcett) INTERNAL USE ONLY

15. Breach and Sanction Information Employee Misconduct: Probation & Jail Time • 2008: 25-year-old LPN working at Northeast Arkansas Clinic inappropriately accessed a patient’s PHI & shared it with her husband, who immediately called the patient & threatened to use PHI against him in upcoming legal proceeding • LPN fired. Indicted for wrongful disclosure of PHI for personal gain and malicious harm • LPN faced maximum of 10 years in prison, fine of no more than $250,000 or both, and term of supervised release of not more than 3 years • LPN sentenced to 2 years probation & 100 hours community service • Arkansas State Board of Nursing: suspend or revoke license • 2010: Licensed cardiothoracic surgeon working at UCLA School of Medicine as a researcher looked at employee and patient medical records he was not authorized to view • Pled guilty to four misdemeanor charges. Prosecutor asked for 90 days in jail and fine of $500, because he had received formal training on HIPAA violations, unlawfully accessed records after hours & was terminated. • Sentenced to four months in federal prison and $2,000 fine • First HIPAA violation resulting in incarceration INTERNAL USE ONLY

16. UA HIPAA Sanctions • Employees, students, and volunteers who do not follow HIPAA rules are subject to disciplinary action • UA sanctions depend on severity of violation, intent, pattern/practice of improper activity, etc., and might include: • Dismissal from academic program • Termination of employment • Suspension without pay • Denial of an annual raise or reduction in pay • Civil and/or criminal penalties including incarceration INTERNAL USE ONLY

17. Authorization as Permitted Use and Disclosure of PHI • A covered entity can generally 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 any questions concerning authorization, please contact your Privacy Officer • For a complete list of permitted uses and disclosures of PHI without the patient’s authorization, see your entity’s Notice of Health Information Practices INTERNAL USE ONLY

18. TPO as Permitted Use and Disclosure of PHI PHI may be used and disclosed to facilitate TPO, which means: • For Treatment • For Payment • For certain healthcare Operations, such as quality improvement, credentialing, compliance, and patient/employee safety activities INTERNAL USE ONLY

19. Can Family/Friends Know? • Yes, but only PHI directly relevant to that person’s involvement with the patient’s healthcare or payment related to patient’s healthcare • And, only if the provider reasonably infers that the patient does not object INTERNAL USE ONLY

20. What About Deceased Patients? • Family/friends involved in care can receive information related to care or payments, unless inconsistent with patient’s prior expressed preferences • Records of person deceased for more than 50 years is no longer protected under HIPAA INTERNAL USE ONLY

21. What About Immunization Records to Schools? • Okay to disclose proof of immunization to School where state or other law requires School to have information prior to admitting student • Need oral agreement (phone/email) documented in patient’s medical record INTERNAL USE ONLY

22. Use or Disclosure of PHI for Fundraising Permissible to give to business associate or related foundation • Demographic information • Dates health care provided for fundraising, but only if included in Notice of Health Information Practices & patient is given chance to opt out INTERNAL USE ONLY

23. 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 INTERNAL USE ONLY

24. 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) INTERNAL USE ONLY

25. Question Jenny, a pediatric nurse, needs to report lab results to the mother of a 3 year old child who is sitting in the waiting room. She sticks her head in the waiting room door and says, “Good news. The lab results are normal.” Is this a privacy breach? • Yes • No INTERNAL USE ONLY

26. Correct Answer a: Yes, unless no one else was in the waiting room. The nurse should have asked the mother to step out into the hallway or taken other steps to minimize the risk that someone would overhear the conversation. INTERNAL USE ONLY

27. 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, on fax machines/printers, 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 unauthorized photographs in patient care areas including audio and video INTERNAL USE ONLY

28. Notice of Health Information Practices • Explains how the covered entity will use/disclose patient’s PHI • Explains a patient’s rights and where to file a complaint • Is offered to a patient at the time of the first visit (and patient should sign & date acknowledgement of receiving at time of first visit) • Is posted on facility’s web page and in patient reception area INTERNAL USE ONLY

29. Patient Rights Under HIPAA The Notice of Health Information Practices outlines the patient’s following rights to: • Restrict disclosure of PHI to health plan if patient pays out of pocket in full for the healthcare item/service • Look at and obtain a copy of record/PHI or ePHI • Amend incorrect or misleading information in record • Receive an accounting of disclosures of PHI • Be notified of a breach of PHI • File a complaint INTERNAL USE ONLY

30. Question Charlie works at a medical center and is responsible for entering billing data into the computer system. He looks at his mother-in-law’s medical records, because he is concerned that she has not been fully honest with her family about some recent health problems. Since he has been HIPAA trained, is this a breach of privacy? • Yes • No INTERNAL USE ONLY

31. Correct Answer a: Yes. Although Charlie has been HIPAA trained, his access is based on the minimum necessary requirement to complete his job. He does not need to access health records to enter billing data. Unless his mother-in-law has given permission, in writing on a HIPAA-valid authorization, for him to access her records, this action was a violation of Privacy Policies. INTERNAL USE ONLY

32. Business Associate (BA) Agreements • Are required before a covered entity can contract with a third party individual or vendor (subcontractor) to perform activities or functions which may involve the use or disclosure of the covered entity’s PHI • Law now requires BA to comply with certain Privacy and Security rules & subjects BA to HIPAA criminal and civil penalties. • BA also subject to breach of contract claims • BA Agreement must be approved in accordance with appropriate UA policies and procedures Individual employees are NOT authorized to sign contracts on behalf of UA. INTERNAL USE ONLY

33. HIPAA Put New Requirements on Research • If you work for a HIPAA-covered Health Care Provider, do not release PHI for research unless: • The patient has signed a valid HIPAA authorization, or • The Institutional Review Board (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 UA’s Office for Research Compliance. INTERNAL USE ONLY

34. Breach Notification • HIPAA requires that we notify affected individuals and federal officials when a breach or potential breach of privacy has occurred • The following slides discuss: • The types of breaches requiring patient notification and those that are exempt • Time in which the notification must occur • Responsibility of employee to report any incident INTERNAL USE ONLY

35. What is a Breach? • Breach is defined as the unauthorized acquisition, access, use, or disclosure of unsecured PHI which compromises the security or privacy of the information. • Impermissible use or disclosure is presumed to be a breach unless the facility or business associate proves that there is a low probability that PHI has been compromised. INTERNAL USE ONLY

36. Risk Assessment Required To assess the probability that PHI has been compromised, we are required to consider: • The nature and extent of PHI and likelihood of re-identification (credit card/SSN, etc.) • Unauthorized person who used PHI or to whom disclosure was made • Whether PHI was actually acquired or viewed • The extent to which the risk of PHI has been mitigated (recipient destroyed it) INTERNAL USE ONLY

37. Exceptions When Breach Notification Not Required • Unintentional acquisition, access, or use of PHI by an employee or individual acting under the authority of a covered entity or business associate if made in good faith or within course and scope of employment • Inadvertent disclosure of PHI from one person authorized to access PHI at a covered entity or business associate to another person authorized to access PHI at the covered entity or business associate • 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

38. Home Free – No Notification Required • “Home free” methods under which breaches involving the misuse, loss, or inappropriate disclosure of paper or electronic data would indicate no harm done, and therefore, no patient notification: • PHI is encrypted in both storage (servers, desktops, laptops, thumb drives, tablets, etc.) and in transit (https: or SSL encryption while accessing electronically). • PHI has been properly disposed (paper is shredded with an appropriate shredder, pulped or incinerated; electronic storage devices such as hard drives, thumb drives, CD/DVD, etc., are properly erased with a DoD-approved data erasure process). INTERNAL USE ONLY

39. Encryption • Security Rules require Covered Entity/Business Associate to consider implementing encryption as a method for safeguarding Electronic Protected Health Information (PHI) • If you encrypt, then patient notification is not required in event of breach INTERNAL USE ONLY

40. What Constitutes a Breach? • A breach could result from many activities. Some examples are • Accessing more than the minimum necessary • 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 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

41. Question 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 that requires notification to the patient? • Yes • No INTERNAL USE ONLY

42. Correct Answer b: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

43. Question 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 requiring patient notification? • Yes • No INTERNAL USE ONLY

44. Correct Answer a: 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

45. Breach Notification Regulations • If it is determined that a breach of PHI occurred, then the covered entity must notify the affected individual (or next of kin) without unreasonable delay, but not later than 60 calendar days from discovering the breach. • Time runs when incident first known or reasonably should have been known (true for covered entity and business associate), NOT when it is determined that a breach occurred. • Breach is treated as discovered when workforce member or other agent has knowledge of incident • That means an employee or volunteer must IMMEDIATELY report! • Delay permissible in certain circumstances where law enforcement has requested a delay INTERNAL USE ONLY

46. Responsibility to Report Promptly • When receiving a privacy complaint, learning of a suspected breach in privacy or security, or noticing something is “just not right,” we must work together • 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 • It is much better to investigate and discover no breach than to wait and later discover that something DID happen INTERNAL USE ONLY

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

48. Rules for Access • Access to computer systems and information is based on your work duties and responsibilities • Access privileges are limited to only the minimum necessary information you need to do your work • Access to an information system does not automatically mean that you are authorized to view or use all the data in that system • Different levels of access for personnel to PHI is intentional • If job duties change, clearance levels for access to PHI is re-evaluated • Access is eliminated if employee is terminated • Accessing PHI for which you are not cleared or for which there is no job-related purpose will subject you to sanctions INTERNAL USE ONLY

49. Question Once employees have completed HIPAA training, their access to PHI is • Unlimited • Based on work duties and responsibilities • Limited to the minimum necessary information to complete required work • Both B and C INTERNAL USE ONLY

50. Correct Answer d: Access to PHI is based on need-to-know which is determined by the employee’s duties and responsibilities. The employee should only access the minimum PHI necessary to complete the required task. INTERNAL USE ONLY