HIPAA PRIVACY FOR NON-EMPLOYEES Edition
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1 HIPAA PRIVACY FOR NON-EMPLOYEES 2010 Edition
2 Introduction The HIPAA Privacy Standards have been in effect since April 14, The purpose of the HIPAA Privacy Standards is to protect the privacy of what is known as protected health information while permitting protected health information to be used in ways that benefit the patient.
3 Instructions This presentation contains a number of questions and answers designed to acquaint you with how the HIPAA Privacy Standards work. At the end, you will be asked to take a short test, based on this information and submit it for grading.
4 True or False? Protected health information ( PHI ) only includes medical information. It does not include patients names and addresses.
5 The Answer Is: False protected health information includes demographic information. PHI is individually identifiable health information that is: (i) Transmitted by electronic media; (ii) Maintained in any medium described in the definition of electronic media; or (iii) Transmitted or maintained in any other form or medium.
6 True or False? HIPAA only protects information in a medical record.
7 The Answer Is: Again, False Health Information is any information, whether oral or record in any form or medium, that: (i) Is created or received by a health care provider, etc; and (ii) Relates to the past, present, or future physical or mental health or condition of an individual; the provision of health care to an individual; or the past, present, or future payment for the provision of health care to an individual.
8 True or False? It is appropriate for a caregiver to share protected health information with a patient s relatives and friends.
9 The Answer Is: True, IF The patient, if present, either agrees or, by inference, does not object. If the patient is not present, the provider, using professional judgment, determines that the disclosure is in the patient s best interest and discloses only the PHI that is directly relevant to the relative s/friend s involvement with the patient s health care (picking up prescriptions, medical supplies, x-rays, etc.) Disclosure is also appropriate if there is written authorization from the patient.
10 Access to Information Under the HIPAA Privacy Standards, there are 7 ways in which protected health information ( PHI ) can be used or disclosed: 1. Pursuant to the patient s written authorization 2. For treatment purposes 3. For payment purposes 4. For healthcare operations 5. For required disclosures 6. For permitted disclosures where the patient can object 7. For other permitted disclosures
11 True or False? I can share PHI with other caregivers.
12 The Answer Is: True, IF The use or disclosure relates to treatment. The use or disclosure relates to payment or healthcare operations, and the minimum necessary standard is followed. The patient has given written authorization False, IF the use or disclosure relates to gossip.
13 Minimum Necessary Standard Reasonable efforts need to be made to limit PHI to the minimum necessary to accomplish the intended purpose of the particular use, disclosure or request.
14 Minimum Necessary Standard The standard does not apply to: disclosures to/by providers for treatment disclosures to the patient disclosures pursuant to the patient s authorization disclosures for HIPAA compliance, including disclosures to DHHS/OCR disclosures required by law
15 Right of Access You may be able to access PHI on hospital computers for patients other than those assigned to you. However, it is your responsibility to limit your access to only those patients and only that information needed to perform your job duties and responsibilities.
16 True or False? Physicians have a right to access to PHI about any patient in the Hospital.
17 The Answer Is: False, Physicians may access PHI only for the following purposes: Treatment Payment Healthcare Operations With the patient s written authorization.
18 True or False? I can get in trouble if I tell a physician protected health information about his/her patient and somebody overhears it.
19 The Answer Is: False, IF reasonable precautions are taken to minimize the chance of incidental disclosures to others who may be nearby: Health care staff may orally coordinate services at hospital nursing stations. Nurses or other health care professionals may discuss a patient s condition over the phone with the patient, a provider, or a family member.
20 Incidental Disclosures A physician may discuss a patients condition or treatment regimen in the patient s semi-private room. Health care professionals may discuss a patient s condition during training rounds in an academic or training institution. A pharmacist may discuss a prescription with a patient over the pharmacy counter, or with a physician or the patient over the phone. A health care professional may discuss lab test results with a patient or other provider in a joint treatment area.
21 Incidental Disclosures In the circumstances listed above, reasonable precautions could include using lowered voices or talking apart from others when sharing protected health information. In an emergency situation, in a loud emergency room, or where a patient is hearing impaired, such precautions may not be practicable. Providers are free to engage in communications as required for quick, effective, and high quality health care.
22 Incidental Disclosures The HIPAA Privacy Standards do not require the following types of structural or systems changes: Private rooms. Soundproofing of rooms. Encryption of wireless or other emergency medical radio communications which can be intercepted by scanners. Encryption of telephone systems
23 Incidental Disclosures The following are examples of the types of adjustments or modifications that may constitute reasonable safeguards : Pharmacies could ask waiting customers to stand a few feet back from a counter used for patient counseling. Hospitals could ensure that areas housing patient files are supervised or locked.
24 Incidental Disclosures In an area where multiple patient-staff communications routinely occur, use of cubicles, dividers, shields, curtains, or similar barriers may constitute a reasonable safeguard. For example, a large clinic intake area may reasonably use cubicles or shield-type dividers, rather than separate rooms, or providers could add curtains or screens to areas where discussions often occur between doctors and patients or among professionals treating the patient.
25 True or False? A hospital cannot confirm that an individual is a patient there.
26 The Answer Is: False, IF the patient has consented to being included in the hospital s directory, which can include: The patient s name The patient s room number/location A general description of the patient s condition The patient s religious affiliation (disclosed only to clergy)
27 What Happens If There Is a HIPAA Complaint? Complaint to hospital Internal investigation Documentation of all complaints received Documentation of disposition of complaint Complaint to Office for Civil Rights ( OCR ) Investigation by OCR, which is the federal agency responsible for HIPAA privacy compliance Possible fines and penalties ranging from $100 per violation up to $250,000 and up to 10 years in prison
28 REPORTING A HIPAA VIOLATION Brett Randolph, Privacy Officer privacyofficer@chhi.org
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