Privacy Officer Job Description 4/28/2014. HIPAA Privacy Officer Orientation. Cathy Montgomery, RN. Presented by:

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1 HIPAA Privacy Officer Orientation Presented by: Cathy Montgomery, RN Privacy Officer Job Description Serve as leader Develop Policies and Procedures Train staff Monitor activities Manage Business Associates Oversee complaints Manage breaches Facilitate audit activity 1

2 The 5 Rules of HIPAA (1996) 1. Privacy Rule (4/03) 2. (4/03) 3. Transaction Rule (10/03) 4. Identifiers Rule (5/07) 5. Enforcement Rule (3/06) ARRA American Recovery and Reinvestment Act of 2009 Updated to include HITECH Act Requires HHS to audit providers and their business associates compliance with HIPAA = 2014 audits HIPAA Omnibus Rule More news! OMNIBUS Affects the HITECH Act as well as the 2

3 HIPAA Omnibus Rule Before The Security and Privacy Rules did not apply directly to business associates of covered entities. Now Business Associates, and their subcontractors, are directly liable for HIPAA Privacy and Security Requirements. HIPAA Omnibus Rule Violation Category Each Violation Violation Cap Did not know $100-$50,000 $1.5 million Reasonable Cause $1000-$50,000 $1.5 million Willful neglect *corrected $10,000-$50,000 $1.5 million Willful neglect *uncorrected $50,000 $1.5 million 3

4 HIPAA Omnibus Rule Improved ability to target fundraising efforts Greater ability to combine research authorization forms Less formal documentation for providing student immunization records to schools HIPAA Omnibus Rule Marketing Issues Authorization Required: Cases involving payment require authorization Payments = money NOT Marketing: Refill reminders Telephone communications Health in general Government programs Privacy Rule Privacy Notices Provide at initial visit & upon request Post in general areas Explain how the CE may use and disclose PHI Explain how to file a complaint Go through individual rights 4

5 Privacy Rule Highlights Private pay situations GINA PHI no longer expires at 50 years Notification of breaches Marketing & fundraising rules REQUIRED vs. ADDRESSABLE The Department of Health and Human Services (DHHS) provides flexibility to covered entities by stating whether a specification is "required" or "addressable. REQUIRED If the specification is "required," the covered entity must implement the specification as stated in the. 5

6 If the specification is "addressable, then the covered entity must: 1. Assess whether the specification is a reasonable and appropriate safeguard in its environment and is likely to contribute to protecting the entity's electronic protected health information. 2. Implement the specification or document why it would not be reasonable and appropriate and implement an equivalent alternative measure if reasonable and appropriate. 5 Components for Risk Management Physical Safeguards Technical Safeguards Administrative Safeguards Policies & Procedures Organizational Requirements ADMINISTRATIVE SAFEGUARDS Security Management Process Risk Analysis (R) Risk Management (R) Sanction Policy (R) Information System Activity Review (R) Assigned Security Responsibility (R) Workforce Security Authorization and/or Supervision (A) Workforce Clearance Procedure (A) Termination Procedures (A) 6

7 ADMINISTRATIVE SAFEGUARDS Information Access Management Isolating Health Care Clearinghouse Function (R) Access Authorization (A) Access Establishment and Modification (A) Security Awareness and Training Security Reminders (A) Protection from Malicious Software (A) Log-in Monitoring (A) Password Management (A) Security Incident Procedures Response and Reporting (R) ADMINISTRATIVE SAFEGUARDS Contingency Plan Data Backup Plan (R) Disaster Recovery Plan (R) Emergency Mode Operation Plan (R) Testing and Revision Procedure (A) Applications and Data Criticality Analysis (A) Evaluation (R) Business Associate Contracts and Other Arrangement Written Contract or Other Arrangement (R) PHYSICAL SAFEGUARDS Facility Access Controls Contingency Operations (A) Facility Security Plan (A) Access Control and Validation Procedures (A) Maintenance Records (A) Workstation Use (R) Workstation Security (R) Device and Media Controls Disposal (R) Media Re-use (R) Accountability (A) Data Backup and Storage (A) 7

8 TECHNICAL SAFEGUARDS Access Control Unique User Identification (R) Emergency Access Procedure (R) Automatic Logoff (A) Encryption and Decryption (A) Audit Controls (R) Integrity Mechanism to Authenticate Electronic PHI (A) Person or Entity Authentication (R) Transmission Security Integrity Controls (A) Encryption (A) ORGANIZATIONAL SAFEGUARDS Business Associate Contracts or Other Arrangements (R) Group Health Plans (R) Policies and Procedures (R) Documentation Time Limit (R) Availability (R) Updates (R) Security Requirements 8

9 Mobile Device Safety Passwords Encryption Remote wiping or remote disabling File sharing Firewalls Mobile Device Safety Security software Mobile apps? Physical control Wi-Fi security https Delete prior to discarding Risk Assessment National Institute of Standards and Technology NIST Conduct an accurate and thorough assessment of the potential risks and vulnerabilities to the confidentiality, integrity, and availability of electronic protected health information held by the organization. 9

10 Risk Assessments Design appropriate personnel screening processes Identify what data to backup and how Decide whether and how to use encryption Address what data must be authenticated in particular situations to protect data integrity Determine the appropriate manner of protecting health information transmissions Risk Assessments Scope of analysis Data collection Identify & document potential threats and vulnerabilities Assess Current Security Measures Determine likelihood of threat occurrence Determine impact of threat occurrence Determine level of risk Risk Assessments MYTHS Optional for small providers Certified EMR voids the need for an assessment Must be outsourced Checklists = risk assessments Assessments are only done once Assessments are required annually 10

11 What is a Breach? Breach is: The acquisition, use, or disclosure of PHI in a manner not allowed by HIPAA and That poses a significant risk of financial, reputational, or other harm to the affected individual. THE BURDEN OF PROOF IS ON THE CE. Notice Required Individuals Within 60 days of recognition in writing HHS Electronically thru their website Within 60 days if 500 or more Within 60 days after the end of the year if less than 500 Notice to Media For breach affecting more than 500 residents of a state, provider must give notice to prominent media outlets serving that state Notice must be provided without unreasonable delay and no later than 60 days following discovery of the breach Must include the same information required for the notice to individuals 11

12 Contents of Individual Notice Description of the breach (what happened) Type(s) of information disclosed Steps affected individuals should take to protect themselves from potential harm What the provider is doing to investigate the breach, mitigate the harm, and prevent further breaches Contact information for the provider (including a toll-free number if substitute notice is provided on a website or by media) HIPAA Dermatology practice resolves potential HIPAA violations with a $150,000 settlement Concord Mass. Stolen thumb drive 2,200 patients 9/14/11 Self reported 10/7/11 No policies and procedures for breach notification until 2/7/2012 No staff training until 2/7/2012 No risk assessment until 10/1/2012 Dec 26, 2013 final settlement, $150,000 payment due Corrective Action Plan for 3 years HIPAA The US Department of Health and Human Services (HHS) Office for Civil Rights (OCR) has announced that HIPAA audits will take place after January 1, 2014, not at the beginning of the federal Fiscal Year 2014, which starts October 1, One focus in the audits will be on risk analysis, Rodriguez said, sending a clear message about the importance of a Risk Analysis, the first requirement in the HIPAA. 12

13 State Laws 46 states have enacted data security laws Definitions Protected Health Information (PHI) or Protected Medical Information (PMI): This is any data about the patient that would tend to identify the individual: name, hospital #, SSN, diagnosis, lab results, past or current photos, etc, etc. Privacy Officer (PO): Each facility will have an employee who is responsible for implementing and enforcing this law. Some may have one over a multi-facility network (Seton) others one at each site (St. David s Partnership). As a nursing student, this individual (after your instructor or preceptor) could be your point of information regarding HIPAA. Covered Entity (CE): This includes any health plan, healthcare provider, agency that processes claims, and any company that subcontracts with them are covered by this law. 13

14 Definitions Release/Disclosure: These are terms used in describing the release of PHI to other CEs for TPO, treatment, payment, or health care operations. Accounting of Disclosure (AOD): The patient has the right to have an AOD for his PHI or PMI. Directory: This is CE s census or list of patients used by volunteers and operators to direct visitors. Business Associate: Any person or entity that performs certain functions or activities that involve the use or disclosure of PHI on behalf of or provides services to a covered entity. A member of a covered entity s workforce is not a business associate. Excellentia HIPAA Services On Site Risk Assessments HIPAA Corrective Action Plans Virtual Assistance for Policies & Procedures QUESTIONS? Excellentia Advisory Group ext. 105 Like us on Facebook Excellentia-Advisory- Group/ Follow Us on Twitter 14

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