HIPAA Patient Privacy Training

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Evan Day
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1 HIPAA 101 Patient Privacy Training for Participants in the Freeman Health Academy, Freeman Job Shadowing Program, Freeman Hospital Tours, and Freeman Maternal Child Health Program Tours

2 HIPAA Is A Federal law called the Health Insurance Portability and Accountability Act (HIPAA) of 1996 HIPAA sets national standards for the protection of patient or client information, with a compliance deadline of April 2003

3 Who does HIPAA apply to? Health Care Providers such as Hospitals Public Health Departments Physician Offices Insurance Companies Laboratories Home Healthcare Companies Surgery Centers

4 Why do I have to know about HIPAA? It is EVERYONE s responsibility to maintain the confidentiality and security of Freeman s patient information During your Freeman shadow/tour, at some point you are likely to come into contact with patient information (whether it be spoken, written, or electronic), which means that you have become a part of the HIPAA regulations that Freeman adheres to All employees, volunteers, and student program participants at Freeman and its facilities must undergo HIPAA compliance training

5 What does HIPAA cover? HIPAA covers all forms of Protected Health Information (PHI) Oral Written Electronic

6 What is Protected Health Name (first, middle, last) Address Phone/fax numbers Social Security number Medical record number Patient account number Insurance number Photographs address Information? Any information that can be used to identify a patient: Anything about the patient s medical conditions and treatment Past Present Possible Billing and payment records

7 ANY HEALTH INFORMATION THAT IDENTIFIES OR COULD BE USED TO IDENTIFY A FREEMAN PATIENT MUST BE PROTECTED

8 Minimum Necessary All PHI should only be accessed and shared on a minimum necessary basis: Only the necessary amount of PHI should be accessed- for example, a billing clerk may not need a patient s entire medical chart to bill for one procedure PHI should only be shared with a clinical or business need to know Nurses, doctors, other clinical staff members can share patient information as long as it is needed to treat the patient

9 How does HIPAA affect me while I am at Freeman? As part of the Health Academy, Shadowing Program, or Tour Programs, you will always be accompanied by a Freeman staff member Your Freeman preceptor may allow you into areas where you see/hear information about patients and their medical care It is YOUR responsibility to ensure that the patient information you come into contact with remains confidential within the hospital and once you leave the hospital

10 How does HIPAA affect me while I am at Freeman? As part of a job shadow or tour, there should be no reason why you would need to ACCESS patient information within the hospital Your Freeman preceptor may choose to share pertinent patient information with you that will enhance your shadow/tour You should not try to access additional PHI and should avoid situations where you may be exposed to additional PHI Do not try to log-on to any computers Do not read any charts, electronic screens, forms, etc. unless given permission from your Freeman preceptor Do not answer any phone calls Stay in areas that you have been directed Do not wander into areas that are not part of your shadow/tour Stay with your Freeman preceptor

11 How does HIPAA affect me while I am at Freeman? As part of a job shadow or tour, there should be no reason why you would need to SHARE patient information within the hospital Do not provide information to other clinicians, family members, or other shadowing/tour students If asked to provide patient information, you should consult your Freeman preceptor

12 How does HIPAA affect me while I After your tour/shadow: am at Freeman? You cannot share information that may identify a patient, with anybody For example, all items highlighted in red could potentially identify this Freeman patient: Hey mom! Did you see that lady on the news yesterday that got mauled by that lion that escaped the circus train in Neosho? I think her name was Dorothy Anyways, I got to see her surgery at Freeman today during my job shadow. You know, for an 87 year old lady, she looked pretty good. At least before the mauling and the 18 hour surgery to remove all of the bits of fur left behind The nurses told me that she will probably need more surgeries and psychological care but that she is doing pretty good now. Hey, wait, isn t she related to our next door neighbor? You may want to let him know how Dorothy is doing. Poor thing

13 Scenarios Scenario 1- During your shadow you hear a doctor discussing a case scheduled for the next day with the nurse who is your Freeman preceptor. The patient they are discussing is the mom of your best friend. You CAN- Let the nurse you are shadowing with know that you have a relationship with the patient they are discussing so that you do not overhear any information above what you need to during your shadow You CAN T- Go home and call your best friend to find out what is wrong with her mom or share any information about the scheduled procedure.

14 Scenarios Scenario 2- During a tour of the Birthing Center with your Child Development class, you see Tiffany, a girl that you went to 8 th grade with, in a postpartum room with a new baby. You CAN- Continue your tour without alerting any other students in the group who may not have seen Tiffany. You CAN T- Identify the patient by name to others in the group; talk about Tiffany when you return to school; let your mom know what you saw so that she can call Tiffany s mom and tell her congratulations.

15 Scenarios Scenario 3- While participating in a Health Academy activity at Freeman, you are in the back of a group that has stopped near a nurses station. You see a nurse entering patient information on a computer while talking quietly about the patient s care plan with another nurse. You CAN- Move closer to your group and try not to eavesdrop on a conversation that is not pertinent to your group s activity. If you have questions about the type of care that the nurses were discussing, you can ask your group leader later on without providing patient identifying information. You CAN T- Try to listen to the information the nurses are discussing; try to read the information that is being entered on the computer; disrupt the nurses who are doing their job to protect the care and privacy of the patient.

16 Other Examples of HIPAA Potential Violations An employee passing on information to her son about his spouse or their children Allowing a former employee, friends, family, or co-workers into off-limits areas where PHI is located Releasing information to a caller who is not properly identified as being authorized to receive information Mailing/faxing PHI to the wrong person Looking at the PHI of a co-worker, supervisor, family, friends or self for non-work reasons Discussing patient information in public areas such as elevators, hallways, or cafeteria Discussing patient information in front of visitors without the documented authorization of the patient

17 Cell Phones and Cameras Cell phone usage is absolutely not allowed during shadows, tours, or Health Academy activities Cameras and video recorders are also forbidden Taking photos or videos of a patient, patient files, or patient care area is forbidden Text messaging medical information about a patient to ANYONE is forbidden

18 Social Media Don t discuss or post ANY patient information Do not use social media during your shadow/tour/activity Be very careful with anything you post on social media about your experience at Freeman! Do not provide any information that might inadvertently identify a patient Do not take/post pictures that may have patients or their information in the background Do not post statements such as crazy day in the Emergency Room at Freeman or I had such a sad experience while I was shadowing on the pediatrics floor today

20 HIPAA Violations Can Result In Corrective action and termination from participation in Freeman sponsored activities Negative effect on future employability at Freeman Fines of up to $1.5 million Jail terms up to 10 years If you observe a HIPAA violation during your time at Freeman, please contact Freeman s Privacy Officer- Carlos Haley or or you can place your concerns in writing and place in the Compliance Drop Boxes located within Freeman facilities

21 In Conclusion Confidentiality and protecting PHI is everyone s job- including yours as a visitor to Freeman facilities Privacy and security matters Don t discuss protected healthcare information in public or with those who do not need to know Remember It could be YOUR health information that someone is talking about

HIPAA RULES AND REGULATIONS

HIPAA RULES AND REGULATIONS INTRODUCTION Everyone who works in or around health care has heard about the HIPAA, the Health Insurance Portability and Accountability Act. And certainly, everyone who is in