Health Insurance Portability and Accountability Act (HIPAA) Compliance Training
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1 Health Insurance Portability and Accountability Act (HIPAA) Compliance Training 1
2 Objectives By the end of this lesson, you should be able to: Define protected health information (PHI) covered under HIPAA regulations Recall patients rights regarding PHI information maintenance, sharing and disclosure. Examine how UTHealth uses patient information in providing care to our patients and communicating with health care providers and others. Recognize employees responsibilities in upholding these rights and protecting our patients PHI confidentiality and privacy.
3 Health Insurance Portability & Accountability Act (HIPAA) was designed to improve efficiency and effectiveness of health care systems by standardizing the electronic exchange of administrative and financial data. 3
4 The Health Information Technology for Economic and Clinical Health (HITECH) Act, part of the American Recovery and Reinvestment Act of 2009, promote the adoption and meaningful use of health information technology. 4
5 What is HIPAA? The HIPAA Privacy Rule provides federal protections for personal health information held by covered entities and gives patients an array of rights with respect to that information. At the same time, the Privacy Rule is balanced so that it permits the disclosure of personal health information needed for patient care and other important purposes. 5
6 Six Patient Rights 6
7 Six Patient Rights 7
8 Six Patient Rights 8
9 Six Patient Rights 9
10 Six Patient Rights 10
11 Six Patient Rights 11
12 Six Patient Rights 12
13 Use and Disclosure of PHI Protected Health Information (PHI) may only be used and disclosed under certain circumstances, following specific guidelines: Treatment, Payment or Healthcare Operations Some Public Policy exceptions, including the waiver of authorization granted by the Institutional Review Board (IRB) for research purposes Authorization of the patient 13
14 Use Sharing PHI Within UTHealth Point 1 PHI may be used to treat patients, obtain payment for services, educate UTHealth students and residents, and conduct normal health care business. Point 2 UTHealth may share information inside the institution only while following the privacy law and the privacy policies of the institution. Point 3 Point 4 That means we must ensure that the person to whom we give information is part of treatment, payment or healthcare operations or has an authorization signed by the patient. If the person is a researcher, even a UT researcher, they must present either an authorization signed by the patient or a waiver of authorization prepared by the IRB.
15 Disclosure Sharing Outside of UTHealth Disclosure means: To release or transfer PHI outside of UTHealth, which includes giving access to or divulging information in any way. Any entity: That provides services to UTHealth to whom we disclose information under contract must also sign a business associate agreement which details the parameters under which they must use and disclose the PHI that they receive. Before giving information: To others outside UTHealth, double check to ensure that the information is going to the right place and the person who says he has a right to the information, in fact, does so. In any setting: Where health care services are provided, a certain amount of incidental disclosure of PHI is unavoidable. Health care providers are required, under HIPAA, to take precautions to ensure that reasonable safeguards to protect incidental disclosures are in place. 15
16 Disclosure Continued If reasonable safeguards are in place, the following activities are permitted: Using patient sign-in logs Calling out the patient s name in the waiting room Disclosing PHI in group or family therapy sessions Disclosing PHI to family members or other person involved in the patient s care Discussing a patient s treatment among care providers, and posting patient schedules in treatment areas
17 Authorization Disclosing Patient Information The Authorization Form: Valid Authorization Form: There are occasions when we must disclose the patients information for purposes other than treatment, payment, or operations. The patient must sign a specific authorization to give UTHealth the authority to disclose information for such purposes. Must contain nine specific elements, and forms that outline these elements are available in the records departments. Please ask for assistance from the Privacy Office if you need to develop or fill out an authorization form. If you are not sure if an authorization form is valid, check with the Privacy Office before making a use or disclosure pursuant to the form. 17
18 PROPERTIES Allow user to leave interaction: Show Next Slide Button: Completion Button Label: After viewing all the steps Don't show Next Slide
19 Treatment, Payment, Operations 19
20 Treatment, Payment, Operations 20
21 Treatment, Payment, Operations 21
22 Treatment, Payment, Operations 22
23 Authorization Exceptions Sometimes it is okay to use or disclose PHI outside of TPO. Only the minimum necessary should be shared. These very specific cases are: For public health activities such as disease reporting About victims of abuse, neglect or domestic violence Where permitted by an IRB waiver, for research To avert a serious, imminent threat to public safety For health oversight activities, like the FDA or a licensure board For judicial or administrative proceedings For some law enforcement activities Certain government functions Anything else required by law Consult the UTHealth Privacy Handbook and/or the Privacy Officer for guidance
24 PROPERTIES Allow user to leave interaction: Show Next Slide Button: Completion Button Label: After viewing all the steps Don't show Next Slide
25 Accidental Release or Breach 25
26 Accidental Release or Breach 26
27 Accidental Release or Breach 27
28 Accidental Release or Breach 28
29 Accidental Release or Breach 29
30 Protocol If you discover that Protected Health Information is accidentally released, you need to act immediately to minimize risk and damage. Accidental release can be anything from calling the wrong patient to distributing a spreadsheet, to losing a portable device. You must report as soon as you discover the potential breach, as there is a limited time frame to respond. Inform your supervisor in writing. Notify the Office of Legal Affairs, UCT 1477 at (713) If IT resources are involved send an to [email protected] or call (713) Breaches of the HIPAA Privacy and Security Rules have serious ramifications for all involved. In addition to sanctions imposed by UTHealth, such breaches may result in civil and criminal penalties.
31 In The News In the News Published February 2014 Compliance Training In 2010, a former UCLA Health System employee became the first person in the United States to receive jail time in a federal prison for a misdemeanor HIPAA offense. The employee used his employee access to the University s electronic medical records system to view the medical records of his supervisors, co-workers, and high-profile patients. While none of the information was used or sold, the access was nonetheless illegal because the employee lacked a valid reason for looking at the records.
32 PHI and All s Digital IDs Digital IDs Disposal of PHI All s containing PHI, including those sent to other University addresses, must be digitally signed and encrypted. If the recipient does not have a digital ID, you must find an alternate way to send the information. Remove PHI from unencrypted s that you receive, before you reply or forward the . Double check all addresses when you send PHI. DO NOT RELY upon auto-complete to find the addresses for you. Remember that people using PDAs and Smart phones, or people moving from computer to computer, will not have the ability to install a Digital ID on their device and cannot read encrypted s. This DOES NOT mean that you should send unencrypted s with PHI. When disposing of documents that contain PHI follow the records retention schedule, archive records according to University policy and procedure, and shred all documents containing PHI.
33 Contact Information If you have questions about information contained in this module, please contact: Christina Solis, JD UTC 1447 (713) Office of Legal Affairs 47
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