University Medical Center HIPAA Privacy and Security Training

Compliance is Everyone’s Job

UMC’S HIPAA Privacy/Security Officer: Jan Chaissonjchaisson@cchs.ua.edu

348-1231

University Medical Center

Topics to Cover• General HIPAA Privacy and Security Overview• HIPAA Privacy

– Use and Disclosure of PHI– Notice of Privacy Practices– Authorization Form– Accounting for Disclosures– Business Associate Agreements

• HIPAA Security– Security and Other Related-UA Policies – Access Controls– Contingency Planning– Audit Controls– Reporting Breaches & Security Incidents

• Questions/Acknowledgment of Training

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What is HIPAA?

• The Health Insurance Portability and Accountability Act

• Law passed to ease the movement of healthcare data between providers.

• Privacy and Security regulations must be followed by a “Covered Entity”

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Applicability of HIPAA to UA

• UA is a “Hybrid Entity” –Only A Few Areas Must Comply – HIPAA Applies to UA’s Covered “Health Care Components”:

• University of Alabama Medical Center • Brewer-Porch Children's Center • The Speech & Hearing Center

– HIPAA Applies to UA’s Covered Health Plans • UA Group Health Insurance/Flexible Spending Plan/Other (EAP)

• Also applies to Administrative Departments supporting any of these covered entities (like Legal Office, Auditing, Financial Affairs, UA Privacy/Security Officer, etc.)

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What is Protected Health Information (PHI)

• Any information, maintained in any medium, including demographic information

• Created/received by covered entity• Relates to/describes physical/mental health or payment

for healthcare• Can be used to identify the patient

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Some Records are not PHI:• Student records that fall under the Family

Educational Rights and Privacy Act (FERPA).• Medical records, exempt from FERPA, of students 18

or over attending UA and that are made or maintained by a health care provider and used only to treat the student and disclosed only to individuals providing the treatment.

• The University’s employment records.• Not PHI if you de-identify by removing all of the 18

identifiers

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Data to Remove to De-Identify Patient Information

• Names• Geographic subdivisions smaller than state (address, city,

county, zip)• All elements of DATES (except year) including DOB, admission,

discharge, death, ages over 89• 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• Full face photographic and comparable images• Any other unique identifying #, characteristic, or code

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HIPAA Privacy & Security Work Together

• Privacy Rule applies to all PHI of covered entity and sets rules for use or disclosure of PHI, and gives person certain rights to PHI—requires entity to safeguard PHI

• Security Rule applies to PHI in electronic form (EPHI) and requires various safeguards to protect the confidentiality, integrity and availability of EPHI

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HIPAA Privacy & Security Work Together

• Confidentiality ensures the protection of data during all aspects of its life. This includes data at rest on computers, data in transit between computers and destruction of data when no longer needed or the asset holding the data is no longer needed. Remember the rule of “Least Privilege” - Users should have access to the data they need to perform their jobs and nothing else.

• Integrity is upheld when we are confident that the data is maintained in an accurate manner free of unauthorized modification. This requires controls to be in place for the hardware, software and network components to ensure that the data is free of any possible interception and/or unauthorized changes.

• Availability provides the necessary capacity and performance to access data in a predictable manner. Appropriate protection mechanisms should be in place to prevent attacks both from the inside and the outside that could jeopardize Availability. Environmental issues can also affect availability such as heat, cold, humidity, static electricity and contamination.

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HIPAA Security/Privacy Rule Penalties• State Breach of Privacy Claims • DOJ-Imposed Criminal Penalties for the 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.

• Federal-Imposed Civil Penalties for UA:– Up to $100 per violation– Each Name in a Data Set Can Be a Violation. Not to Exceed $25,000 Per

Calendar Year. – Feds have six years from occurrence to initiate civil penalty action

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UA HIPAA Sanctions• UMC Employees who do not follow Privacy and

Security Policies and related workplace rules and policies are subject to disciplinary action, up to and including dismissal

• Type of sanction depends on severity of violation, intent, pattern/practice of improper activity, etc.

• Sanction records maintained 6 years• Possible notification to Enforcement Officials

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General Rule for Use and Disclosure of PHI

• A covered entity can always use and disclose PHI for any purpose if it gets the person’s written authorization.

• HIPAA requires certain components to be in the authorization in order for it to be valid.

• There are many exceptions to the requirement for authorization.

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Exceptions:• No authorization is needed if for Treatment, Payment

and Healthcare Operations (TPO).• PHI (except psychotherapy notes) may be

used/disclosed for the covered entity’s own TPO. • PHI may be disclosed to other covered entities or

health care providers for the payment activities of the entity that receives the information, such as an ambulance company.

• PHI may be disclosed to another covered entity or health care provider for its health care operations, under limited circumstances.

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No Authorization is Required to Disclose to Business Associates

• PHI may be disclosed to a Business Associate (BA) if UMC has executed a Business Associate Agreement with that organization or vendor.

• Regulations define who qualifies as a BA.• Each UA Health Care Provider must maintain

records of who its identifies as a Business Associate, and must ensure agreements are in place.

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No Authorization is Needed to Disclose PHI:

• When required (not permitted) by law;• To Public Health/Legal Authorities charged with

preventing and controlling disease, disability or injury;• To FDA to ensure quality, safety, or effectiveness of FDA-

regulated products;

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And:

• To persons who may have been exposed to communicable disease or may be at risk of contracting or spreading a disease;

• To entities charged with overseeing victims of abuse, neglect or domestic violence, consistent with reporting obligations;

• To a health oversight agency for activities authorized by law (gov’t. licensing or accreditation agencies)

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And:• In response to a Court order;• In response to a subpoena that meets certain

requirements (always check with the Legal Office);• Law enforcement officials seeking to identify a suspect,

witness, or victim of a crime;• Coroners/medical examiners/funeral directors to

identify a deceased person or determine a cause of death;

• Organizations handling organ, eye or tissue donation;

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And:• To prevent/lessen a serious and imminent threat to

patients or others health and safety;• To military command authorities and federal officials

for intelligence and national security activities;• To comply with workers compensation laws;• Facility directories, if asked by name.• Individuals involved in patient’s care or payment.• Persons involved in disaster relief.

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HIPAA requires UA’s health care providers to:

• Provide Notice to individuals of privacy practices

• Authorization Forms• Control access• Account for use and

disclosures• Manage complaints

• Have a privacy officer• Conduct training• Provide sanctions• Develop Business

Associate Agreements• Have policies and

procedures

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Under HIPPA, Patients Have the Right to:

• Receive Notice of Health Information Practices.• Authorize use of their data.• Request access to their data.• Request an accounting of the uses and disclosures of

their data.• Request amendment and corrections to their data.• Request restrictions on use of data.• File a complaint.

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UA Must Meet the Minimum Necessary Standard

• Providers should disclose or use only the minimum necessary amount of PHI in order to do their jobs.

• Minimum necessary does not apply to:1. Disclosures used for treatment;2. To the individual who is the subject of the disclosure;3. When a valid HIPAA authorization is signed;4. Uses and disclosures required by law;5. Disclosures to HHS.

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Incidental Disclosures are Permitted if:

• They cannot be reasonably prevented;• Are limited in nature;• Are a by-product of otherwise permitted use; and• The Covered Entity has established “reasonable

safeguards” to ensure only necessary information is disclosed.

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Incidental Uses and Disclosures Include:

• Waiting room sign-in sheets • Patient charts at bedside • Physician conversations with patients in semi-private

room • Physicians conferring at nurse’s stations.

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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)

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UA’s Covered Health Care Providers are Required to Have and Use:

1. Notice of Privacy Practices 2. Authorization Forms 3. Accounting for Disclosures 4. Business Associate Agreements

UA has developed template forms and policies for its health care components/health plans.

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1. Notice of Privacy Practices

• Notice of patient’s rights with respect to PHI and our privacy practices.

• We must make a good faith effort to obtain the patient’s written acknowledgement at the time of receipt of the Notice of Privacy Practices, except in emergency circumstances.

• Each patient must receive a Notice of Privacy practices no later than the date of first service delivery.

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The Notice of Privacy Practices:

• Must list each type of disclosure that may be made by the covered entity and distinguish between those that are made pursuant to law and those that are not.

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2. The Authorization Form

• An Authorization Form is required for the use and disclosure of PHI for business-related purposes other than Treatment, Payment, and Operations and other than the permitted exceptions.

• Authorizations are always required to disclose psychotherapy notes in order to give psychotherapy notes stronger protections.

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Psychotherapy Notes

• Must be kept separately from the patient’s medical record.

• Consists of the “process notes” that the therapist makes about counseling sessions.

• Does not include summary information used for treatment such as symptoms; summary notes; diagnosis, and medications.

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Authorization Required for Marketing

• UA is prohibited from using or disclosing PHI for marketing purposes without the patient’s express authorization.

• Prohibited from selling patient lists to third parties.• CAN talk with patients about our treatment options,

and have common health care communication about wellness, prescription refill reminders, therapies, and appointment notifications without an authorization.

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Authorization for Marketing:

• Must disclose if UA is receiving benefits or payment from any third party receiving the patient’s information.

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3. Accounting For Disclosures

• Individuals have the right to receive an accounting of disclosures of PHI made by UA (even to our Business Associates), except for:– Disclosures made to carry out Treatment, Payment and

health care Operations;– PHI provided to the patient about them;– PHI disclosed to family members or friends involved in

a patient’s care;– Disclosures made pursuant to authorization

UA has designed forms for tracking disclosures.

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4. Business Associate Agreements• BA performs specific tasks involving the

use/disclosure of PHI on our behalf, such as billing, legal services, and accreditation.

• Agreement requires BA to– not use/disclose PHI except as necessary to perform duties

on our behalf– safeguard PHI and ePHI– report security incidents/breaches of confidentiality– log/track its disclosures of PHI.

• UA has a BAA Template, which Legal has approved• If UA is the BA, Legal should review agreement

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HIPAA Put New Requirements on Research:

• If you work for a Health Care Provider under HIPAA, do not release PHI for research unless:– The patient has signed a valid HIPAA authorization, or– The IRB at UA has approved a waiver of authorization; or – The IRB agrees that an exception applies.

Separate training on HIPAA & Research is available through the Privacy Office.

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Security Standards – General Rules

• HIPAA security standards ensure the confidentiality, integrity, and availability of PHI created, received, maintained, or transmitted electronically (ePHI – Electronic 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

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The HIPAA Security Rule Requires…

• General Security Requirements• Risk Analysis and Management• HIPAA Security Sanction Policy• Information System Activity Review• Named Security Officer• Workforce Security• Information Access Management• Security Awareness and Training• Protection from Malicious Software• Security Incident Procedures

Contingency Planning Facility Access Controls Workstation Use and Security Device and Media Controls Medial Reallocation and Disposal Access Controls Audit Controls Data Authentication Person or Entity Authentication Transmission Security

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HIPAA Security Policy Documents

Managing Access to Information• Access to UMC’S computer systems and information is based on your work

duties and responsibilities with UMC• 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 EPHI is intentional!

– Doctors access is for physicians– Nursing access is for nursing – Students access is for students

• Access in one capacity may not permit access in another capacity• If job duties change, clearance levels for access to EPHI is re-evaluated• Access is eliminated if employee terminated• Accessing EPHI for which you are not cleared or for which there is no job-

related purpose will subject you to sanctions!

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Information Access Control• Do not allow unauthorized persons into restricted areas where

access to PHI or ePHI could occur• Arrange computer screens so they are not visible to

unauthorized persons and/or patients; use security screens in areas accessible to public

• Log in with password, log off prior to leaving work area, and do not leave computer unattended

• Close files not in use/turn over paperwork containing PHI • Do not duplicate, transmit, or store PHI without authorization• Storage of PHI on removable devices (Disk/CD Rom/DVD/

Thumb Drives) is prohibited without prior authorization

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Password Management• Do not allow coworkers to use your computer without first logging off your

user account• Do not share passwords or reuse expired passwords• Use passwords that cannot be easily guessed (B’day, pets, kids)• Choose new passwords when they must be reset• Do not write down passwords that could provide access to EPHI• Change password if you suspect anyone else knows it• Change passwords or delete accounts when employees are transferred or

terminated• Pick good passwords – Recommendations for good passwords:

– 7 characters long– 3 of 4 data types – Upper, Lower, Numeric and Special Character– Change periodically – Good password scheme is critical for complex passwords – R0llt!de (don’t use

this, just an example)

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Log-in Monitoring by Security Officer• Look for Inappropriate Access – Outside Normal Classification• Monitor Logs for Brute Force Attacks

– Same ID, Multiple Password Guesses– Multiple ID/Password Attempts That Fail– Multiple Attempts to Log-in to Administrative Accounts

• Log-in Outside Normal Hours• Multiple Log-ins With Same ID• Significant findings are recorded and presented to management

and safeguards adjusted based on findings

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Protection from Malicious Software• Malicious software can be thought of as any virus, worm, malware, adware, etc. • As a result of an unauthorized infiltration, ePHI and other data can be damaged or

destroyed• Practice good PC hygiene

– Automatic patch update for your Operating System– Install and use a good anti virus/anti spyware software package and set updates to daily and a

full system scan once a week– If possible, enable firewall protection for your PC

• Notify your supervisor, system support representative, and/or security officer immediately if you believe your computer has been compromised or infected with a virus—do not continue using computer until resolved.

• Do not disable anti-virus software on individual workstations• Do not open e-mail or attachments from an unknown, suspicious, or untrustworthy

source or if the subject line is questionable or unexpected—DELETE THEM IMMEDIATELY

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Use of Technology• Email, internet use, fax and telephones are to be used for UA business

purposes (see UA policies) • No ePHI is permitted to leave facility in any format without prior approval • Email should never be used to communicate PHI without being encrypted• We must be sure electronically transmitted ePHI is not improperly

modified without detection• Fax of PHI should only be done when the recipient can be reliably

identified• Verify fax number and recipient before transmitting• Uploading of PHI for instruction or communication is prohibited w/o prior

approval and demonstration of appropriate de-identification procedures

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General Misuse of Workstations• Do not misuse e-mail privileges by sending and forwarding non-business related

mass e-mails, chain e-mails and junk e-mail• Do not misuse internet privileges by spending excessive time on the internet for

non-work related business or accessing inappropriate sites• Do not download, install, or run unauthorized software• Do not use non-work related chat rooms and instant messaging programs at

work• Do not knowingly enable an external/remote party to gain unauthorized access

or control of any device, application, or system to the data networks• Only individuals with administrative responsibilities or their designee may be

granted access to the e-mail account of their former employee or vendor

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Links to UA Policies

• Network and Computing Support Policies: http://ncs.ua.edu/policies/index.html • Electronic Media Policy:

http://www.hr.ua.edu/empl_rel/policy-manual/electronic-media.htm

• University of Alabama General Policies: http://policies.ua.edu/

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Media Reallocation and Disposal• All computers, disks, removable storage devices must be

properly cleaned/erased before transfer or disposal– No computer or disk/CD Rom/DVD or any other removable storage

device should leave the facility for disposal/transfer without ensuring that ePHI has been properly cleaned

– Do not throw away a disk/CD Rom/DVD or any other removal storage device containing ePHI

– Do not transfer computers to another department before taking steps to ensure that any ePHI has been PROPERLY erased/deleted from that computer

– Do not transfer any hard drive/disk/CD Rom/DVD or other removable storage device before taking steps to ensure that any ePHI has been erased/deleted

– Merely deleting files is not a proper cleaning method. See Media Reallocation and Disposal Policy for proper sanitization methods

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Facility Access Controls

• Access to our centers must be managed and controlled to prevent unauthorized visitors from accessing the facilities or PHI

• Help to monitor the controls we have for Facility Access– Sign-in Visitors and Vendors– Insure that locks, card access, or any other physical access controls are

working as expected• Report any problems or possible problems to your supervisor,

administrator, and/or your security officer.

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Contingency Planning

• Contingency planning allows us to continue some critical operations in the event of an emergency

• Help us prepare for emergencies by pointing out critical areas necessary for continuing operations

• This includes emergency communications plans, emergency operations plans, back up and recovery plans and many other items included in an Impact Analysis and Disaster Recovery Plan

• Some of you may be asked to participate in the creation of these plans and will be involved in testing

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Audit Controls

• Audit Controls are required to insure that we are following all of the required regulations associated with the HIPAA Privacy and Security Rules

• This will require us to make sure that we have procedures in place that provide tracking and audit records demonstrating compliance with all rules and regulations

• Please notify your supervisor and Security Officer of any improvements necessary or deficiencies that would assist with properly tracking and controlling access to PHI

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Reporting Security Incidents• Notify your Security Officer or supervisor of any unusual

or suspicious incident• Security incidents include the following:

– Theft of or damage to equipment– Unauthorized use of a password– Unauthorized use of a system– Violations of standards or policy– Computer hacking attempts– Malicious code– Security Weaknesses– Breaches to patient, employee, or student privacy

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Questions/Comments• Know Your Security and Privacy Officer:

– UMC’S Privacy/Security Officer: Jan Chaisson, jchaisson@cchs.ua.edu, 348-1231

– UA Privacy Officer: Jan Chaisson– UA Security Officer: Ashley Ewing

• Other References– Privacy:

• www.hhs.gov/ocr/hipaa– Security:

• www.cms.hhs.gov/SecurityStandard

• Acknowledgement:– Please Complete the Training Acknowledgement Form to Obtain Credit for

Completing the Annual Training

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