1. HIPAA Basic Training for Privacy and Information Security Vanderbilt University Medical Center VUMC HIPAA Website: www.mc.vanderbilt.edu/HIPAA HIPAA Basic Training

2. Vanderbilt Credo “We treat others as we wish to be treated” Vanderbilt Credo Behavior “I respect privacy and confidentiality”

3. What is HIPAA? What Does HIPAA Do? Limits how we use and share patient information Gives patients more control over their information Protects the integrity, availability and confidentiality of patient information Defines violation penalties Health Insurance Portability and Accountability Act of 1996

4. What is Protected under HIPAA? Individually identifiable health information: That is collected from an individual, or That is created or received by A health care provider Employer Health insurer’s plan This information can be in any form: Written, verbal, or electronic

5. Information pertaining to HIV, alcohol and drug treatment, psychotherapy notes, etc. have even more stringent protections. What is Protected under HIPAA?

6. Patient Rights ALL Patients have the right to: Receive a Notice of Privacy Practices that describes how we use and share their information Review and obtain copies of their medical and financial records Request amendments to their medical record if they believe information is incorrect or missing. HIPAA regulations provide individuals with certain rights that are reflected in VUMC policy.

7. Sharing Patient Information Treatment (physicians involved with care, family members involved in patient’s care, etc.) Payment (insurance companies, other third parties) Administrative functions (QI, financial analysis, educational or training activities Other specific exceptions (required by law, Department of Public Health) You must obtain patient authorization except in the following circumstances:

8. Protecting the Privacy of Patient Information Only share patient information with other faculty and staff who need the information to do their job. Avoid accessing a patient’s record unless you need to do so for your job or you have written permission from the patient. You are not allowed to access the record of your co-worker, spouse, or family member unless there is written authorization in the patient’s record.

9. Key Information Security Practices Passwords & Electronic Signatures Logging Off/Locking Computers E-mail Files Passwords Web sites E-mail

10. Passwords and Electronic Signatures DO choose ones that you can remember DO remember that the longer they are, the better DO use numbers, uppercase and lowercase letters, and special symbols to create them, where allowed Some Do’s related to passwords and electronic signatures.

11. Some Don’ts related to passwords and electronic signatures. DO NOT share them with anyone DO NOT write them down where others can see them or store them where others can access them DO NOT use words, names, or personal data others may guess, such as the name of your pet. Passwords and Electronic Signatures

12. Logging Off Computers Log Off OR\ Lock the computer screen If you need to walk away from a computer you are using, always:

13. E-mail E-mail sent over the Internet is generally unencrypted and not secure. Find alternative ways to communicate confidential information (e.g., encryption, MyHealthAtVanderbilt, password protected files, VPN) Limit the amount of patient information. Beware of E-mail Attachments!

14. Auditing The Privacy Office conducts audits daily on the medical records of employees who come to the hospital to monitor for inappropriate access. Audits are also conducted whenever a patient suspects that their medical record may have been inappropriately accessed.

15. Sanctions for Privacy and Information Security Violations VUMC considers it a serious incident anytime that a privacy or security violation occurs. HIPAA requires that we monitor information system activity which assists in identifying violations and that we document all incidents. Disciplinary/corrective action ranges from training/counseling to termination.

16. What Should Be Reported? Privacy and Security Violations: Looking at someone else’s confidential data Paperwork with patient information lying around unattended Sharing passwords or electronic signatures or the use of another employee’s password or electronic signature

17. Privacy Office (936-3594) or e-mail Privacy.Office@vanderbilt.edu Privacy.Office@vanderbilt.edu Help Desk 343-HELP (343-4357) Compliance Reporting Line (343-0135) Always forward Patient privacy complaints to Patient Affairs (322-6154) or the Privacy Office. Your manager Contact One of the Following to Report Privacy & Information Security Incidents

18. The Bottom Line Consider the patient’s perspective and give them control over how their information is used. Avoid situations in which the patient would object to how their information was used or shared. Implement appropriate security measures to maintain the integrity of patient data, ensure its availability, and keep it confidential. Be familiar with Vanderbilt’s privacy & information security policies at: www.mc.vanderbilt.edu/HIPAA

19. Final Instructions To complete the training you must print off the HIPAA Test and submit it to the manager in your department for filing in your personnel file.HIPAA Test Any questions related to this training may be submitted to the Privacy Office at privacy.office@vanderbilt.edu or callprivacy.office@vanderbilt.edu 936-3594.