2. HIPAA THE PRIVACY RULE Reviewed 10/2014

3. 2 HISTORY In 2000, many patients that were newly diagnosed with depression received free samples of anti- depressant medications in their mail.

4. 3 HISTORY Many of these patients were concerned on how the pharmaceutical companies were notified of their disease.

5. 4 HISTORY After much investigation, the Physician, the Pharmaceutical company and a well known Pharmacy chain were all indicted on breach of confidentiality charges.

6. 5 HISTORY This is just one example of why the Federal government needed to step in and assist in protecting patient privacy.

7. 6 Definitions Privacy – state of being concealed; secret Confidentiality – containing secret information (medical record) Authorization – to give permission for; to grant power to Breach Confidentiality – to break an agreement, to violate a promise

8. 7 HIPAA Health Insurance Portability and Accountability Act –Much of the patient’s health information is documented in a computerized format. Protecting this information has become vitally important. –The first federal legislation (effective April 14, 2003) that attempts to protect a patient’s right to privacy, and the security and access of personal medical information and usage.

9. 8 HIPAA  Health Insurance Portability and Accountability Act Privacy Rule –Imposes restrictions on the use/disclosure of personal health information –Gives patients greater protection of their medical records –Hopefully provides patients with greater peace of mind related to the security of their information

10. 9 Confidentiality Deals with : –C ommunication or in- formation given to you without fear of disclosure –Legitimate Need to Know & Informed Consent Potential breeches of confidentiality can occur

11. 10 Protected Health Information What is Protected Health Information (PHI)? –When a patient gives personal health information to a healthcare provider, that becomes Protected Health Information (PHI)

12. 11 Protected Health Information  PHI Includes:  Verbal information  Information on paper  Recorded information  Electronic information (faxes, e-mails)

13. 12 Protected Health Information Examples of patients information –Patients name or address –Social Security or other ID numbers –Doctor’s/ Nurse’s personal notes –Billing information

14. 13 Rules for the Use & Disclosure of PHI PHI can be used or disclosed for –Treatment, payment, and healthcare operations –With authorization/agreement from patient –For disclosure to patient –THIS HELPS with REFERRALS AND BILLING TOO

15. 14 Rules for the Use & Disclosure of PHI You’re required to release PHI –When requested/authorized by the patient (some exceptions apply) –When required by the Department Health and Human Services Patients can request a list of persons who viewed their PHI, but they too must sign a consent

16. 15 Authorization Guidelines Patient authorization for release of PHI must be obtained in the following situations: –Use/disclosure of psychotherapy notes –For research purposes –For use/disclosure to third parties for making activities

17. 16 Authorization Guidelines PHI can be used/disclosed without authorization for the following reasons:  BIRTHS  DEATHS  POLICE INVESTIGATIONS  SEXUALLY TRANSMITTED DISEASE  COMMUNICABLE DISEASE

18. 17 Authorization Guidelines PHI can be used/disclosed without authorization: –To report victims of abuse, neglect or domestic violence –To funeral homes, tissue/organ banks –To avert a serious threat to health/safety

19. *With a MINOR it protects their privacy after a certain age and in certain circumstances. Usually a minor must be accompanied by an adult guardian, and that guardian can control treatment and get all info…UNLESS: PREGNANCY, over the age of 14 HIV testing Suspected cases of abuse 18

20. 19 Notice of Privacy Practices The Notice of Privacy Practices must contain the patient’s rights and the covered entities’ legal duties Patients are required to sign a statement that they were informed of and understand the privacy practices Patients have the right to adequate notice concerning the use/disclosure of their PHI

21. 20 Minimum Necessary Over the phone it is not recommended to give out info. If the caller knows the patient’s full name this is the ONLY info you can disclose: Name, Room #, Stable or Critical, Religion ***Remember, a patient can STILL request you do not even give this information out.

22. 21 Minimum Necessary or “Need to know basis”  Identify employees who regularly access PHI.  Identify the types of PHI needed and the conditions for access.  Grant only that access necessary to perform the job.

23. 22 Protections for Health Information Important Safeguards –Physical Safeguards Computer terminals are not placed in public areas –Technical Safeguards Every associate must keep his/her password confidential –Administrative Safeguards Policy and procedure for release of patient information

24. 23 The Joint Commission Standards Patients Rights –The hospital demonstrates respect for the following patient needs: Confidentiality Privacy Security Resolution of complaints Records and information are protected against LOSS, destruction, tampering and UNAUTHORIZED ACCESS or use

25. 24 The Joint Commission Standards Patients Rights –Patients have a right to confidentiality of all information that is provided to the healthcare professional and institution –Health care professionals ensure that patient information is secured at all times and if there are any complaints, those complaints will be resolved in a timely manner.

26. 25 Faxing Guidelines  Located in non-public areas.  Centralized fax machines: Pick up information immediately  DO NOT FAX the following records/results: HIV results Alcohol abuse Mental Health Substance abuse Narcotic prescriptionsChild abuse

27. 26 Faxing Guidelines When you fax to outside offices:  Check the transmission print out  Verify that the correct number was dialed

28. 27 Privacy No photographs or recordings of any type are to be taken of patients in the clinical setting. No cameras, palm pilots, cell phones or any electronic devices with photography capabilities are permitted in the clinical environment. When you speak to a family member or patient in the room OR ON THE PHONE, use a low voice, give only previously indicated info and put call on hold when you walk away. Protect Your Patient!

29. Computers or Charts Never share your password Always log off Close down screen or shut chart as you walk away. Shield your computer or chart from others view 28

30. 29 Enforcement of the Medical Privacy Regulations  Office for Civil Rights -A patient may complain to the Privacy Officer in a hospital … OR -The Director of Health and Human Services (HHS)

31. 30 Patient Privacy Rights It’s your job to make sure patients know they have the right to: –To see and copy their PHI –Protect patient’s privacy and confidentiality –Contact your hospital’s privacy administrator for any privacy concerns

32. Health Information Technology for Economic and Clinical Health Act

33. Purpose:  Applies to covered health care entities and business associates. Makes massive changes to privacy and security laws  Creates a nationwide electronic health record  Increases penalties for privacy and security violations  Breach Notification requirements (Patient, Department of Health and Human Services, and Media) HITECH ( continued ) Criminal Penalties Criminal provisions Penalties Sharing of civil monetary penalties with harmed individuals

34. Review 33 HIPAA  Health Insurance Portability and Accountability Act HIPAA protects  Health Care workers must protect patient’s confidentiality HIPAA helps with referrals and billing Only share information on a NEED TO KNOW basis Information can be given over the phone but it it is limited to  NAME, LOCATION, GENERAL HEALTH CONDITION, RELIGION You should never share passwords You should shield your screen from others When you walk away from the computer you must close it down Any information that needs to be destroyed MUST be SHREDDED You may speak to a relative on the phone if you give general health condition, speak in a low voice and place the call on hold if you need to walk away HIPAA is excluded in cases of BIRTH, DEATH, POLICE INVESTIGATIONS, SEXUALLY TRANSMITTED DISEASES, COMMUNICABLE DISEASES HIPAA is excluded when it involves minors and parents UNLESS  a pregnancy over the age of 14, HIV testing, Suspected cases of abuse.