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HIPAA Training: Privacy Protection for Patients

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HIPAA Training:
Privacy Protection for Patients
Privacy Training for TUSM students
and Visiting Students
Overview by Steve Pauker, M.D.
Sara Murray Jordan Professor of
Goals for this Program
• Understand basic principles of the new
Privacy Rule
• Understand your role in protecting patient
• Know where to go for help if you have a
question or have incidentally violated rules
What is the HIPPA/ Privacy
Compliance Law?
• HIPPA: stands for Health Insurance
Portability and Accountability Act.
Passed by Congress in 1996;
implemented April 14, 2003
• Ensures that personal medical information
that patients share with health care
providers remains private and is protected
Why Is the HIPAA Privacy Regulation Needed?
• When it comes to personal information that moves across hospitals,
doctors’ offices, insurers or third party payers, and state lines,
the United States has relied on a patchwork of federal and state laws.
• Up to now, personal health information could be distributed – without
either notice or consent – for reasons that have nothing to do with a
patient’s medical treatment or a provider’s health care reimbursement.
• The Privacy Regulation establishes a federal floor of safeguards to
protect the confidentiality of medical information. State laws that
provide stronger privacy protections will continue to apply over and
above the new federal privacy standards.
• Although health care providers have a strong tradition of safeguarding
private health information, in today’s world, the old system of paper
records in locked filing cabinets is not enough.
• With information broadly held and transmitted electronically, the
Privacy Regulation provides clear standards for all parties regarding
protection of personal health information.
HIPAA Provides Benefits to Patients
• Portability of health insurance
• Protects patient privacy
• Ensures that everyone who handles
personally identifiable health
information(including medical students) is
responsible and accountable for protecting
the patients’ privacy
What does the Privacy Regulation Do? -1
• The Privacy Regulation for the first time creates national
standards to protect individuals’ medical records and other
personal health information.
• It gives patients more control over their health information.
• It sets boundaries on the use and release of health records.
• It establishes appropriate safeguards that health care
providers and others must achieve to protect the privacy of
health information.
• It holds violators accountable, with civil and criminal
penalties that can be imposed if they violate patients’
privacy rights.
• And it strikes a balance when public responsibility requires
disclosure of some forms of data - for example, to protect
public health.
What Does the Privacy Regulation Do? - 2
For patients,
• It means being able to make informed choices
when seeking care and reimbursement for care
based on how personal health information may be
• It enables patients to find out how their
information may be used and what disclosures of
their information have been made.
• It generally limits release of information to the
minimum reasonably needed for the purpose of
the disclosure.
• It gives patients the right to examine and obtain a
copy of their own health records and request
What Does the Privacy Regulation Do? -3
For the average health care provider,
HIPAA requires activities, such as:
• Providing information to patients about their privacy rights and how
their information can be used.
• Adopting clear privacy procedures for the particular practice or
• Training employees so that they understand the privacy procedures.
• Designating an individual to be responsible for seeing that the
privacy procedures are adopted and followed.
• Securing patient records containing individually identifiable health
information so that they are not readily available to those who do
not need them.
• Responsible health care providers and businesses already take many
of the kinds of steps required by the regulation to protect patients’
The Privacy Law
• Protects all health information created by a
healthcare provider, health plan or
healthcare clearinghouse
• Protects this information no matter how it is
transmitted (verbally, electronically or in
• Defines who is allowed to use patients’
protected health information
Common HIPAA Jargon for
IIHI- Individually Identifiable Health Info
PHI- Protected Health Information
CE- Covered entity
– Payment
– Operations (healthcare)
• NPP- Notice of Privacy Practices
To Whom Does HIPPA Apply?
• Covered Entity: under HIPAA, this means
health plans, healthcare clearinghouses,
healthcare providers who transmit any
health information
– Healthcare providers include all workforce
members of hospitals and clinics including
medical students
Who Must Comply With the HIPAA?
• Tufts University is a “hybrid entity.”
This means that some, but not all, of its
functions fall under HIPAA.
• Since medical students see patients and
clinical data at covered entities (affiliated
clinics and hospitals), medical students are
required to comply with the Privacy
Protected Health
Information (PHI)
• PHI is any health information that is created by or
received by a covered entity; and
• relates to the past, present or future (e.g. genetic
predisposition) physical or mental health or
condition of an individual; or the past, present or
future payment for the provision of health care to
an individual
• The standards apply to information, not to specific
records; therefore, the protections apply to the
information in any form (verbal, written, etc.)
IIHI: Individually Identifiable
Health Information
• All information which may potentially
identify the individual or with respect to
which there is a reasonable basis to believe
that the information can be used to identify
the individual
• Individually identifiable health information
is protected under the law
Individually Identifiable Health Information
Contains any of the following 18 HIPAA identifiers
– Names
– Geographic subdivisions
smaller than a State
– Dates (except year) directly
related to patient
– Telephone numbers
– Fax numbers
– E-mail addresses
– Social security numbers
– Medical record numbers
– Health plan beneficiary
– Account numbers
– Certificate/license numbers
– Vehicle identifiers and serial
– Device identifiers and serial numbers
– Web URLs
– Internet Protocol (IP) address
– Biometric identifiers, including
finger and voice prints
– Full face photographic images and
any comparable images
– Any other unique identifying
number, characteristic, or code,
except as permitted under HIPAA to
re-identify data
Patient Rights
• To have their privacy protected and respected.
• To receive a notice of our privacy practices at first contact aft
April 14, 2003 (and acknowledge receiving that notice).
• To request/authorize disclosure of their PHI,
although some disclosures do not require the patient’s
• To receive a copy of their records,
within a specified time frame, if they ask.
• To request their records be amended
(we do not have to comply,
but we must respond in a specified time frame).
• To request that PHI be communicated to the patient at
alternative locations or by alternative means if possible
(e.g., different address).
Patient Rights (cont)
• To request that our use or disclosure of their PHI
be restricted (but we do not have to comply).
• To receive an accounting of disclosures of their PHI
generally within 60 days, except for disclosures for
treatment, payment, our operations, disclosures the
patients authorize, and certain other disclosures.
• To complain about alleged violations of their rights
to DHHS.
Notice of Privacy Practices
• Each patient must receive such a notice at least once.
• Such receipt must be documented by an acknowledgment
receipt form, which must be signed, dated, and kept on
• At most hospitals, this process will be handled by
registration, the clinics, admitting, etc
• Private offices must provide a separate notice specific to
the practice’s privacy practices.
The practice must handle this process and record keeping.
• As covered entities need to track and account for certain
disclosures, requests for copies of medical records or parts
thereof should go through the Medical Records
Department or some other central mechanism.
• An exception is when a clinician sends a letter or a copy of
a routine discharge summary to a referring clinician or a
referral form to another facility or the VNA (or other
homecare agency), as such communication is explicitly for
treatment purposes.
• Similarly the reporting of a test or a procedure result to a
referring clinician for treatment purposes is not an
accountable disclosure and can be sent as usual to the
referring or receiving clinician.
Minimum Necessary Standard
• For treatment purposes (actually T, P or O)
PHI can be used without seeking authorization
(unless the patient has requested and we have agreed to
restriction to such use).
• However, even when providing treatment, HIPAA
requires us to use the minimum amount of information
required to accomplish the intended purpose.
• But, the rule of thumb should always be
Safety and Patient Care Comes First
• However please distinguish between
need to know and right to know.
• Only access PHI based on your need to know.
Minimum Necessary Standard (cont)
• The minimum necessary standard does not apply
when requesting PHI from or disclosing PHI to
another health care provider for treatment purposes.
• When disclosing information for non-TPO purposes,
HIPAA asks we disclose the minimum amount of PHI
needed to comply with the need.
• The minimum necessary standard does not apply to
disclosures to the patient or authorized by the patient.
• In an academic institution,
teaching is a key part of operations.
• Bedside rounds, teaching rounds, conferences, clerkships,
etc are all permissible.
• On the wards or in the clinics, take measures to minimize
incidental disclosures, such as speaking softly .
• At conferences, minimize disclosure of patient identifiers
as much as possible without compromising the educational
goals. Tufts attempts to “de-identify” patient information
used in lectures and other teaching activities.
• Any student must complete this HIPAA training before
having access to any PHI. In some circumstances, our
affiliated covered entities, may require more training than
completion of this module from the medical school.
• Special rules apply.
• See information provided the Institutional Review Board.
• Can use “De-Identified Data”
– All 18 HIPAA identifiers removed
• Can Use With Patient’s Authorization
– Research Authorization Form: Signed, Time and Use Limited
• Can Use Limited Data Set
• Contains Date and Geographic Region But No Other Identifiers
• Requires Data Use Agreement
• Can Use If Waiver Given By Institutional Privacy Board
but not for inconvenience to investigator
• Can Use If Patient Is Deceased
• Can Use If Chart Review in preparation for research, but
individually identifiable data may NOT be extracted from
the charts.
Research (cont)
• Research sponsors are not usually Business
Associates (BAs) and their seeing the data
constitute a disclosure about which the
patient must be informed.
• Coded data Are De-Identified
but code sheets/files are PHI
Incidental Disclosures
• Incidental disclosures cannot all be avoided and HIPAA
recognizes that, but the risk of such disclosures should
be minimized.
• Do not discuss PHI in public places,
e.g., elevators, hallways, restaurants, etc.
• Do not use your cell phone to discuss PHI in public
• Speak softly when another patient is nearby (e.g.,
double rooms, ICUs, etc).
Incidental Disclosures (cont)
• In clinics, speak to your patients in private rooms,
not in the waiting room.
• It is OK to call a patient by name from a waiting
room or keep a patient list containing only their
• Keep charts, mail, test results, etc in protected
• If necessary for patient care and safety, limited
disclosure may be made (e.g., identifying a patient
as being on precautions).
Important Measures to Comply
with Privacy Rule
Environmental safeguards
Suggestions for use of PCs and PDAs
Use of shredders
Suggestions for phone calls and faxes
Students may not take PHI out of the hospital or
• Patient Logs and Notes
• E-mail
The Physical Environment
• Keep PHI in protected areas, as much as possible.
• Some hospitals and practices white boards or bulletin
boards. In general, such boards should not contain
diagnoses or clinical information. Most will list patient
name, nurse and house officer, but not the attending
clinician (which more likely implies the diagnosis).
• White boards that have any more information should be in
protected, non-public areas.
• Use shredders or secure disposal containers for PHI.
• In clinics, keep appointment schedules in a protected area.
• If charts are put in holders on a clinic or patient door, they
should be turned so as not to display the patient’s name
and medical record number.
Using PCs
• Protect your password. Do not share it.
Change it if it may be compromised.
• Log off your computer or the application
when your are done with your task. If that is
inconvenient, use a screen saver.
• Position the monitor screen so it can not be
easily viewed by casual passers-by as you
are working.
• Many covered entities, such as NEMC, have
placed shredding receptacles or other disposal
receptacles for PHI in clinical spaces.
• Utilize shredders for any PHI no longer needed.
Phone Calls and Faxes
• Be certain you know to whom and to where you are
phoning or faxing before disclosing PHI.
• Fax cover sheets should contain a confidentiality notice
such as:
Note: The information contained in this facsimile may be privileged and
confidential and protected from disclosure. If the reader of this facsimile is
not the intended recipient, you are hereby notified that any reading,
dissemination, distribution, copying, or other use of this facsimile is strictly
prohibited. If you have received this facsimile in error, please notify the
sender immediately by telephone at __________________ and destroy this
facsimile. Thank you.
• Be wary of making calls in public areas.
Speak as softly as possible.
• Be aware that cell phone conversations
on non-digital phones can be intercepted.
• Receiving fax machines should be in a secure location.
Taking PHI Outside of a Clinical Setting
• Great care must be exercised if PHI that is taken from any clinical
setting physically or outside its firewall electronically.
In general, DO NOT DO IT.
• Such exposures include notes you are editing or writing, rounding
card decks, signout sheets or cards, and information contained in
your PDAs, laptops, on disks, on CDs, etc.
• Destroy or erase such data when its use outside of that clinical
setting is no longer absolutely necessary.
• However, if access to such PHI is necessary for safe patient care,
be extremely careful and protect our patients’ privacy.
• As a medical student, you would ordinarily NOT require such
access to PHI outside the clinical setting for patient care.
Taking PHI Outside of a Clinical Setting
• Before you remove any PHI from a clinical setting ask
• If you do take any PHI outside of the clinical setting,
you are personally accountable for any disclosures,
even incidental disclosures.
• Violation of this policy could preclude your returning to
that setting, and may subject you to disciplinary action at
the school.
PDAs, Laptops
• Password protect your PDA and laptop,
in case they are lost or stolen.
• If any PHI is present on the hard disk of a computer you use,
delete and purge (overwrite) those sectors of your hard disk.
• If that computer requires repair, consult the Student Affairs
Office, because PHI could be recovered from the hard disk on
the computer and that would constitute a disclosure of PHI.
• To repeat, violation of this policy could preclude your
returning to that clinical setting and may subject you to
disciplinary action at the school.
Patient Logs and Notes
• Some students have the habit of keeping personal copies of their notes
and other PHI for their own records.
– This is an extremely dangerous practice
and could subject you to disciplinary action
and personal legal consequences if that PHI were to be disclosed,
even inadvertently or incidentally.
– At the very least, be certain that EVERY one of the 18 HIPAA
identifiers has been removed from any such notes.
• Some rotations require students to keep patient logs.
Such logs should NOT contain any of the 18 HIPAA identifiers, unless
approved by the privacy officer of the clinical setting.
Unlike E-mail sent within a covered entity that remains within its
firewall, any e-mail sent outside of the covered entity (including email sent to Tufts, the HNRC or other hospitals travels over the
internet and may therefore cause a disclosure (unless it is specially
– If you are given an e-mail account at a hospital, Do NOT forward that e-mail
outside of that hospital, even manually, if it MIGHT contain any PHI.
• There is no easy, standard way to encrypt e-mail at this time.
• Because of the nature of unencrypted e-mail transmission and the
risk of privacy breaches, the use of e-mail that contains PHI (any of
the 18 identifiers, one of which is the patient’s email address)
outside of a covered entity’s network firewall may either be
prohibited by that institution or may require the patient’s explicit
written consent, even e-mail among clinicians.
• Your Tufts e-mail account is NOT behind a HIPAA-safe firewall and
cannot be e-mailed to from another institution without the message
traversing the internet.
What if I am unsure whether I can
disclose protected health information,
or whether information is, in fact,
protected health information?
• If in doubt, do not give out information without
first checking with your attending, clerkship,
course director, or other person responsible for the
confidentiality of health information in the
practice setting, usually the “Privacy Officer”.
• Remember that HIPAA is a new law and the
faculty, providers, and the public are just now
working through its implications for practice,
teaching, and research.
Basic Rule
No Use or Disclosure of PHI without patient authorization
• For treatment, payment and health care operations
Remember: Patient care and safety come first!
– In a teaching hospital, teaching is a part of treatment and a part
of our health care operations.
• Or When a specific regulatory exception under HIPAA
applies, e.g., public health reporting, in emergencies/
disasters, to identify patients or locate family members;
and as required by law.
Keep in mind, there are special requirements under state law
for the use and disclosure of certain categories of highly
confidential information (e.g., HIV information, genetic
testing information, alcohol and drug abuse treatment
information, and mental health treatment information).
Basic Principles
Only use PHI that you need
Ask yourself: “Do I really need this?”
Only disclose PHI to meet a legitimate need
Ask yourself: “Do I need to disclose this?”
The golden rule:
– Ask yourself: “What would you wish done if
you or a close family member were the
HIPAA Review Certification
This is a required component of your application to the TUSM Visiting Student Program.
I certify that I have reviewed the TUSM HIPAA Guidelines:
Printed Name:_____________________________________
Print ONLY this page of this document and mail along with your application and other supporting
materials to:
TUSM Visiting Student Program
Registrar’s Office
145 Harrison Ave.
Boston, MA 02111
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