ALLIANCE FOR CLINICAL EDUCATION (ACE) HIPPA TRAINING SEPT 2012 1

ALLIANCE FOR CLINICAL EDUCATION (ACE) HIPPA TRAINING SEPT 2012 1

OBJECTIVES Describe the HIPPA Privacy rules and regulations Identify patients’ rights and your role in protecting them Discuss your responsibilities under HIPPA – related policies and procedures Explain the penalties for non-compliance 2

PROTECTING PATIENT PRIVACY IS EVERYONE’S RESPONSIBILITY 3

YOUR RESPONSIBILITIES Respect the patient’s right to privacy Know the facility’s privacy policies Be sensitive 4

DEFINITIONS HIPPA – the Health Insurance Portability and Accountability Act of 1996. A federal law that specifies the types of measures required to protect the security and privacy of personally identifiable health information. Patient Confidentiality – keeping information about a patient’s health care private. The information is shared only with those who need to know in order to perform their duties on behalf of the patient. 5

DEFINITIONS CONTINUED Protected Health Information (PHI) – medical information that can be traced to, or identified with, a particular patient. PHI is information created or received by a health care organization that relates to the past, present, or future health or condition of an individual. Transaction – the exchange of information between two parties to carry out financial or administrative activities related to health care. 6

HIPPA What is it? “Patients have the right to have health information kept private and secure” **HIPPA is mandatory, there are penalties for failure to comply 7

COVERED INFORMATION Confidentiality and Privacy All protected, identifiable health information (PHI) must be considered and treated as confidential and all patients have the right to request restrictions on who will see their PHI. Security Establishes the requirements for ensuring the confidentiality, availability and integrity of PHI 8

PATIENTS HAVE THE RIGHT TO: Expect privacy and freedom from intrusions or disturbances regarding his/her personal affairs. Expect that all communications and records concerning his/her care will be treated as confidential. Information will be shared only with those who need to know the information to perform their duties on behalf of the patient. Review the records pertaining to his/her medical care. 9

What must be Kept CONFIDENTIAL? 10

CONFIDENTIAL? HOW DO I KNOW? Did you learn the information through caring for your patient? If yes, then consider it confidential 11

UNDERSTANDING PHI (PROTECTED HEALTH INFORMATION) Protected Health Information Is created by a health care provider Is information that there is a reasonable basis to believe it could be used to identify the patient Relates to past, present or future physical or mental condition of an individual; provision of healthcare or for payment of care provided to an individual Is transmitted or maintained in any form (electronic, paper or oral representation) 12

PRIVACY PROTECTED ELEMENTS HEALTH INFORMATION IS CONSIDERED INDIVIDUALLY IDENTIFIABLE IF ANY OF THE FOLLOWING ARE PRESENT: Name Full address Names of relatives Name of employers Birth date Telephone numbers Fax numbers Electronic e-mail addresses Social security number Medical record number Health plan beneficiary number Account number Certificate/license number Any vehicle or other device serial number Web Universal Resource Locator (URL) Internet Protocol (IP) address number Finger or voice prints Photographic images Any other unique identifying number, characteristic, code that could be used to identify the patient 13

PATIENTS RIGHT TO RECEIVE NOTICE OF PRIVACY PRACTICES Items required to be included in the Notice: How medical information is used and disclosed by an organization How to access and obtain a copy of their medical records A summary of patient rights and facility responsibilities under HIPPA How to file a complaint and contact information for filing a complaint 14

FACILITIES NOTICE OF PRIVACY PRACTICES The patient has the right to receive a Notice of Privacy Practices: Must provide the notice at the first encounter with the patient Must attempt to obtain written acknowledgement of receipt of the Notice of Privacy Practices 15

MINIMUM NECESSARY HIPPA Requirement: Identify members of the work group who need access to confidential information Identify what information can be accessed Limit access WHAT GROUP DO YOU BELONG TO? Complete Access: Clinical departments Health Information Management Students & Clinical Instructors: limited to assigned patients only Limited Access: Admissions/Business Office No Access: Departments or individuals whose job does not require any handling of PHI (Food Services, Environmental Services/Housekeeping) 16

DISCUSSIONS OF PHI Staff will discuss patient information to share information and the treatment plan. Every effort should be made to protect the privacy of the patient by minimizing risk that others can overhear the conversation. The discussion of PHI should never occur in public areas such as the cafeteria or elevators. Discussions can occur at the nursing station and with a patient in a treatment area. 17

MINIMUM NECESSARY What can I access as a student or clinical instructor? Only the information you “NEED TO KNOW” to care for assigned patient(s) DO NOT access information when you are not assigning or student is not caring for that patient any longer or for any patients you not assigned to care for 18

PATIENT RIGHT TO ACCESS Patients have the right to: Access or inspect their health record Obtain a copy of their health record from the healthcare provider Reasonable fees may be charged for copying Access and copying for as long as the information is retained Facility must act on request for access no later than 10 days after receipt (Colorado Law) Students: Refer requests for access to the facility staff 19

PATIENTS RIGHT TO REQUEST PRIVACY RESTRICTIONS The patient has the right to request an organization restrict the use and disclosure (release) of their protected health information Can request restriction in use of information for treatment, payment or healthcare operation purposes (TPO) Organization is not required to agree with the request for restrictions Requests must be made in writing No staff level individual should accept any requested restrictions Students: Refer requests for restrictions to the facility staff 20

PATIENTS RIGHT TO AMEND Patients have the right to request an amendment to their PHI Amend is defined as the right to add/revise information with which s/he disagrees. The original information is not removed from the record but the amended/corrected information is added to the record. Students: Refer requests for amendments to the facility staff 21

AS A STUDENT HOW DO I HANDLE . An individual asking for access to their record? Students: Refer requests for access to the facility staff The staff will follow-up per specific facility policy 22

DISCLOSURE ? WHAT IS IT? The release, transfer, access or divulging of PHI (protected health information) to an outside person or entity Students do not participate in this process 23

DISCLOSURE CAN OCCUR WITHOUT THE PATIENT’S CONSENT UNDER THE FOLLOWING CONDITIONS: When required by law For public health activities to control disease, injury or disability For disaster relief In cases of abuse and neglect For coroners, funeral directors and organ donation For legal proceedings For worker’s compensation In cases of communicable diseases 24

STUDENT RESPONSIBILITIES In a patient room or exam room Knock before entering room Identify yourself as a student Close door after entering the room if okay with patient Ask visitors to leave the room unless patient requests otherwise Speak softly if roommate present In a clinic or office setting Sign in sheets should contain minimal amount of PHI Street address or reason for visit should not be on sign in sheets 25

STUDENT RESPONSIBILITIES CONT At the Nurses’ Station Do not leave patient information, e.g. flow sheets, charts, sticky notes, lab reports or x-rays out in the open where others may view. When finished working on it, put it back where it belongs Shred all documents with PHI, do not put in garbage, do not take them home When at the nurses’ station, speak softly when discussing PHI. It is best to use a private area to discuss the patient 26

STUDENT RESPONSIBILITIES CONT At the Computer Have screen facing away from the public so it is not visible to patients, visitor and other unauthorized persons Always log off when leaving the computer Change the password on your computer if required by clinical facility Do not share your log-in information or password with anyone else. You are responsible for what is done under your log-in 27

STUDENT RESPONSIBILITIES CONT Using E-mail Always use protected, encrypted email to communicate with your faculty and clinical instructors Never use PHI in e-mail attachments or in the email itself for the following reasons E-mail can easily be sent to the wrong person, either on purpose or by accident E-mail does not ensure privacy of information transmitted 28

STUDENT RESPONSIBILITIES CONT Do not post PHI or discuss patients you have met on webbased chat rooms (My Space, Facebook) Do not take photos of patients Do not photocopy medical records At the Fax Students do not use the fax machine during the clinical experience 29

STUDENT RESPONSIBILITIES CONT Using an Interpreter When interpreter services are needed, follow clinical agency practice In Public Never mention a patient’s PHI in public as people are often watching and listening, as you never know who knows the patient Never carry, review, discuss or disclose a patient’s chart or PHI in a public place 30

SCENARIOS Following are scenarios to help you think through privacy related situations in the clinical facilities After reading each scenario, think how you would answer the question before going to the next slide Scenario answers follow each scenario 31

SCENARIO #1 One of your fellow students who had lab work done recently, called you from home and asked you to look up her lab results on the computer and give her the results. Do you look up your fellow students lab results? 32

SCENARIO #1 ANSWER No. Since you are not providing treatment to your fellow student, you are not permitted to look up her lab results and provide them to her. She needs to get this information from her doctor This applies to your own records as well 33

SCENARIO #2 You see your fellow student reading through a patient's medical record. She is not providing treatment for this patient. What do you do? 34

SCENARIO #2 ANSWER Tell your clinical instructor. He/she will follow-up with the student. The clinical instructor then needs to notify the facility privacy officer of this action 35

SCENARIO #3 Your sister’s close friend is having surgery at the organization where you are doing a clinical rotation. She asks you to find out what you can about the friend’s condition. Should you call and ask around to the nurses you know? Should you look up the friend’s medical record? 36

SCENARIO #3 ANSWER No. Even if you and your sister have the best intentions you have no right to look at private information about her friend’s health. Suggest to your sister that she call the facility or visit the information desk. If the patient has agreed to have her information available, hospital staff will assist her in obtaining information on her friend. Do not seek out confidential patient information unless you need it to do your job. When you happen to hear confidential information, do not repeat it to anyone. Looking at patient records for any non business reason is cause for disciplinary action and can have possible legal consequences. 37

SCENARIO #4 You are called to work in a patient's room to perform a routine job. You knock on the door and are invited in. You see that a nurse is in the room discussing the patient’s condition or medication. What should you do? 38

SCENARIO #4 ANSWER If you must do the job immediately to properly care for the patient, ask whether you can interrupt. If the job can wait, explain that you are there to perform a routine job and will return in 15-20 minutes. This protects the patient’s privacy by allowing him/her to openly discuss his/her condition without being overheard Some patients may say that it is acceptable for you to stay in the room during the conversation. But remember that a patient may not feel comfortable sharing everything about his/her symptoms or medical history while you are in the room. They also might not feel comfortable asking you to leave. It would be best for you to come back later. 39

SCENARIO #5 You are working the ER when you see that a neighbor has arrived for treatment after a car crash. You hear someone saying he will be taken to surgery soon. Your neighbor’s wife works in another part of the hospital. Should you notify her that her husband is in the ER? 40

SCENARIO #5 ANSWER No. Tell the nursing staff that you know the patient and his wife. Tell them that if they need to locate her, you can help. When patients are in the hospital, they have the right to decide who should know that they are there. Your neighbor has a right to privacy and may not want to notify his family of the accident. If he is conscious, the ER staff will allow him to decide whom to notify that he is there. If he is unconscious, the doctors and nurses will use their professional judgment about whether to notify his wife. Leave the decision up to the ER staff. They will let you know whether they need your help to find the patients wife. 41

SCENARIO #6 You are in the nurses’ station where the patient’s medical records are located in the chart rack. You spot the name of a close friend. Should you stop by her room? 42

SCENARIO #6 ANSWER No. if you learned of your friend’s stay only by seeing the name on a medical record on the chart rack, you should not go to her room. You should inform your clinical instructor of your relationship with her so that you are not assigned to care for her. If you find out from the patient or her family member that she is a patient there, feel free to visit her after your shift. 43

SCENARIO #7 You are walking by a trashcan and notice a pile of photocopied records has been laid on top of the trash. How should you handle this? 44

SCENARIO #7 ANSWER Don’t just take the records to a shredder or locked disposal container yourself. Gather the records and take them to your Clinical instructor. He or she will report it to the Manager of the unit who will investigate the incident and report it to the organization’s privacy officer. 45

SCENARIO #8 A woman provides the name of a patient and asks for information. What can you tell her? 46

SCENARIO #8 ANSWER Refer the woman to the information desk Check the facility directory. If the patient is listed in thedirectory, you can tell the woman the patient’s location. If the patient has requested that his name not be included in the directory, you can not give out any information about them to anyone or even acknowledge that they are here, regardless of the person’s relationship to the patient. 47

SCENARIO #9 At the nurses’ station, you are approached by someone asking to see a patient record. What do you do? 48

SCENARIO #9 ANSWER Refer to agency staff for clarification of identification and appropriateness of request. 49

WHAT HAPPENS IF . A privacy policy is violated? Patients have the right to file a complaint and Civil and criminal penalties could occur 50

PATIENT’S RIGHT TO FILE A COMPLAINT The patient has the right to file a complaint if s/he believes privacy rights have been violated* *Organization must provide contact information for filing a complaint 51

DOING YOUR PART Access confidential information ONLY if you need it to care for your patient. Protect your computer passwords Understand the facility’s privacy policies Report problems to the facility staff 52

AS A STUDENT Patient identification Cannot use patients’ initials Need to assign a number to the patient for identification Care plans Any notes with PHI gathered must be shredded after the assigned shift The use of PDAs or pocket PCs to RECORD patient information is not allowed 53

PENALTIES . Both criminal and civil penalties for: Failure to comply with HIPPA requirements Knowingly or wrongfully disclosing or receiving individually identifiable health information Obtaining information under false pretenses Obtaining information with intent to: Sell or transfer it Use it for commercial advantage Use it for personal gain Use it for malicious harm Fines as high as 250,000 and prison sentence of up to 10 years 54

FAMILY EDUCATIONAL RIGHTS AND PRIVACY ACT FERPA refers to confidentiality in regards to students. Your information is also to be kept confidential and accessed only by those who need to know. FERPA generally prohibits the improper disclosure of personally identifiable information derived from education records. 55

REFERENCES HIPPA Programs from: Arapahoe Community College Craig Hospital Centura HCA-HealthONE Denver Health Presbyterian St. Luke’s Regis University 56