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Learning HIPAA Controls and Compliance Issues

The HHS publishes rules and regulations through HIPAA to provide standards that control and require compliance for the security of e-PHI. HIPAA Privacy and Security Rules provide the regulations that covered entities must follow to protect e-PHI. The HIPAA Enforcement Rule explains the consequences of violating the Privacy and Security Rules. These three rules are not just technical safeguards but also physical and administrative safeguards, including auditing, enforcement, and punishment standards. To fully understand these rules, you must understand the issues concerning these rules and the reasons for creating the rules. The following issues are explained as they relate to HIPAA.

  • Security: Keeping e-PHI secure is a concern for HIPAA because HIPAA is designed to protect e-PHI. The security measures include all the administrative, physical, and technical safeguards in any IS containing or processing e-PHI. This includes security protocols that HIT technicians must follow, such as administrating security access.

    HIPAA security protects e-PHI created, received, used, or maintained by a covered entity. The OCR is responsible for enforcing HIPAA security. The following portions of HIPAA security ensure the confidentiality, integrity, and availability of e-PHI.

  • Violations: The breach of a HIPAA rule must be defined for covered entities to know boundaries of what is not acceptable behavior to maintain privacy of patients. A breach can be theft, unauthorized access or disclosure, loss, or improper disposal of e-PHI.
  • Fines: Normally, the OCR does not intervene when there is a violation to HIPAA rules. Instead, the covered entity that violates the rule issues voluntary compliance and corrective action that reaches a satisfactory resolution with the OCR. If the violating entity does not handle the offense properly, there are monetary penalties. HIPAA states the fine for each incident should not exceed $100 or $25,000 for identical violations within a calendar year. In 2009, the ARRA increased these amounts into a tiered structure, as outlined in Table 3-2.

    Table 3-2 The ARRA Defines These Penalties If a Covered Entity Violates a HIPAA Rule

    HIPAA Violation

    Minimum Penalty

    Maximum Penalty

    Individual did not know (and by exercising reasonable diligence would not have known) that he/she violated HIPAA.

    $100 per violation, with anannual maximum of $25,000 for repeat violations

    $50,000 per violation, with an annual maximum of $1.5 million

    HIPAA violation due to reasonable cause and not due to willful neglect.

    $1,000 per violation, with an annual maximum of $100,000 for repeat violations

    $50,000 per violation, with an annual maximum of $1.5 million

    HIPAA violation due to willful neglect but violation is corrected within the required time period.

    $10,000 per violation, with an annual maximum of $250,000 for repeat violations

    $50,000 per violation, with an annual maximum of $1.5 million

    HIPAA violation is due to willful neglect and is not corrected.

    $50,000 per violation, with an annual maximum of $1.5 million for repeat violations

    $50,000 per violation, with an annual maximum of $1.5 million

  • Requirements: States have the capability to tighten the rules for security. When you start a new job, especially if you are in a new state, be sure to check with your local state regulations because the state may have different rules than what you knew from your last job. Covered entities must
    • Ensure confidentiality, integrity, and availability of e-PHI they create, receive, maintain, or transmit.
    • Identify risks to e-PHI and implement resolutions to anticipated threats.
    • Ensure compliance by their workforce.

HIPAA enables certain hospital personnel to access patient information to perform job duties. However, if a patient wants his patient information released to a person or organization that is not a covered entity, the covered entity must receive written permission to access and distribute the e-PHI.

This website shows an example of a release form used in New York: http://www.nycourts.gov/forms/Hipaa_fillable.pdf. For example, a patient might need this form to release medical information to an athletic program.

A covered entity might access e-PHI to distribute to the individual or its own personnel for treatment of the patient or to retrieve payment from the patient’s insurance provider without acquiring a release form. Access permission is restricted based on the role of the personnel, called role-based access control. Personnel should have access to e-PHI only as required to fulfill their job descriptions, no more, no less. Ultimately the CFO has the final say in what access to the information systems used in the hospital is granted to hospital personnel. The CFO makes these determinations by approving access to each job role when each IS is initially configured. Therefore, the CFO does not need to be involved with assignments for each employee. When a professional starts a job at a healthcare facility, he is given access to e-PHI as defined by his job. For example, all lab technicians should have access as defined for a lab technician. All nurses should have access as defined for a nurse. A lab technician and a nurse might not have the same access. While performing duties of their job, these personnel do not require signed release forms from patients. The personnel is required to sign an acknowledgment of understanding HIPAA rules. These access policies are controlled by the covered entity and are expected to comply with HIPAA and state regulations.

The HHS offers case studies of HIPAA violations on its website. An example of one case study was a hospital employee who left a voicemail for a patient on the patient’s home answering machine. The message included the medical condition and treatment plan of the patient. However the patient did not live alone and others in the household listened to the message. The patient had specifically asked to be contacted at her work phone number. The hospital employee did not follow confidential communication requirements as set by the hospital. To resolve this violation, the hospital implemented new policies for communication. For example, the policy set rules for the minimum information required to leave in a voicemail so as to not reveal PHI. The hospital also trained employees how to review registration information from patients to verify special instructions from the patient on how to contact them. Finally, the hospital integrated training for these new policies into the annual refresher series for employees.

With the background surrounding agencies, laws, and regulations covered, now turn your focus to a topic a little more practical: the rules of record retention and disposal.

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