Title: Alliance%20for%20Clinical%20Education%20(ACE)%20HIPPA%20Training%20%20Sept%202012
1Alliance for Clinical Education (ACE)HIPPA
TrainingSept 2012
2Objectives
- 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
3Protecting Patient PrivacyIS EVERYONES
RESPONSIBILITY
4Your Responsibilities
- Respect the patients right to privacy
- Know the facilitys privacy policies
- Be sensitive
5Definitions
- 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 patients 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.
6Definitions 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.
7HIPPA
- 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
8Covered 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
9Patients 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.
10What must be Kept CONFIDENTIAL?
11Confidential? How do I know?
- Did you learn the information through caring for
your patient? - If yes, then consider it confidential
12Understanding 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)
13Privacy Protected Elements Health information is
considered individually identifiable if any of
the following are present
- 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
- 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
14Patients 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
15Facilities 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
16Minimum 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)
17Discussions 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.
18Minimum 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
19Patient 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
20Patients 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
21Patients 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
22As 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
23Disclosure ??? 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
24Disclosure can occur without the patients
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 workers compensation
- In cases of communicable diseases
25Student 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
26Student 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
27Student 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
28Student 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
29Student Responsibilities cont
- Do not post PHI or discuss patients you have met
on web-based 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
30Student Responsibilities cont
- Using an Interpreter
- When interpreter services are needed, follow
clinical agency practice - In Public
- Never mention a patients 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
patients chart or PHI in a public place
31Scenarios
- 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
32Scenario 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?
33Scenario 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
34Scenario 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?
35Scenario 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
36Scenario 3
- Your sisters 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 friends condition. Should you call
and ask around to the nurses you know? Should
you look up the friends medical record?
37Scenario 3 Answer
- No. Even if you and your sister have the best
intentions you have no right to look at private
information about her friends 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.
38Scenario 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 patients condition or
medication. - What should you do?
39Scenario 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
patients 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.
40Scenario 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 neighbors wife works in
another part of the hospital. - Should you notify her that her husband is in the
ER?
41Scenario 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.
42Scenario 6
- You are in the nurses station where the
patients medical records are located in the
chart rack. You spot the name of a close friend. - Should you stop by her room?
43Scenario 6 Answer
- No. if you learned of your friends 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.
44Scenario 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?
45Scenario 7 Answer
- Dont 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 organizations privacy officer.
46Scenario 8
- A woman provides the name of a patient and asks
for information. - What can you tell her?
47Scenario 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 patients 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
persons relationship to the patient.
48Scenario 9
- At the nurses station, you are approached by
someone asking to see a patient record. - What do you do?
49Scenario 9 Answer
- Refer to agency staff for clarification of
identification and appropriateness of request.
50What Happens If.
- A privacy policy is violated?
- Patients have the right to file a complaint and
- Civil and criminal penalties could occur
51Patients 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
52Doing Your Part
- Access confidential information ONLY if you need
it to care for your patient. - Protect your computer passwords
- Understand the facilitys privacy policies
- Report problems to the facility staff
53As 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
54Penalties.
- 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
55Family 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.
56References
- HIPPA Programs from
- Arapahoe Community College
- Craig Hospital
- Centura
- HCA-HealthONE
- Denver Health
- Presbyterian St. Lukes
- Regis University