Has been a federal privacy regulation since 2003. Covers privacy and security of health information.

Reviewed in annual education

Taught in new employee orientation

The facility Security Officer is Michael Boudreaux

The facility Privacy Officer is Alane Bryan

Does not replace HIPAA—it gives it TEETH!

Requires a breach notification policy

Encourages EHR adoption

Provides strict data protection regulations for more secure patient privacy

Violation Type Each Violation Repeat Violations/Yr.

Did not know $100 - $50,000 $1.5 million

Reasonable Cause $1,000 - $50,000 $1.5 million

Willful Neglect – Corrected $10,000 - $50,000 $1.5 million

Willful Neglect – Not Corrected

$50,000 $1.5 million

•Healthcare organizations or providers may be held liable for violations.

•Individual employees may be prosecuted or may be sued for civil penalties.

Must notify individuals and HHS and, in some cases the media, of any substantiated breaches within 60 days.

Breaches affecting 500 or more patients will be posted to the HHS.gov website.

Four factors are used to determine if low to high probability of PHI is compromise:

1. The nature and extent of the PHI involved in the incident Is the PHI sensitive information i.e. Social Security Numbers, or

infectious disease test results2. The unauthorized recipient of the PHI

Is another physician receiving the PHI?3. Whether the PHI was actually acquired or viewed4. The extent to which the risk to the PHI has been mitigated

Was it immediately destroyed?

Mass General

California Breaches

BCBS of TN Breach

Individual Prosecution

Personal Gain

Stolen laptops/computers

Lost CDs

ID theft/Social Security Numbers

Medicare Fraud

Access to EMR with no job-related need

Using Social Networking to talk about patients

Discussing PHI with employees or family who do not have a job-related need

Looking at EMR out of concern or curiosity

Telling others that a patient was “in” for treatment

Discussing progress or prognosis in front of family without permission

Using chart to get information to use against patient in lawsuit or divorce

Looking in minor child’s EMR

Taking a peek for “educational purposes”

Starting conversations with “Don’t tell anyone I told you this, but…”

Sharing computer access/passwords

Treatment, Payment, Operations

Some law enforcement exceptions

Public health reporting

When in doubt, get a Signed Release

Disclose “minimal necessary” amount of PHI

Patients/family members requesting patient information AFTER DISCHARGE should be referred to the HIM Department

If a patient requests information during an admission, make sure the report is FINAL before giving the information to the patient or to their designee (document the designee). We do not release information unless it is in a FINAL status.

Discuss patient information as quietly as possible

Try not to say the patient’s name repeatedly Make sure paper containing PHI makes it to a shred bin Shred bins should be dumped in large bins each day Use fax cover sheets with the confidentiality clause Do not leave messages with too much information Wear your employee ID badge at all times Do not take pictures in patient care areas. Patients ,

their names, or their family members may be visible without you realizing it. It is not worth the risk!!

Use workstations for intended purposes No gaming, no unauthorized downloading of files,

personal emails are subject to access by P&S Surgical Hospital

Log-off or lock your computer when you are not using it

Make sure others cannot view your computer screen

Keep passwords secure

Use your own individual password

Avoid sharing passwords

Trigger encryption for emails containing PHI being sent outside the organization

If photos must be taken of a patient, use a P&S camera or device; NEVER use your personal camera or smart phone

Never share proprietary or confidential information in blogs or on social media sites

Report potential breaches, inappropriate disclosures, or otherwise suspect behavior to your direct supervisor, the Privacy Officer, the Security Officer, or the Corporate Compliance Officer

End of presentation