HIPAA “Light” General Training

Office of the General CounselJohns Hopkins Medicine

(Pathology Version)

Hopkins Insures Privacy Awareness for All

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HIPAA “Light”

Privacy & Confidentiality of Patient Information Guidelines

for All Employees/Staff

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Hopkins’ Commitment . . . .

Protecting the privacy of our patients’ health information is part of providing for our patients’ health needs!

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What is HIPAA?

The Health Insurance Portability and Accountability Act (“HIPAA”) is a federal law which governs the use, transfer and disclosure of certain health information.

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HIPAA is Also . . . .

The Privacy Regulations adopted under HIPAA include new rights for individuals and privacy requirements for health care providers and health plans. These new requirements go into effect April 14, 2003.

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Why Was HIPAA Passed? . . . .

Some people misused identifiable health information:

A person stole computer disks with lists of HIV positive patients’ names on it

A banker gained access to patients’ medical records and used it to make financial decisions

The press gained access to psychiatric records about famous people and used it to hurt them

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Why HIPAA? . . . .

Privacy groups went to Congress to do something about protecting patient privacy and medical records

Congress passed HIPAA as a privacy standard so that health information is used only as intended

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What Does HIPAA Do? . . . .

The privacy regulations give new rights to people (living and dead) regarding protection of their health information

HIPAA requires us to use or disclose health information only as allowed under the law

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Things Hopkins Must Do Under HIPAA . . . .

Provide patients with Privacy Notice Create policies and practices regarding the use of

medical records Use medical records only as allowed Create methods to respond to patient rights Train all workforce members including physicians,

staff, employees and volunteers (all new employee/staff)

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HIPAA and You

HIPAA Privacy Regulations give patients new privacy rights with respect to personal health data (Protected Health Information or PHI)

HIPAA Privacy Regulations affect all members of the Johns Hopkins Medicine community: faculty, staff, students, and others; and to all JHM activities: patient care, teaching, human subject research, administration, quality assurance, fundraising, etc.

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Key Privacy Requirements

Permission: You must have permission to use PHI

Confidentiality: You may reveal PHI only to those who have a legitimate need to know about it

Minimum Necessary: Except for treatment, you must use only the minimum amount of PHI

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Patient Privacy Rights Under HIPAA . . . .

The right to receive Hopkins written Privacy Notice

The right to review and get a copy of medical records

The right to find out who outside of Hopkins has been given an individual’s certain medical information (begin April 14, 2003)

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More Patient Privacy Rights . . . .

The right to ask that their medical record be amended

The right to ask for restrictions in the use of their medical records

The right to ask for confidential communications

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Identifiable Health Information? . . .

Identifiable health information is information about a person’s health, treatment, billing or payment for health services

Health information can be verbal, written on paper, or in E-mails, or recorded or any other form (such as x-rays)

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Protected Health Information (PHI)

All individually identifiable health information in any form (electronic or non-electronic) that is created or received by a covered entity

HIPAA protects any patient information that could be used to identify an individual

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Examples of Health Information . . .

A person comes in for cancer treatment and the following items are used to identify them for treatment or billing purposes:

Name, address, age, telephone number Diagnosis, department or doctors’ names Vital signs and lab or x-ray results Billing info or Medical Record Number Anything that can link health information to an

individual

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Hopkins Institutions Covered Under HIPAA . . . .

JH Hospital & JH Health System JH Bayview Medical Center JH Howard County Hospital JH Community Physicians JH Home Health Services

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Hopkins Institution covered . . . .

JH Pharmaquip JH Pediatrics at Home JH HealthCare JH Priority Partners Managed Care

Organization

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More Hopkins Institutions Covered. . . .

Johns Hopkins University: School of Medicine School of Nursing Parts of the:

School of Public Health School of Engineering School of Arts & Sciences

JH Kennedy-Krieger Institute

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HIPAA Covers our Business Partners, Also

Business Associates Companies who do any work for Hopkins

and receive patient informationConsultantsVendorsTemp agenciesAccreditation/Regulatory Organizations

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Business Associate Agreement

Hopkins must have a written business associate agreement with all business associates

A business associate agreement obligates the recipient to treat the PHI just as Hopkins must treat PHI under the HIPAA Privacy Regulations

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PRIVACY AUTHORIZATIONS

Specific authorizations from the patient are required for activities not included under treatment, payment and health care operations (TPO)

Activities requiring authorization are: - Fundraising - Marketing - Research - Use of PHI in publications

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Research

Authorization required from patient to use or disclose PHI

Waiver of authorization allowed in research protocols where it is impractical to obtain individual privacy authorizations and the Institutional Review Board (IRB) finds that the privacy of the PHI can be protected

Records must be kept of authorizations or waivers

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Pathology Policies & Procedures

Covered entities must obtain, maintain, use and disclose PHI in compliance with HIPAA. 1. Faxing Policy 2. Paper Documents Containing PHI 3. Telephone Inquiry Regarding PHI

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Faxing Policy

Coversheet – confidentiality clause Send only to intended receiver(s) Verify fax number prior to transmission Locate fax machine in a secured, non-public area Verify fax transmission Remind fax recipients to provide notification if fax

information changes

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FAX VERIFICATION FORM

Complete all information to establish a Fax account in the Department of Pathology Each recipient / site will be called for verification prior to set up. It is the recipient responsibility to immediately inform the Department of Pathology of any changes to the information provided in this request Please complete the request and fax or send to:

Johns Hopkins Medicine

Division Contact Person Bldg and Room # Street Address City, State Zip code

Fax: Phone: ______________________________________________ RECIPIENT NAME (last, first) ______________________________________________ SITE/CLINIC NAME ______________________________________________ STREET ADDRESS __________________ _______ __________________ CITY STATE ZIP _____________________________ ___________________________ FAX NUMBER CONTACT NAME _____________________________ ___________________________ FAX SPECIFIC LOCATION (Room or Area) Is Fax Location Secure? _________ ___________________________

Nearest Phone Number to Fax Machine This Fax machine is in operation between ----------- A.M and --------- P.M. (EST) On the following days of the week (circle days): M T W Th F S Su _____________________________ ________________________________ Recipient/Authorized Signature Print Name _________________ _____________ Phone Number Date Pathology use only: Request verified by: ________________________ Date:___________________ Request completed by:______________________ Date:___________________

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Paper Documents Containing PHI

Avoid unnecessary printing, photocopying, faxing Shred/destroy documents no longer needed Store documents in secure or limited access areas Do not leave unattended in public areas Mask patient identifiers (teaching,QA activities,

etc) Limit access to vendors, consultants, visitors, etc Do not remove from premises

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Telephone Inquiry Regarding PHI

Purpose: To ensure that telephone callers requesting patient data (PHI) are appropriately identified and have a legitimate need for requested PHI

Remind users of online resources (PDS/EPR) Caller must request patient’s data using required identifiers

(ex. name & MR#) Pathology staff makes reasonable attempt to identify caller

and legitimate need to know May need to request a fax with additional details

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Scenarios

Example 1: A worker with computer access could look up birthdays of a co-worker if they knew the co-worker had been a patient. The worker has no professional need-to-know of the date of birth, which is PHI, and therefore the worker should not access the PHI.

Example 2: An overhead page alerts a laboratory area that their assistance is needed for a particular procedure. The patient’s name and the procedure are included in the page. The information has become PHI when the procedure has been linked with a name. Confidentiality is in question when PHI is overheard by staff other than those who need to know.

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Scenarios

Example 3: Housekeeping is emptying waste baskets at the end of the day. They find copies of lab reports in the trash. They need to alert their supervisor and the materials need to be shredded or secured. PHI should never be thrown in a trash can, unless it has been shredded.

Example 4: An employee pulls up patient lab records on the computer to troubleshoot a specimen problem. The information is left on the screen and can be viewed by nursing staff dropping off specimens. To protect patient privacy, information should be removed from computer screens when leaving the workstation.

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Scenarios

Example 5:.A staff meeting is held in a conference room. Previously, the room was used by doctors discussing a case study. Extra hand-outs are still on the table. Staff need to ignore the patient records and tell their supervisor who will determine if the materials need to be shredded or secured.

Example 6:. A blood bank technologist calls from another local hospital to ask about a patient’s transfusion history. Staff must make a reasonable attempt to ascertain the identity of the caller and the need for the requested PHI. You can take the caller’s phone number and call them back or request a fax with additional details regarding the caller’s identity and the need for the PHI.

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Scenarios

Example 7:.When a faculty member puts together a teaching lesson, if the name, SSN or other identifying information is not critical for the lesson, this information should not be included when copies or slides are made.

Example 8:. The lab receives a telephone call from a doctor. He is at home and needs lab results on a patient admitted to the hospital. He does not know the patient’s medical record number, only the name. Laboratory staff need to determine the identity of the caller and legitimate need to know before communicating PHI. The caller can be asked to fax their request for information along with documentation regarding their identity.

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Enforcement of HIPAA Law . . . .

Federal Office of Civil Rights has the responsibility to investigate complaints of HIPAA privacy violations and can issue:

Civil Penalties - fines which may accumulate for each type of violation

Criminal Penalties - against institutions and individuals who

intentionally misuse medical information

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Your “To-Do” List . . . .

DO tell department management if you see an unattended PC that has patient information on the screen

DO tell department management if you see patient information that is unattended

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More “To-Dos” . . . .

DO remove patient information from trash bins and shred or dispose of patient information in confidential bins

DO access only the information that you require to perform your job duties

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Things OK “To Do” . . . .

DO report any suspicious activity related to patient information to your management

DO refer patient information requests to appropriate personnel or department

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Do, As Part of Your Job . . . .

DO treat all patient information with the utmost concern for confidentiality and privacy

DO shut doors or pull privacy curtains before talking to patients or their

families

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Your “Do-Not-Do” List . . . .

DO NOT open sealed, confidential envelopes addressed to someone else

DO NOT throw patient information in the trash

DO NOT tell your friends or relatives about patients in the hospital

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Can’t Do These Either . . . .

DO NOT send patient information in e-mails

DO NOT discuss patient information in public areas, especially food lines and elevators

DO NOT discuss patient information on house phones or cell phones in public areas

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More Things “Not-To-Do” . . . .

DO NOT leave patient information unattended in public areas

(e.g. when delivering patient records)

DO NOT share patient information with anyone who does not

have a need to know

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Wrong Things To Do . . . .

DO NOT access health information of co-workers, family members or celebrities

DO NOT sell patient information

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Related Work Examples . . . .

What do you do when Health Information is spotted or overheard while you do your job

Health Information that is “needed” or “not needed” to do your job

Consider the privacy of patients when discussing their health condition

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Work Examples, continued . . . .

How to respond when a person you don’t know asks about a patient

Cannot share Health information regarding a friend or member of your family being treated at Hopkins

Resist temptation to tell friends or family members when a “famous person” has been treated at Hopkins

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Work Examples, continued . . . .

Request Health Information of your child or family member appropriately

Report suspicious activities or inquiries about health information to your supervisor or security

In transporting a patient from one treatment area to another, be sensitive in public areas

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Hopkins Compliance Line . . . .

1-877-WE COMPLY1-877-932-6675 (Toll Free)

The Compliance Line is administered through an independent company and is in place to give you a way to report your concerns to Hopkins' management in a confidential manner, without fear of reprisal.

Callers do not have to give their names if they don’t want to.

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Hopkins Compliance Line . . . .

The Compliance Line is a toll-free, 24-hour, 7-day-a-week telephone resource that allows you to report workplace concerns Suspected illegal or unethical behavior Non-compliance with laws, regulations and

policies Safety violations Criminal offenses Other concerns

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What Do You Know About HIPAA?

HIPAA is:

A. A State law covering patient privacy.

B. A Federal law covering how medical information can and cannot be used.

C. A Hopkins policy that is used to tell patients what they must do.

D. None of the above.

E. All of the above.

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What Do You Know About HIPAA?

As a Hopkins employee you can:

A. Remove patient medical information from plain view of the public.

B. Report suspicious activities related to patient information to supervision or security.

C. Verify identity of anyone requesting patient information.D. None of the above.E. All of the above.

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What Do You Know About HIPAA?

As an employee, you work on one of the Wilmer units. It’s OK to tell your brother that Stevie Wonder is coming for an examination next week.

A. True

B. False

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What Do You Know About HIPAA?

Why was HIPAA passed?

A. Medical information was used inappropriately.B. Psychiatric information was released about famous

people.C. Congress was asked to do something about

insuring patient privacy.D. None of the above.E. All of the above.

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What Do You Know About HIPAA?

HIPAA does not give any rights to patients regarding their medical records.

A. True

B. False

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What Do You Know About HIPAA?

What are some examples of Health Information?

A. Patient’s name.B. Doctor’s name or office where a patient was seen.C. Billing information.D. None of the above.E. All of the above.

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What Do You Know About HIPAA?

Bayview and Howard County Hospitals are Hopkins Institutions that are not covered under HIPAA.

A. True

B. False

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What Do You Know About HIPAA?

As an employee of Hopkins, I can:

A. Tell a co-worker my PC password.B. Open confidential envelopes that come to my work

area.C. Share patient information with anyone who asks

me.D. None of the above.E. All of the above.

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What Do You Know About HIPAA?

As long as my supervisor knows about HIPAA, I have no responsibility to know anything about that Federal law.

A. True

B. False

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What Do You Know About HIPAA?

My friend was treated at Hopkins on a unit where a co-worker is assigned. It is OK for that co-worker to tell you what they know about your friend or make a copy of the doctors’ notes for you.

A. TrueB. False

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Resources

http://pathology.jhu.edu/hipaa www.insidehopkinsmedicine.org/hipaa www.hhs.gov/ocr/hipaa/privacy.html

HIPAA “Light” General Training

Office of the General CounselJohns Hopkins Medicine

Hopkins Insures Privacy Awareness for All