HIPAA
Health Insurance Portability and Accountability Act
• Federal law passed by Congress in 1996
• Regulations promulgated by the Dept of Health
and Human Services
• Guidelines implemented in April, 2003
What part do students play in implementing HIPAA?
How does this law affect your student role?
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Begin Program
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HIPAA regulations were designed to:
1) protect individuals’ rights to privacy and
confidentiality
and
2) assure the security of electronic transfer of
personal information
The first, protecting privacy and confidentiality
rights, is the subject of this instructional program.
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Health information is used by multiple agents in the
course of a single episode with a health problem.
Below are some of the agencies and individuals who
may handle health information. You could, no doubt,
add several more.
• Admitting clerks
• Caregivers from the
ED to the morgue
• Physical therapists
• Nutritionists
• Lab personnel
• Receptionists in
MD offices
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• Transport techs
• Respiratory therapists
• Billing clerks
• Insurance agents/clerks
• School teachers/nurses
• Home health personnel
• Medical records clerks
• Website managers
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HIPAA applies to us all--in all settings. That
means at school, at home, on the shuttle
buses, as well as the hospitals and clinics.
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Objectives
• After completing this program you will be able to:
– Discuss the general concepts of HIPAA guidelines
– Adapt HIPAA guidelines for the various settings in
which you might practice throughout the curriculum
– Discuss the seven patient/client rights regarding his/her
health information
– Differentiate individuals who have a ‘need to know’
from those who don’t. This determines those with
whom you can discuss protected health information
– Discuss application of HIPAA to the student role
– List legal, professional, and academic consequences of
violating HIPAA rules
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Why HIPAA??
• Genetic advancements - as more is known about our
genetic predisposition to diseases, HIPAA will ensure that,
for example, an individual is not denied insurance because
the company knows that she may eventually develop MS.
• Marketing - as information is more easily captured
concerning, for example, the prescriptions we purchase,
HIPAA is designed to prevent marketing of unsolicited
products or services based on harvested marketing data.
• Technology - as information is quickly and sometimes
loosely moved around networks, HIPAA standards will
hold violators accountable for accidental or intentional
‘interception’ of protected health information (PHI).
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Why HIPAA?
• An Atlanta truck driver lost his job in early 1998 after his
employer learned from his insurance company that he had
sought treatment for a drinking problem.
• The late tennis star Arthur Ashe’s positive HIV status was
disclosed by a healthcare worker and published by a
newspaper without his permission.
• Tammy Wynette’s medical records were sold to National
Enquirer by a hospital employee for $2,610.
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When and How Often do I need to be
Certified?
• The law requires that we comply with the regulations
and adhere to agency guidelines.
• The ‘certificate of compliance’ you will receive upon
the completion of this program will be sufficient
until new or updated policies are developed by the
Dept. of Health and Human Services.
• Be aware that individual agencies may have unique
HIPAA policies, and it is your responsibility to know
and implement those policies.
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What Objectives do the Privacy
Regulations Accomplish for Patients?
• Give patients more control over their health information.
• Set boundaries on the use and disclosure of health records.
• Establish appropriate safeguards for all people who participate
in or are associated with the provision of healthcare to ensure
that they honor patients’ rights to privacy of their PHI.
• Hold violators accountable through civil and criminal penalties.
• Strike a balance when public responsibility requires disclosure
of some forms of data--for example, to protect public health.
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With HIPAA we now have new terms
and abbreviations to learn!!
• Protected Health Information (PHI) or Protected Medical Information
(PMI) This is any data about the patient that would tend to identify the
individual: name, hospital #, SSN, diagnosis, lab results, past or current
photos, etc, etc.
• Privacy Officer (PO) Each facility will have an employee who is
responsible for implementing and enforcing this law. Some may have one
over a multi-facility network (Seton) others one at each site (St. David’s
Partnership). As a nursing student this individual (after your instructor or
preceptor) could be your point of information regarding HIPAA.
• Covered Entity (CE) This includes any health plan, healthcare provider,
agency that processes claims, and any company that subcontracts with
them are covered by this law.
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And more new terms and
abbreviations to learn!!
• Release/Disclosure These are terms used in describing the
release of PHI to other CEs for TPO, treatment. payment, or
health care operations.
• Accounting of Disclosure (AOD) The patient has the right to
have an AODs for his PHI or PMI.
• Directory This is CE’s census or list of patients used by
volunteers and operators to direct visitors.
Different agencies may have other terms they use to
communicate HIPAA policies. You will need to keep alert to
these instances to comply with the spirit of the law.
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The next few slides will present the
basic principles of HIPAA as it applies
to the student role:
• The seven rights in the HIPAA privacy guidelines
• Using equipment--computers, printers, fax, and similar
machines to transmit patient data
• Identifying patients/clients PHI in school papers
• Discarding or destroying papers containing patient PHI
• Communicating privacy questions/concerns in the agency
• Describing the consequences of violating HIPAA guidelines
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What are the Seven Patient Rights Regarding
Privacy of PHI (Protected Health Information)
Individuals have the right to:
1. Receive notice of an agency’s privacy practices.
2. Know that an agency will use its PHI ONLY for
treatment, payment, operations (TPO), certain
other permitted uses and uses as required by law
3. Consent to and control the use and disclosure of
their PHI.
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Seven Rights…continued
4. Access their protected health information (PHI),
except for psychotherapy notes (they might be
charged for copies)
5. Request amendment or addendum to their PHI
(not always granted)
6. Receive accountings of disclosures
7. File privacy complaints to agency officer
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HIPAA Restricts Sharing PHI
Personal information cannot be released to individuals
or companies interested in marketing ventures, without
the patient’s written permission. For example:
– Names of patients on antihypertensive drugs cannot be
released to a company marketing nutritional products to
lower blood pressure.
– Names and addresses of pregnant women cannot be
provided to infant formula companies.
– Contact information of previous patients cannot be used to
raise money for a hospital building campaign.
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How do students assure patients’ rights
to privacy and confidentiality?
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Who has Access to PHI?
The ‘Need-to-Know’ Principle
PHI should be shared with as few individuals as
needed to ensure patient care and then only to the
extent demanded by the individual’s role.
For example, the nursing assistant ‘needs to know’
only the facts concerning the patient’s current
admission.
As a nursing student, you will discuss PHI only as it
applies to your education or your patient’s care.
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Protecting your patient’s PHI
• Take all reasonable steps to make sure that
individuals without the ‘need to know’ do not
overhear conversations about PHI.
• DO NOT conduct discussion about PHI in
elevators or cafeterias.
• Do not let others see your computer screen while
you are working. Be sure to log out when done
with any computer file.
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Protecting your patient’s PHI
When preparing care plans or other course required
documents take extra care to:
• identify the patient/client by initials only
• use other demographic data only to the extent necessary
to identify the patient and his/her needs to the instructor.
• protect the computer screen, PDA, clip board, or notes
from other individuals who don’t have a ‘need to know’
• protect your printer output from others who don’t have a
‘need to know’
• protect your floppy/zip/CD-ROM/PDA from loss
• consider using Webspace to save your documents
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Protecting your patient’s PHI
In the student role you are NOT to photoduplicate or
fax patient documents in the process of working with
your patient’s PHI. As an employee of an agency
you must use the agencies’ security procedures to
transmit PHI.
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Destroying PHI/PMI
DO NOT put notes
with PHI/PMI in the
trash or paper
recycle cans.
A paper shredder is
available in the
Learning Center for
these materials.
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Consequences of HIPAA Violations
In addition to federal laws, failure to comply with
HIPAA also violates
• Nursing’s Code of Ethics
• Texas Board of Nurse Examiners Standards of
Practice
• School of Nursing’s academic and scholarly
policies
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Potential Consequences of
HIPAA Violations
Legal consequences
• Civil or criminal penalties
• Fines plus imprisonment
Professional consequences:
• Disciplinary action by the Board of Nurse Examiners
Academic consequences:
• Reprimands
• Loss of points toward grade or failure of course
• Dismissal from School of Nursing
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Application of HIPAA to Common
Situations Facing Nursing Students
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Resisting the Need to Share PHI—Honoring
the Patient’s right to Privacy
Johnny, an active 4 year old, breaks his arm
after falling from a climbing form at his
daycare. As the nursing student caring for him
after the casting, you know that he is HIV
positive. Your daughter attends the same
daycare. You alert some of the other moms at
that center.
What’s wrong with this scenario?
Who in this setting has a ‘need to know’ the
HIV status of this child?
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Formulate your answer
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Next
Sharing this information with the other parents is a
violation of the HIPAA statute--ensuring the
child’s/family’s right to privacy and confidentiality.
The other parents did not ‘need to know’ this
information. Really, nobody has the ‘need to know.’
A good action on your part as a registered nurse (or
student nurse) would be to look into the day care’s
first aid policies and help them develop policies that
observe universal precautions in the care of all
children and staff. This should be done even if you
didn’t know that one of the children were HIV
positive
Next Scenario
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Found PHI
While working a 3-11 shift in the city/county health
clinic, you see some patient data in the trash can. What
should you do?
Click on the best response
A. Remove it and take it to the document shredder.
B. Report it to the Agency’s HIPAA officer.
C. Call the toll-free number and make an anonymous
violation report.
D. Report it to your instructor or preceptor.
Next Scenario
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No, this is not the best response. You will want to protect
the PHI better than this.
Try Again
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Well…this is an option, but maybe over-kill at this stage.
You should either tell your instructor or preceptor (tell the
head nurse or unit manager only if your instructor or
preceptor are not available). They will see that the
individual responsible gets further education.
Try Again
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Yes, this is the best option. You should either tell your
instructor or preceptor (tell the head nurse or unit manager
only if your instructor or preceptor are not available).
They will see that the individual responsible gets further
education.
Next Scenario
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No, this is not the best response. You’re thinking in the
correct direction, but you don’t want to stick your hand
into any hospital trash can. You will want to tie up this
bag, label it, and get someone to take it to a shredder. As a
nursing student your best action would be to discuss with
your instructor or preceptor.
Try Again
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No, this is not the best response. This is NOT a good way
to win friends for you or the School! Unless you are
finding consistent HIPAA violations that after reporting
are not being corrected, let the agency have a shot at reeducating its staff OR STUDENTS.
Try Again
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Your Best Friend
You work on the neuro unit at the public hospital. You
were able to convince your best friend to move to Austin
and work with you. In the cafeteria, she begins telling
you about this handsome guy that was just admitted to
her unit after a bad car wreck. She continues to tell you
some of the gory details including ‘driving while
intoxicated’ (DWI). What should you do?
Click on the best response
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A. Remind her of HIPAA and tell her that you
shouldn’t discuss this type of information.
B. Ask her how old he is.
C. Tell her to get his phone number from the chart.
D. Call the agencies/networks privacy official.
E. Report her to her head nurse
Next Scenario
No, this is not the best response. Did you say she was your
best friend? Unless she is consistently violating a
patient’s rights to protect his/her PHI, you will want to
help each other when you slip.
Try Again
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Really now!!! I am going to get the Agency’s HIPAA
Officer after the both of you!
Try Again
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Yes, this is a good option. Help her recall her
responsibilities to the patient’s right to
confidentiality and privacy.
Next Scenario
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Patient’s Question
While assisting Mrs. Johnson with her bath, she tells you
that she would like remove her name from the patient
data that the volunteers have at the reception desk. Is this
a reasonable request? What would you do with this
request? Click on the best response
A. Not reasonable; this information must be at the info
desk for family members and visitors.
B. Reasonable; report it to the head nurse or the
floor/agency privacy officer.
C. Not reasonable; help her understand that it is a
protected by the volunteers.
D. Reasonable; call the volunteer office and have her
removed from the list.
Next Scenario
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Yes, this is the correct response. Recall that HIPAA
gives patients/clients the right (right #3) to control the
use and disclosure of their PHI. It is within her rights
to have her name removed from the list. Furthermore,
most agencies have special forms for this.
Next Scenario
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Correct, BUT report it and let the right person take
care of the details. Most agencies will have special
forms for this. The best response is ‘B’
Try Again
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No, this is a reasonable request. Recall that HIPAA gives
patients the right (right #3) to direct use and disclosure of
their PHI. It is within her rights to have her name
removed from the list. Most agencies will have special
forms for this.
Try Again
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Consulting Physician Calls
You are the nursing student caring for Mr. Sanchez. His
physician has called in several consultants to assist with
his care. One of the physicians, Dr Han, a neurologist,
calls to get some information about Mr. Sanchez. Can
Click on the best response
you release information to her?
A. No, she is going to have to come in to be identified.
B. Her request would need to be forwarded to the unit
manager.
C. No, she should be instructed to contact Mr.
Sanchez’ primary physician.
D. After obtaining sufficient info to know that it is Dr.
Han, you can share the requested information
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Next Scenario
No, this is not the correct response. After instituting
reasonable safeguards that it is Dr. Han, you should give
her the information that she requests. Recall that PHI
can be shared with other caregivers for TPO (treatment,
payment, & agency operation) without getting additional
approval from the patient.
Try Again
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Yes, this is the correct response. It is not a violation of
HIPAA if you institute reasonable assurances to protect
the security of the patient information and then disclose
to another person who has a ‘need to know.’ Recall
that PHI can be shared with other caregivers for TPO
(treatment, payment, & agency operation) without
getting additional approval from the patient.
Next Scenario
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Patient’s Spouse Wants to Read the Chart
Your patient, Ms Johnson, has confided in you that she and her
husband have been having marital problems. One day while she is
at x-ray, her husband asks to see the chart. You think that she
might not want him to see it, but you’re not exactly sure how to
handle the situation. What would you as the nursing student do?
A.
B.
C.
D.
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Click on the best response
Let him see it.
Refer the request to your instructor or preceptor.
Tell him no, that the chart belongs to his wife.
Delay him, saying that there is nothing in her chart
of interest.
Next Scenario
No, this is not the correct response. You recall that the
patient has the right to decide how her PHI can be
disclosed. As a student, any question about HIPAA or
how to deal with patients or their families should be
referred to your faculty or preceptor.
Try Again
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Well…you’re right, but as a student you might want to
consult with your instructor or preceptor before dealing
with the patient’s husband.
Try Again
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Yes, this is the correct response. It is always the best
policy that as a student you refer your questions to your
instructor or preceptor. In emergencies, if they aren’t
available, speak to the head nurse or unit manager.
Next Scenario
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A FINAL REVIEW
Answer the following true-false questions
To Start
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Patients have a right to see their chart?
Select your answer
True
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False
You’re right!
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No, that’s not right. Do you need to review?
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Patients can ask that parts of their health record be
amended?
True
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False
You’re right!
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No, that’s not right. Do you need to review?
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All PHI is in the patient’s chart?
True
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False
You’re right!
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No, that’s not right. Do you need to review?
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I can talk with my instructor about my patient’s
medical history?
True
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False
You’re right!
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No, that’s not right. Do you need to review?
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As a nursing student questions or concerns about
HIPAA policies or infractions should be directed
to your instructor or preceptor.
True
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False
You’re right! You can also talk with the
agency’s privacy officer, but as a nursing
student it is best to check with your faculty
or preceptor first.
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No, that’s not right. Do you need to review?
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Personal digital assistants (PDAs), clipboards,
floppy disks, zip disks and CD-ROMs used for
storing PMI, careplans, process recordings, or
patient assessments forms must be protected as we
protect the patient’s chart?
True
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False
You’re right!
Any format that contains PHI needs your
special attention.
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No, that’s not right. Do you need to review?
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Complying with HIPAA guidelines is an important
part of a healthcare provider’s role. As a nursing
student, failure to comply can result in academic,
professional, civil, or criminal consequences.
True
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False
You’re right!
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No, that’s not right. Do you need to review?
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The University of Texas at Austin
School of Nursing
HIPAA Supplemental Training for Health Care Settings
Today’s Date: 3/18/2016
Your Name Printed
I have completed this HIPAA training program. I understand the basic provisions
of the law and agree to do my part to ensure the patients’ rights of privacy and
confidentiality. Furthermore, I understand the consequences of failing to do so.
Your Signature and EID Number
TO PRINT THE CERTIFICATE: Press the Escape key to get out of this program. Next go to ‘file’
and ‘print.’ Make sure that you are printing only the CURRENT SLIDE, that you are printing in
the slide mode, and then click on OK.’
Fill in the blanks and deliver the certificate to the box on the Students Affairs receptionist’s desk.
As a student you will need to redo HIPAA training each academic year.
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Exit Program