Education for Physicians

HIPAA and Its Purpose

What is HIPAA?

  • Health Insurance Portability and Accountability Act of 1996
  • Title II–Administrative Simplification
  • It's a federal law
  • HIPAA is mandatory, penalties for failure to comply


  • Protect health insurance coverage, improve access to healthcare
  • Reduce fraud and abuse
  • Improve quality of healthcare in general
  • Reduce healthcare administrative costs (electronic transactions)

HITECH and Its Purpose

What is HITECH?

  • Health Information Technology for Economic and Clinical Health Act
  • Subtitle D of the American Recovery and Reinvestment Act of 2009 (ARRA)
  • It's a federal law


  • Makes massive changes to privacy and security laws
  • Applies to covered entities and business associates
  • Creates a nationwide electronic health record
  • Increases penalties for privacy and security violations
  • Key HITECH Changes

    • Breach Notification requirements
    • Business Associate Agreements
    • Restrictions
    • Right to access
    • Criminal provisions
    • Penalties
    • OCR Privacy Audits
    • Copy charges for providing copies from EHR
    • HIPAA preemption applies to new provisions
    • Private cause of action
    • Sharing of civil monetary penalties with harmed individuals

    Civil Penalties for Noncompliance*

    Violation Category

    Each Violation

    All such violations of an
    identical provision in a
    calendar year

    Did Not Know

    $100 –$50,000


    Reasonable Cause



    Willful Neglect—Corrected



    Willful Neglect—Not Corrected



    *As of 1/25/2013

    Criminal Penalties for Noncompliance

    • For health plans, providers, clearinghouses and business associates that knowingly and improperly disclose information or obtain information under false pretenses. These penalties can apply to any "person."
      • Penalties higher for actions designed to generate monetary gain
        • up to $50,000 and one year in prison for obtaining or disclosing protected health information
        • up to $100,000 and up to five years in prison for obtaining protected health information under "false pretenses"
        • up to $250,000 and up to 10 years in prison for obtaining or disclosing protected health information with the intent to sell, transfer or use it for commercial advantage, personal gain or malicious harm

    Facility Privacy Official

    • Your FPO is Jaime Kocanda, RHIT, CHPS Responsible for:
      • Privacy Program
      • Privacy Rights of patients
      • Requests for Privacy Restrictions
      • Facilitating the training and education of staff

    HIPAA Terminology

    • BAA: Business Associate Agreement
    • HIPAA: Health Insurance Portability and Accountability Act
    • HITECH: Health Information Technology for Economic and Clinical Health Act
    • PHI: Protected Health Information
    • CE: Covered Entity (Hospital)
    • ACE: Affiliated Covered Entity (Common ownership)
      OHCA: Organized Health Care Arrangement (The hospital and medical staff will be considered an Organized Health Care Arrangement)
    • DRS: Designated Record Set (medical record and billing record)
    • AOD: Accounting of Disclosures (patient’s right to receive)
    • Directory: Hospital census list used by volunteers and operators with name and room

    How does HIPAA affect you?

    • Coversheets with confidential statement need to be used on all external faxes.
    • Screens will need to be placed out of public view when possible
    • Patient charts will need to be placed in secure area
    • All PHI (e.g., dietary slips) will need to be placed in shred containers (e.g., Shred-It bins)
    • Patient information must only be accessed if there is a need to know and only the minimum necessary may be used.
    • Patient family members will give a passcode for other than directory releases
    • Patient consent must be obtained before speaking in front of family members or visitors
    • Registration will be giving out a Notice of Privacy Practices to every patient. Physicians in the OHCA are covered by the facility’s Notice
    • Patients will be given the option to “opt out” of directory
    • Patients have a right to a copy of their medical record
    • Written patient authorization is required for most disclosures that are not related to treatment, payment, or health care operations

    What is Protected by HIPAA (PHI)?

    • Name
    • Address including street, city, county, zip code and equivalent geocodes
    • Names of relatives
    • Name of employers
    • All elements of dates except year (i.e. DOB, Admission, Discharge, Expiration, etc.)
    • Telephone numbers
    • Fax Numbers
    • Electronic e-mail addresses
    • Social Security Number
    • Medical record number
    • Health plan beneficiary number
    • Account number
    • 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

    What is a Covered Entity (CE)?

    • Health plans, Health care clearinghouses, and Health care providers that transmit electronically for billing
      • Examples
        • Hospitals
        • Physician practices
        • Insurance companies
        • Ambulance transportation services
        • Hospice
        • Home health

    Organized Health Care Arrangement (OHCA)

    • Defined as a clinically integrated care setting in which individuals typically receive health care from more than one health care provider
      • This defines the relationship between the facility and the physician treating the same patient.
    • Allows information to flow between the covered entities for treatment, payment, and health care operations without patient authorization

    What does that mean to me?

    • You can share information without patient authorization as it relates to TPO
    • Other covered entities will request only minimum necessary to perform their job
    • You may request the minimal information necessary from them for reasons of TPO without patient authorization
    • May need to verify the identity of the requestor according to policy

    Disclosing PHI to Family Members and Friends Who Call the Unit

    • Patient will be assigned a four-digit passcode that will be needed to obtain non-directory information
    • Distribution of passcode will be the responsibility of the patient
    • Passcode may be changed during treatment
      • Revocation and password change form must be routed to FPO

    Verification of Requestors

    • Requestors via phone will need:
      • Patient SS#, DOB and one of the following:
        • Account number, street address, medical record number, birth certificate, insurance card or policy number
      • Scenarios
        • Unknown physician calling from cell phone
        • Family member or friend calling without passcode

    External Faxing Guidelines

    • Limit when possible
    • Verify fax number
    • Utilize preset numbers when applicable
    • Fax machine located in secure location
    • ALWAYS use cover sheet with confidentiality statement for transmittals
    • Highly sensitive information should NEVER be faxed (HIV status, abuse records, etc.)

    Patient’s Right to Access

    • Forward to HIM for processing
    • Must be able to provide access and/or electronic or paper copy of record
    • If patient is in-house, HIM will manage access process

    Patient’s Right to Amend

    • Forward request to HIM for processing
    • Right of patient to request amendment to records. Request must be in writing
    • Cannot change or omit documentation already in the medical record
    • If patient in in-house HIM will manage amendment process

    Patient’s Right to Opt out of Directory

    • Patient can opt out of directory at anytime but will probably happen during admission process
    • You may not acknowledge the patient is in the facility or give information about the patient to friends, family or others who may inquire
    • Can still release information to family and friends with 4-digit passcode as defined in the Directory policy.

    Right to Privacy Restrictions

    • Patients have the right to request a privacy restriction of their PHI
    • NEVER agree to a restriction that a patient may request
    • All requests must be made in writing and given to the FPO to make a decision on
    • NO request is so small that it should not be routed to the FPO

    Patient Privacy Complaints

    • FPO must maintain complaint log in accordance with the complaint process
    • ALL privacy complaints must be routed to the FPO
    • Responses cannot be accompanied by retaliatory actions by the hospital
    • Disposition of complaint must be consistent with the facility’s Sanctions for Privacy and Information Security Violations

    Accounting of Disclosures (AOD)

    Includes all releases of the DRS EXCEPT those:

    • Authorized by the patient
    • Used for treatment, payment or health care operations
    • Released to individuals themselves
    • Used for national security or intelligence purposes
    • Used for law enforcement agencies that have custody of an inmate
    • Disclosed as part of a limited data set
    • Releases that occurred before April 14, 2003


    Additional requirements forthcoming as a result of HITECH regulations

    Notice of Privacy Practices

    • Patient will receive Notice upon each registration
    • Outlines patient rights
      • Breach Notification
      • Right to Access
      • Right to Amend
      • Fundraising and the Right to Opt Out
      • Confidential Communication
      • Right to Privacy Restriction
      • Right to Opt out of Directory
    • Physicians in the OHCA are covered by the facility’s Notice for hospital patients
    • FPO to review Notice (handout)

    Sharing Information with Other Treatment Providers

    • Information may be shared for TPO with physicians and office staff, hospitals, or other treatment facilities on mutual patients
    • Need to verify the identity of the requestor according to policy
    • PHI can be released for reasons of treatment, payment or health care operations

    Breach Notification

    • HITECH provisions require the following notifications when breaches (as defined in the regulations) occur:
      • To the patient
      • To the Department of Health and Human Services
      • To the media when the breach involves more than 500 individuals in the same state or jurisdiction

    Ensuring Security Compliance

    • Ensure users log off terminals when not in use.
    • Computers should have screen savers whenever possible.
    • Computer screens should be positioned so information (PHI) is not readable by the public or other unauthorized viewers.
    • Printers should be positioned in protected locations so that printed information is not accessible or viewable by an unauthorized person.
    • PHI must be properly disposed of in shred bins.

    Common Exposures

    • Discussions of patient information in public places such as elevators, hallways and cafeterias
    • Printed or electronic information left in public view (e.g., charts left on counters)
    • Discussing patient information on social networking sites (e.g., Facebook, Twitter)
    • PHI in regular trash
    • Records that are accessed without need to know in order to perform job duties
    • Unauthorized individuals (e.g., patient visitors) hearing patient sensitive information such as diagnosis or treatment


    • Two categories of privacy and security violations
      • Negligent
        • Accidental/inadvertent and/or due to lack of proper education or an unacceptable number of previous violations
      • Intentional
        • Purposeful or deliberate violation of privacy or information security policies or an unacceptable number of previous violations
      • FPO to review sanctions policy

      To Test Your Knowledge

      • Do you know who your FPO is?
      • Does the patient have the right to access or obtain a copy their medical record?
      • Can a patient amend their record?
      • Do you know who to refer patient privacy questions or complaints to?