GBMC HIPAA Compliance Program

1. Back Next Menu Health Insurance Portability and Accountability Act GBMC HIPAA Compliance Program

2. Back Next Menu HIPAA Requires • Standards for Electronic Transactions and Code Sets • Compliance Date: October 16, 2003 • Enforced by: Centers for Medicare and Medicaid (CMS) • Standards for Privacy of Individually Identifiable Health Information • Compliance Date: April 14, 2003 • Enforced by: Office of Civil Rights (OCR) • Standards for Security of Electronic Protected Health Information • Compliance Date: April 20, 2005 • Enforced by: Centers for Medicare and Medicaid (CMS)

3. Back Next Menu Diagram of the HIPAA Statute Security Code Sets

4. Back Next Menu Protected Health Information Electronic Protected Health Information Minimum Necessary User Identity Patient Rights Password Management Notice of Privacy Practices Appropriate Use of Computing Devices Privacy Policies Security Policies Privacy Officer Security Officer Reporting Privacy Concerns Reporting Security Concerns Training Focus The training that you are receiving today will focus on learning what responsibilities you have in order to ensure GBMC complies with HIPAA Privacy and HIPAA Security Regulations. The following topics will be covered: HIPAA PRIVACY HIPAA SECURITY

5. The Privacy Rule Protects information known as PROTECTED HEALTH INFORMATION (PHI) that exists in written, oral, and electronic formats. Back Next Menu HIPAA Privacy Protected Health Information

6. Examples ofPHI Back Next Menu HIPAA Privacy • Vehicle and Serial Number • Device Identifier and Serial Number • Precinct • Date of Death • Medical Record Number • Internet Protocol Number • Full Face Photographic Images • Zip Code • Telephone Number • Health Plan Beneficiary Number • Biometrics Identifiers (i.e. finger prints) • Any Other Unique Identifying Number, Characteristic, or Code • Name • Birth Date • Fax Number • Account Number • Web Universal Resource Locator (URL) • Street Address • Admission Date • Electronic mail address • Certificate/License Number • License Plate Number • City • Discharge Date • Social Security Number Protected Health Information

7. Back Next Menu HIPAA Privacy The Privacy Rule • Limits the way in which members of the GBMC workforce may use and disclose (release) PHI. GBMC workforce must have a job-related reason to use and or disclose PHI. • Requires that all GBMC workforce use only the minimum amount of PHI necessary to get the job done. This is what HIPAA defines as the MINIMUM NECESSARY Standard. “Workforce” means employees, volunteers, trainees, and other persons who conduct work for GBMC and are under the direct control of GBMC, whether or not they are paid by GBMC. Minimum Necessary

8. Back Next Menu Annual Acknowledgment of the Minimum Necessary Standard • Every year, employees affirm their commitment to this standard by electronically signing the GBMC Code of Business Ethics Acknowledgment, Confidentiality of Information Agreement, and Appropriate Use Agreement. • Failure to comply with this standard will lead to disciplinary action, up to and including termination. Minimum Necessary

9. Minimum Necessary Scenarios • A patient that I cared for in the ICU was transferred to a medical unit. May I look in the patient’s record to see how she is doing? May I call the unit and talk to the nurse who is now caring for her? • As much as this may reflect your compassion and concern for patients whom you have taken care of in the past, you may not inquire into her status unless there is a job-related reason. For example, if you have to complete a note in her record after she has left your unit, you may access her record to complete your note. Minimum Necessary

10. Minimum Necessary Scenarios • I am a unit clerk and while I was working night shift, a nurse named Mary became very ill. Another nurse named Alice transported Mary to the Emergency Dept (ED) & described for the nursing staff in the ED what symptoms Mary had complained of having. Alice was thanked for her assistance & told that she could return to her floor. Later that evening, I walked by Alice while she was on the computer & she called me over. She had Mary’s lab results up on her screen. Can she do this? • No, Alice should not look at this information. She has violated the minimum necessary standard. Such violation is punishable up to and including termination. Minimum Necessary

11. Back Next Menu HIPAA Privacy The Privacy Rule • Provides patients with certain rights - these rights are commonly referred to as the PATIENT PRIVACY RIGHTS. • These rights are communicated to the patient in the Notice of Privacy Practices. • If a patient wishes to exercise any of these Patient Privacy Rights (which are outlined on the next slide), they must do so in writing. You should contact Medical Records - Correspondence Department (443-849-2274) for the correct forms. Patient Rights

12. Back Next Menu HIPAA Privacy The Patient Privacy Rights • Right to access PHI • Right to request an amendment to PHI • Right to request restrictions on how PHI is used for treatment, payment, and healthcare operations • Right to receive confidential communications • Right to request an accounting of disclosures • Right to complain to the Department of Health and Human Services’ Office for Civil Rights Patient Rights

13. Back Next Menu Notice of PrivacyPractices Effective April 14, 2003 GBMC includes Greater Baltimore Medical Center, Gilchrist Hospice Care and GBMC Foundation. Notice of PrivacyPractices Effective April 14, 2003 GBMC includes Greater Baltimore Medical Center, Gilchrist Hospice Care, and GBMC Foundation. Notice of PrivacyPractices Effective April 14, 2003 GBMC includes Greater Baltimore Medical Center, Gilchrist Hospice Care, and GBMC Foundation. Notice of PrivacyPractices Effective April 14, 2003 GBMC includes Greater Baltimore Medical Center, Gilchrist Hospice Care, and GBMC Foundation. HIPAA Privacy The Privacy Rule • Requires that GBMC provide all patients with a copy of its NOTICE OF PRIVACY PRACTICES (NOPP). • Each patient must sign an acknowledgment after receiving the NOPP unless the patient is unable to do so at the time of registration. • Copies of the NOPP may be ordered from Purchasing. Notice of Privacy Practices

14. Back Next Menu Notice of PrivacyPractices Effective April 14, 2003 GBMC includes Greater Baltimore Medical Center, Gilchrist Hospice Care and GBMC Foundation. HIPAA Privacy The Notice of Privacy Practices • The Notice is a useful tool not only for you but also for the patient. The NOPP: • describes how GBMC may use a patient’s PHI • provides a clear and concise description of the patient’s rights • discusses how a patient may opt-out of the facility directory • discusses how the medical staff may interact with the patient’s family Notice of Privacy Practices

15. Back Next Menu HIPAA Privacy The Privacy Rule • Requires that GBMC create policies regarding how GBMC’s workforce is allowed to use and disclose (release) PHI. • Also requires that GBMC make available to and educate its workforce on those policies. • All of GBMC’s PRIVACY POLICIESare located on the Compliance Page of the GBMC InfoWeb. • Hardcopies of the policies may be printed directly from the InfoWeb or obtained from the Compliance Department. Privacy Policies

16. Back Next Menu HIPAA Privacy THE GBMC Privacy Policies • Examples of GBMC Privacy Policies include: • #003.102 Minimum Necessary Use and Disclosure of Protected Health Information • #003.105 Uses and Disclosures for Involvement in the Individual’s Care and Notification Purposes • #003.114 Uses and Disclosures of Protected Health Information for Law Enforcement Purposes Privacy Policies

17. Back Next Menu HIPAA Privacy The Privacy Rule • Requires that GBMC designate someone who is responsible for • the development and implementation of the privacy policies • privacy related training and education • investigating privacy related complaints • conducting routine audits to make sure that all of GBMC’s workforce are complying with the privacy policies • The PRIVACY OFFICER for GBMC is Stacey McGreevy. Privacy Officer

18. Back Next Menu HIPAA Privacy THE Privacy Rule • Requires that GBMC provide a way for patients and workforce to REPORT PRIVACY CONCERNS or ask privacy questions. Reporting Privacy Concerns

19. Back Next Menu HIPAA Privacy Privacy Compliance Tips • Keep all PHI locked and secured when you are away from your work area. • Do not include any patient identifiers in the subject line of an email. • Do not discuss PHI in public or common areas. • Make sure to check the fax number for accuracy before sending a fax that contains PHI. All faxes must include a completed GBMC standard fax cover sheet (see fax policy for limited exceptions). • If a fax is sent to the wrong recipient in error, you must complete the Accounting of Disclosures log located on the Compliance page of the InfoWeb and send it to Medical Records. • Sign-in sheets are allowed as long as we continue to follow the standard protocols that have always been in place at GBMC. Sign - in sheets should be limited to patient name and appointment time.

20. The Security Rule Requires administrative, physical, and technical safeguards be implemented to address the confidentiality, integrity, and availability of ELECTRONIC PROTECTED HEALTH INFORMATION (ePHI). Security of patient information is EVERYONE’S job! We owe it to our patients! Back Next Menu HIPAA Security Electronic Protected Health Information

21. The Security Rule Requires GBMC provide each computer system user with a uniqueUSER IDENTITY. Your user identity is the combination of your user id and your password – do not share or write down your password where it can be easily retrieved by someone other than you. Your user identity is what is used to monitor your activity on the system(s). Do not leave yourself signed onto a computer and then walk away without signing off. You are responsible for any activity that occurs under your user identity. Your user identity appears on audit reports which are frequently monitored. Back Next Menu HIPAA Security User Identity

22. Protecting Your Password In order to protect against unauthorized access to our computers, GBMC has taken appropriate steps to monitor all activity on the network to ensure that people are not trying to break-in to those systems. However, as a user of a GBMC system, it is important that you also take measures to ensure that people cannot access GBMC systems – this is partly accomplished through PASSWORD MANAGEMENT. Password management includes selecting a strong password, protecting your password, as well as frequently changing your password. Back Next Menu HIPAA Security “A password should be like a toothbrush. Use it every day; change it regularly and DON’T share it with friends” - Usenet Password Management

23. Examples of How to Create a Strong Password Back Next Menu HIPAA Security • Mix upper and lowercase characters • 3bLINdmice • 5gOLDenrings • 4cALLingbirdS 2. Replace letters with numbers • Replace “E” with “3” • “Sp3cial” or “3l3gant” 3. Combine two words by using a special character • Roof^Top • Sugar$Daddy • B@tterup! 4. Use the first letter from each word of a phrase from a song “Oops! I did it again” becomes “O!idia” In general, passwords should have a minimum length of 6 characters but each application may have other requirements/limitations. Password Management

24. The Security Rule Requires that GBMC train its workforce on appropriate computer security and APPROPRIATE USE OF COMPUTING DEVICES. As a user of a GBMC system (including the Internet) you are required to: Use only your officially assigned user identity (e.g. user id and password) Save GBMC data only to the GBMC Network unless prior GBMC approval has been granted Notify your manager and the HIPAA Security Officer if your password has been disclosed, or otherwise compromised, and immediately change your password Back Next Menu HIPAA Security Appropriate Use of Computing Devices

25. Back Next Menu HIPAA Security The “Do Not’s” When Using GBMC Systems • As a user of a GBMC system (including the Internet) you may not: • Install unauthorized software (e.g. screensavers, games, or instant messenger programs) • Install any unlicensed software on a GBMC computer or device • Abuse your Internet or e-mail access privileges • Relocate any computer equipment without prior MIS approval • Bring into GBMC any personal computer equipment without prior MIS approval (e.g. printer, burner, scanner, PDA, or digital camera) Appropriate Use of Computing Devices

26. The Security Rule Requires that GBMC create SECURITY POLICIES regarding how GBMC will implement appropriate safeguards to ensure the confidentiality, integrity, and availability of ePHI. Examples of existing GBMC security policies are: # 304 Email Policy # 348 Information Security Policy All GBMC policies are located on the GBMC InfoWeb. Back Next Menu HIPAA Security Security Policies

27. The Security Rule Requires that GBMC designate someone who is responsible for: The development and implementation of information security policies and procedures Regular reviews of records of information system activity, such as audit logs, access reports, and security incident tracking reports The development of awareness and training programs for all members of its workforce The SECURITY OFFICER for GBMC is Stacey McGreevy. Back Next Menu HIPAA Security Security Officer

28. Back Next Menu HIPAA Security The Security Rule • Requires that GBMC establish a way for all GBMC workforce to REPORT SECURITY CONCERNS. • Report all risks you are currently aware of and as you see them, such as: • Unauthorized or suspicious visitors • Logged-on but unattended workstations • Uncontrolled access to areas that house equipment and/or PHI • Passwords on Post-it™ notes • Staff accessing records without a need to know • Report all security concerns to Stacey McGreevy. Reporting Security Concerns

29. Back Next Menu HIPAA Privacy & Security We hope this Computer-Based Learning course has been both informative and helpful. Feel free to review this course until you are confident about your knowledge of the material presented. Print, sign, and date the HIPPA acknowledgement form to complete the competency. Please turn in your completed form to your clinical instructor.