Maryland HIPAA Compliance for Healthcare Providers

To ensure compliance with Maryland's HIPAA regulations, healthcare providers must designate a privacy official and a security official.

The privacy official is responsible for overseeing the implementation of the HIPAA Privacy Rule, which includes developing policies and procedures for protecting patient information.

Healthcare providers must also train their workforce on HIPAA policies and procedures, ensuring that all employees understand their role in protecting patient information.

HIPAA laws and guidelines are in place to protect the confidentiality, integrity, and availability of protected health information (PHI). Most federal HIPAA requirements apply at the state level in Maryland.

To meet these requirements, healthcare organizations must implement a HIPAA compliance program. This includes establishing a HIPAA authorization form in Maryland, which is required under certain circumstances, such as when a covered entity wants to use or disclose PHI for marketing purposes.

A valid HIPAA release form in Maryland must contain specific "core elements", including a description of the specific information to be used or disclosed, the name or identification of the person(s) authorized to make the request, and an expiration date or event.

In Maryland, healthcare organizations must implement a HIPAA compliance program to meet federal requirements. Most federal HIPAA requirements apply at the state level in Maryland.

To report a breach, organizations must notify the affected patient within 60 days of discovery, and if the incident affected 500 or more patients, they must also notify media outlets. Breach notification letters must be mailed to affected patients, and a substitute notice must be available on the organization's website.

Organizations subject to HIPAA that report incidents following HIPAA standards also meet the requirements of the Maryland breach notification law. The HIPAA Breach Notification Rule requires healthcare organizations to report breaches that compromise the confidentiality, integrity, or availability of protected health information.

Incidents that are considered reportable breaches include hacking or IT incidents, unauthorized access or disclosure of PHI, theft or loss of an unencrypted device with access to PHI, and improper disposal of medical records.

Maryland also has its own data breach notification law, the Maryland Personal Information Protection Act (PIPA), which imposes stricter breach notification requirements than HIPAA. Under PIPA, businesses that handle the personal information of Maryland residents must report breaches affecting that information within 45 days of the breach.

Here's a summary of the key differences between HIPAA and PIPA:

HIPAA's Privacy Rule sets standards for use, disclosure, and protection of all health information created by "covered entities." This includes rights for patients to access and amend their own medical records. Every physician who transmits health information electronically must comply, and a written agreement must be in place with all business associates.

The Privacy Rule limits use and disclosure of PHI to the "minimum necessary" and demands that "reasonable" safeguards be taken to prevent improper use or disclosure of PHI. The Rule imposes civil and criminal sanctions for non-compliance.

Healthcare organizations are required by law to maintain the privacy and security of your protected health information. They will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.

The Hospital is a key player in the healthcare system, and it's essential to understand how it fits into the HIPAA framework. The University of Maryland Medical Center (UMMC) has formed its own Organized Health Care Arrangement (OHCA) with the School of Medicine.

This OHCA helps improve the exchange of Protected Health Information (PHI) among these entities. The University of Maryland Medical Center is not part of the School of Medicine/FPI/PAs OHCA.

To be HIPAA compliant in Maryland, you need to identify your security weaknesses through six self-audits annually. These self-audits uncover vulnerabilities in your security practices, which you must then address through remediation plans.

Administrative safeguards, such as auditing computers for signs of misuse and reminding employees to follow security rules, are crucial to HIPAA compliance. Each entity's information technology group manages many of these safeguards.

To protect sensitive information, you should pick complex log-in passwords, use passwords on portable devices, and not share computer log-in accounts or passwords with anyone. If you must write down your passwords, keep them in a secure place.

Here are some key security measures to keep in mind:

HIPAA violations in Maryland often occur due to failures in risk assessments, patient record access, business associate agreements, or timely breach reporting.

To avoid HIPAA violations, healthcare organizations must provide patients timely access to their medical records.

Discarding unneeded medical records in the trash is a HIPAA violation, whereas shredding them is the recommended practice.

Giving out patient information without confirming the recipient's identity is also a HIPAA violation.

Conversations that might be overheard or PHI accidentally seen are considered incidental uses and disclosures, which are difficult to prevent, but reasonable efforts should be made to limit them.

Each entity in an Organized Health Care Arrangement (OHCA) remains responsible for complying with HIPAA, even if they are working together to share PHI.

Designated HIPAA Officers in each entity oversee compliance and training to ensure HIPAA regulations are met.

The Privacy Rule sets standards to protect health care information by regulating information that can be linked with a person.

Health care information linked with personal identifying information is called Protected Health Information (PHI), which is a key concept in HIPAA compliance.

To be HIPAA compliant, healthcare organizations must conduct six self-audits annually to identify security weaknesses and vulnerabilities. These self-audits are crucial in uncovering deficiencies in security practices.

The HIPAA Security Rule demands that healthcare organizations implement safeguards for data systems and networks that store, process or transmit Protected Health Information (PHI). Administrative safeguards include auditing computers for signs of misuse and reminding employees to follow security rules.

Remediation plans are essential in addressing identified deficiencies. These plans list the weaknesses and vulnerabilities found during self-audits and outline actions and a timeline to address them. By creating remediation plans, healthcare organizations can ensure they meet HIPAA safeguard requirements.

Most HIPAA violations occur when healthcare organizations fail to conduct accurate and thorough risk assessments. Conducting regular self-audits can help prevent such violations by identifying potential security risks and weaknesses.

The HIPAA Security Rule sets safeguards for data systems and networks that store, process or transmit PHI. It follows the best security practices used in industry and government.

Administrative safeguards are in place to ensure employees follow security rules. This includes auditing computers for signs of misuse, reminding employees to follow security rules, and having a disaster recovery plan.

Physical precautions are also crucial, such as posting security guards at building entrances, logging off, and placing servers in locked rooms. This helps to prevent unauthorized access to sensitive information.

Technical safeguards are measures such as using strong passwords and encrypting transmitted data. These measures help to protect the security and integrity of PHI.

Here are some key security measures you're responsible for:

To meet Maryland HIPAA requirements, you must implement written policies and procedures that are customized for your practice's specific needs.

These policies and procedures must be directly related to how your business operates, taking into account any changes in your business practices.

You must review your policies and procedures annually to ensure they remain up-to-date and make amendments where necessary.

This ongoing review process will help you stay compliant with HIPAA Privacy, Security, and Breach Notification requirements.

HIPAA training is a must for healthcare organizations in Maryland, and it's required for all employees who have access to protected health information (PHI).

HIPAA training must be provided annually, and employees must legally attest that they understand and agree to adhere to the training material.

You'll receive HIPAA training online at the School of Medicine's website, and it's mandatory for all employees, students, residents, fellows, volunteers, and business associates of the School of Medicine, UPI, and the PAs.

Many employees will also need to take specialized HIPAA training that focuses on their job duties, so be sure to check your specific requirements.

HIPAA training is not just a one-time thing - it's an ongoing process that requires annual refreshers to ensure everyone stays up-to-date on the latest rules and regulations.

You can't just use any vendor to be HIPAA compliant in Maryland, they need to be willing and able to sign a business associate agreement (BAA).

A BAA is a legal contract that requires each signing party to be HIPAA compliant and be responsible for maintaining their compliance.

Business associate agreements must be signed with each of your business associate vendors, and common examples of business associates include electronic health records platforms, email service providers, and cloud storage providers.

As you work off-campus, it's essential to remember that HIPAA rules still apply. You must protect the security and privacy of PHI, regardless of your location.

Use the same security precautions on your home computer as you would on your office computer. This includes having anti-virus software, keeping software up to date, and using a password-protected screen saver.

Don't let household members access PHI, as this could compromise sensitive information.

Business Associate Agreements are a must-have when working with vendors that have access to your patients' health information. You need to sign a Business Associate Agreement (BAA) with each vendor.

A BAA is a legal contract that ensures both parties are HIPAA compliant and responsible for maintaining their compliance. This is non-negotiable.

You can't just use any vendor and expect to be HIPAA compliant. They need to be willing and able to sign a BAA. Common examples of business associates include electronic health records platforms, email service providers, and cloud storage providers.

If a vendor doesn't sign a BAA, it can't be used for business associate services. It's that simple.

Remember, a BAA is not optional, it's a requirement for any vendor that has access to your patients' health information.

To comply with the HIPAA Breach Notification Rule, you must have a system to detect, respond to, and report breaches. Employees must also have the means to report incidents anonymously and be aware of what to do if they suspect a breach has occurred.

You have a responsibility to report suspected security breaches to your supervisor or department Security Liaison. This includes sharing passwords or log-in accounts, trying to guess another’s log-in or password, and improper email activity.

Examples of security breaches include:

If you suspect a security breach, report it to your supervisor or department Security Liaison as soon as possible.