In California, employees handling protected health information (PHI) must be trained on HIPAA regulations to avoid costly fines and reputational damage. California law requires employers to provide HIPAA training to employees who work with PHI.
HIPAA training is a one-time requirement for new employees, but ongoing training is necessary for employees who handle PHI regularly. This ensures they understand the latest regulations and best practices.
As a California employer, you must also have a designated HIPAA compliance officer to oversee HIPAA compliance and ensure employees follow HIPAA guidelines.
Understanding HIPAA
HIPAA protects sensitive health information, including diagnosis and treatment information, medical test results, and billing information. This information is considered individually identifiable health information.
Protected Health Information (PHI) is created or received by healthcare providers and includes information that identifies an individual and relates to their health condition or payment for healthcare. This can include medical records, test results, and billing information.
HIPAA applies to USC's faculty, staff, students, and other employees or volunteers who use, disclose, or access PHI as part of their job responsibilities. This includes healthcare providers, administrative staff, and anyone who collects, uses, processes, accesses, or discloses PHI.
The following information is protected under HIPAA:
- Diagnosis and treatment information
- Medical test results
- Records held by health insurance providers
- Billing information relating to medical treatment
- Prescription information
- Any other individually identifiable health information
Employees must refrain from sharing patient information with unauthorized individuals, including coworkers, friends, and family members. Private discussions about patient information should be limited to medical personnel and conducted in secure, private spaces.
Here are some examples of what is considered treatment, payment, and healthcare operations:
Employees must be aware of these categories to ensure they are handling PHI correctly.
Employee Responsibilities
As an employee in California, it's essential to understand your responsibilities when it comes to handling Protected Health Information (PHI). Faculty physicians must complete the HIPAA education in order to be appointed or reappointed to USC Care and the medical staff of Keck Medical Center.
You're also responsible for completing the education program in connection with your job responsibilities if you're a hospital employee or KSOM clinical staff. Researchers and research staff who conduct human subjects research and access PHI must complete the Education Program to obtain review and approval from the applicable USC Institutional Review Board.
To ensure you're meeting your responsibilities, here are the key groups and their corresponding requirements:
Remember, it's crucial to handle PHI securely and confidentially, especially when working remotely.
Responsibilities
As an employee, it's essential to understand your responsibilities when it comes to handling sensitive information. You're required to complete the HIPAA education program as part of your job responsibilities.
This applies to hospital employees and KSOM clinical staff, who must complete the education in connection with their job responsibilities. Researchers and research staff who conduct human subjects research and access Protected Health Information are also required to complete the Education Program to obtain review and approval from the applicable USC Institutional Review Board.
You may be required to complete the Education Program as a student if you access Protected Health Information as part of your education. Departments and/or other units that employ or engage Covered Workforce members, such as clinical personnel, are responsible for ensuring that all such Covered Workforce members complete the Education Program by the appropriate deadlines.
Here's a breakdown of the responsibilities:
Remember, understanding your responsibilities is key to protecting sensitive information and maintaining a culture of privacy and data security in your organization.
Unauthorized File Access
Unauthorized file access is a serious issue in healthcare settings. Employees accessing files without authorization can happen out of curiosity or a desire to assist others.
Strict adherence to authorization protocols is vital to prevent such breaches. This means following the rules and only accessing files that you're explicitly allowed to see.
Unauthorized access can lead to the exploitation of patient information. Texting patient information, although convenient, poses a risk of exploitation by hackers.
Encryption of information and utilizing secure Electronic Medical Record (EMR) software can enable efficient communication without compromising patient confidentiality.
Phone Conversations
Phone conversations about patient information are a common occurrence in healthcare settings, but it's essential to handle them with care. You should avoid discussing patient information in public areas to prevent unintentional breaches.
HIPAA provides federal protection for individually identifiable health information, which includes diagnosis and treatment information, medical test results, and prescription information. This means that employees must be mindful of who they discuss patient information with.
To maintain patient confidentiality, private discussions about patient information should be limited to medical personnel and conducted in secure, private spaces. This is crucial to prevent breaches of trust and maintain the integrity of patient information.
Here are some tips for discussing patient information over the phone:
- Do it in private settings to prevent unintentional breaches.
- Avoid public areas during such conversations.
By following these guidelines, you can help ensure that patient information remains confidential and secure.
Business Associates
As an employee, it's essential to understand who qualifies as a business associate under HIPAA. A business associate is any business that provides services related to protected health information (PHI), such as creating, using, maintaining, transmitting, disclosing, or destroying PHI.
Business associates can include contract billing companies, claims processing organizations, data processing or analysis firms, and documentation storage or disposal companies. They can also include external auditors or consultants, accountants, lawyers, or IT firms in contact with PHI, and even external medical transcription or translation services.
If your employer has a self-funded health insurance plan, they are technically operating a covered entity, which means they are subject to HIPAA. This is because they are handling employee medical records for the purpose of employee compensation claims or relating to sick leave or health insurance.
Here are some examples of business associates that may be involved in your workplace:
- Contract billing companies
- Claims processing organizations
- Data processing or analysis firms
- Documentation storage or disposal companies
- External auditors or consultants
- Accountants, lawyers, or IT firms in contact with PHI
- External medical transcription or translation services
As an employee, it's crucial to know that if your employer has a business associate, they must ensure that the associate is HIPAA compliant to protect your PHI.
Compliance and Training
Regular training sessions should be conducted to keep employees informed about HIPAA policies and security controls, reducing the likelihood of inadvertent mistakes.
To maintain compliance, provide mandatory HIPAA training for all employees who have access to PHI, especially during onboarding. This training should be easily accessible and completed by each individual, with certificates of completion signed, dated, and uploaded.
Clear policies and procedures around HIPAA compliance should be established, including a comprehensive Notice of Privacy Practices policy, outlining the measures taken to protect individual PHI.
Policy Purpose
The purpose of compliance and training is to detail requirements for completing the necessary programs and protocols to ensure adherence to regulations like HIPAA, FERPA, and CMIA.
These regulations require individuals who collect, use, disclose, or access Protected Health Information to complete the University of Southern California HIPAA Education Program.
What Is Compliance?
Compliance is all about following the rules and regulations that govern how you handle sensitive information. HIPAA compliance is a must for any organization that handles Protected Health Information (PHI).
To ensure compliance, you need to create a checklist that outlines the specific rules and regulations that apply to your business. This should include determining if your company is a covered entity, business associate, or neither.
Your compliance checklist should also identify which HIPAA rules apply to your situation, such as the Privacy Rule, Security Rule, and Breach Notification Rule. These rules dictate how you can share PHI, protect electronic PHI, and notify individuals in the event of a data breach.
Having a compliance checklist in place helps you stay on top of the latest changes and updates to HIPAA rules and regulations. It also ensures that your employees are aware of their responsibilities and know how to report any potential HIPAA violations.
HIPAA compliance is not just about following rules, it's also about protecting the privacy rights of individuals. By implementing robust security and encryption systems, you can safeguard PHI and prevent unauthorized disclosure.
Provide Regular Training
Regular training is a must for any organization that handles Protected Health Information (PHI).
Properly trained employees are the first line of defense against HIPAA violations. Regular training sessions should be conducted to keep employees informed about policies and security controls, reducing the likelihood of inadvertent mistakes.
HIPAA training should be mandatory for all team members, especially for new hires during onboarding. It should also be easily accessible and include a system to track completion, such as having each individual sign, date, and upload their certificates of completion.
Having an allocated HIPAA expert in your team is a great starting point, but it’s equally important to ensure that all employees understand the importance of HIPAA compliance.
Common Violations and Consequences
Failing to promptly report data breaches to consumers is one of the most common HIPAA violations. HIPAA violations can result in serious consequences for healthcare organizations.
Investigations for HIPAA violations can be triggered by external complaints from healthcare workers, patients, or health plan members. The OCR can only act if the complaint has been filed within 180 days of the violation being detected.
Some common ways businesses commit HIPAA violations include failing to properly secure and store devices, giving unauthorized users access to PHI, leaving PHI data unencrypted, and improperly caring for, handling, transmitting, or disposing of written or electronic records.
Tiered consequences for HIPAA violations include:
Minor HIPAA violations may lead to the implementation of HIPAA-specific guidance and training, while major violations can result in serious fines and penalties.
Patient Information and Disclosure
Patient information is protected under HIPAA, which covers diagnosis and treatment information, medical test results, records held by health insurance providers, billing information, prescription information, and any other individually identifiable health information.
As an employee in California, you must understand that patient confidentiality is a cornerstone of healthcare ethics. Any breach of this trust is a serious violation.
You must refrain from sharing patient information with unauthorized individuals, including coworkers, friends, and family members. Private discussions about patient information should be limited to medical personnel and conducted in secure, private spaces.
Texting patient information poses a risk of exploitation by hackers. To mitigate this risk, you should use encryption of information and utilize secure Electronic Medical Record (EMR) software.
Using platforms like Skype or Zoom for discussing patient information is another potential vulnerability. Employing Electronic Health Record (EHR) software can ensure secure communication channels.
Here are some ways to maintain patient confidentiality:
- Keep patient information private and only share with authorized medical personnel.
- Use secure communication channels, such as encrypted text messages or secure EMR software.
- Avoid discussing patient information in public or in front of unauthorized individuals.
Remember, maintaining patient confidentiality is crucial for upholding the trust between healthcare providers and patients.
Frequently Asked Questions
What is the HIPAA policy for employees?
Employees must protect patient data by storing electronic files offline and encrypting them when transmitted, and take steps to prevent unauthorized access to sensitive information
What is the HIPAA privacy rule in California?
In California, the HIPAA privacy rule is enforced by the California Medical Information Act (CMIA), which protects patient health information from unauthorized disclosure. To access or share protected health information, a signed authorization is typically required.
Sources
- https://policy.usc.edu/hipaa-privacy-rule-education-of-covered-workforce/
- https://factorialhr.com/blog/hipaa-violations-in-the-workplace/
- https://remote.com/blog/hipaa-compliance
- https://www.bowlesrice.com/west-virginia-health-care-law-blog/how-does-hippa-apply-to-employers
- https://garrisonlaw.com/what-can-you-do-if-your-employer-shares-your-protected-health-information-phi/
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