Posts Tagged ‘HIPAA HITECH’

HIPAA Rules and the HITECH Act

Wednesday, November 6th, 2013

The Health Information Portability and Accountability Act (HIPAA) was signed into law in 1996. Two additions were made. Protection for the privacy of Protected Health Information (PHI) became effective April 14, 2003 including standardization of electronic data interchange in health care transaction, effective October, 2003. The second part of HIPAA was security. Protection for the security of electronic Protected Health Information (e-PHI) which became effective April 20, 2005.

The Privacy Rule sets the standards for how covered entities(CEs) and business associates are to maintain privacy of PHI. The Security Rule defines the standards which require covered entities to implement basic safeguards to protect electronic PHI.

HIPAA is a Federal Law and was enacted by Congress as a response to healthcare reform. It is mandatory to protect the privacy and security of a patient’s health information. It also assists to prevent health care fraud and abuse and simplifies billing and other transactions reducing health care administrative costs.

Key Definitions:

Protected Health Information (PHI)

  • Individually identifiable health information
  • Transmitted or maintained in any form
  • Created or received by a covered entity, business associate, or employer

Covered Entity

Once you are a part of a covered entity, you are a covered entity with respect to all PHI, whether it is transmitted electronically, in paper format, or transmitted orally.

Examples of Covered Entities include

  • Health Care Providers
  • Insurers
  • Clearinghouses for electronic billing
  • Covered entities may only use and disclose PHI according to Privacy Rule provisions
  • Business Associates

Disclosures

  • Treatment and payment sources
  • Individual has opportunity to agree or object
  • Limited data set (facially de-identified, requires data use agreement between parties)
  • With authorization

HIPAA Privacy Rule controls privacy unless a state law is stricter.

Treatment

  •  CE may disclose PHI for treatment activities to another healthcare provider

Payment

  • CE may disclose PHI to another CE or healthcare provider for the CE payment

Health Care Operations

  • CE may disclose PHI to another CE for specific activities such as QI

Authorization

  • Individual may authorize the release of the PHI in writing with the signature and data provided

HITECH

On January 17, 2013, the Department of Health and Human Services released the HITECH Act, aka the Omnibus Rule, under HIPAA. This Omnibus Rule represents the most comprehensive set of changes to HIPAA since its origination. It is a part of the American Recovery and Reinvestment Act of 2009. The Act allocated $20 Billion to health information technology projects, expanded the reach of HIPAA by extending certain requirements to business associates, and imposed a nationwide security breach notification law.

The new rule modifies the breach notification standard; imposes new rules regarding disclosures of PHI in marketing and sale of PHI. It enhances patient rights to access and control disclosure of PHI. It also expands specific HIPAA obligations to business associates.

HITECH Breach Notification Provisions

The HITECH Act requires Covered Entities (CEs) and business associates to notify affected individuals, the Department of Health and Human Services, and depending on the breach, the media, following discovery of a breach.

HITECH replaces the original “harm standard” under HIPAA. That standard had stated a breach had occurred if PHI was compromised and had significant risk of financial, reputational, or other harm to an individual as the result of the impermissible use or disclosure of PHI. HITECH amends the breach to clarify that the disclosure of PHI is presumed to be a breach with notification necessary unless a CE can demonstrate low probability that the PHI has been “compromised.”

Four factors must be included in any risk assessment, 1) the type and extent of PHI, 2) who was the unauthorized person committing the breach as well as who received the information, 3) whether the PHI actually was received and viewed, and, 4) the extent to which the PHI has been mitigated. Lawyers are asking what is meant by compromised PHI.

Compliance Officers need to keep HIPAA and compliance in front of personnel. Finding ways to do that can be challenging but well worth the effort. For most organizations, some of their greatest risks are those tied to PHI.

HITECH modifies the definition of business associates to include an entity that “creates, receives, maintains, or transmits” PHI on behalf of a CE. Business associates include subcontractors, vendors of personal health records that provide services on behalf of a CE. Business Associates are held directly accountable now to HIPAA. CEs had to revise their business associate agreements to comply with all applicable provisions of the HIPAA Security Rule. CEs are required to report breaches of unsecured PHI as business associates. CEs must hold business associates to the same stringent standards as they are held.

HIPAA HITECH makes business associates and their subcontractors directly liable for non compliance with the Security Rule and Privacy Rule requirements. Direct Liability flows from the following violations:

  • Failure to provide breach notification to the CE
  • Failure to provide access to a copy of electronic PHI to either the CE, or the patient’s designee
  • Failure to provide an accounting of disclosures
  • Failure to comply with the Security Rule
  • Failure via impermissible disclosures of PHI

Individual Rights

Individuals now have greater rights to obtain all of their health data, to access electronic copies, and to restrict when their information is shared and with whom. Their information must be available to them within a reasonable time. Even offsite stored info must be made available within 30 days.

Compliance Officers

Build security into hardware, software, and processes to the greatest extent possible. Make security provisions operate automatically where possible. When replacing manual processes with technology, validate the process and the fact that it does not increase risk. Technology for the sake of technology needs to be monitored also. Review your processes. Educate personnel to be privacy alert.

Build a meaningful HIPAA and Compliance audit system foundation that has value for the organization. It is mandated by the OCR. Agency audits of organizations began last year. Remember, not having an audit program can be costly, the OCR state fine can go up to $1.5 million for breaches.

Required Elements of a Patient Authorization

When reviewing the patient authorization, be certain it includes:

  •  A description of the PHI to be used or disclosed. Be specific
  •  The persons authorized to use or disclose the PHI
  • The person or agency to whom the CE may disclose the PHI
  • The purpose of the disclosure use
  • The patient’s right to revoke the authorization
  • The consequences if the patient refuses to sign
  • An expiration date of the form
  • Signed and dated by the patient
  • PHI may be re-disclosed by a third party and a business associate, subject to the same HIPAA regulations
  • Must be written in clear language

HIPAA continues to pose a growing liability for agencies. Review agency policies, procedures, and processes now. The audits are being increased. Be certain you have a Corporate Compliance Plan in place with strong attention to HIPAA Privacy, Security, and HITECH

HIPAA Rules and the HITECH Act- Patient Privacy

Tuesday, April 30th, 2013

Compliance officers were awaiting the Office of Civil Rights (OCR) final rules on Breach Notification, Enforcement, and the modification to Privacy and Security Rules of HIPAA HITECH. Now that we have the regulations, it is time to review the basics in this ezine and additional requirements in the next article. HIPAA may be one of your largest potential liabilities for your agency.

Key Definitions

Protected Health Information (PHI)

  • Individually identifiable health information
  • Transmitted or maintained in any form
  • Created or received by a covered entity, business associate, or employer

Covered Entity

  • Health Care Providers
  • Insurers
  • Clearinghouses
  • Covered entities may only use and disclose PHI according to Privacy Rule provisions

Disclosures

  • Treatment and  payment sources
  • Individual has opportunity to agree or object
  • Limited data set (facially de-identified, requires data use agreement between parties
  • With authorization

HIPAA Privacy Rule controls privacy unless a state law is stricter.

Treatment

  • CE may disclose PHI for treatment activities to another healthcare provider

Payment

  • CE may disclose PHI to another CE or healthcare provider for the CE payment

Health Care Operations

  • CE may disclose PHI to another CE for specific activities such as QI

Authorization

  • Individual may authorize the release of the PHI in writing with the signature and data provided

Compliance Officers need to keep HIPAA and compliance in front of personnel. Finding ways to do that can be challenging but well worth the effort. For most organizations, some of their greatest risks are those tied to PHI.

Build security into hardware, software, and processes to the greatest extent possible. Make security provisions operate automatically where possible. When replacing manual processes with technology, validate the process and the fact that it does not increase risk. Technology for the sake of technology needs to be monitored also. Review your processes. Educate personnel to be privacy alert.

Build a meaningful HIPAA and Compliance audit system foundation that has value for the organization. It is mandated by the OCR.  Agency audits of organizations  began last year.  Remember, not having an audit program can be costly, the OCR state fine can go up to $1.5 million.

Required elements of a Patient Authorization

When reviewing the patient authorization, be certain it includes:

  • A description of the PHHI to be used or disclosed. Be specific
  • The persons authorized to use or disclose the PHI
  • The person or agency  to whom the CE may disclose the PHI
  • The purpose of the disclosure use
  • The patient’s right to revoke the authorization
  • The consequences if the patient refuses to sign
  • An expiration date of the form
  • Signed and dated by the patient
  • PHI may be re-disclosed by a third party and if a business associate, subject to the same HIPAA regulations
  • Must be written in clear language

HIPAA continues to pose a growing liability for agencies. Review agency policies, procedures, and processes now. More to follow on that topic

OCR and HIPAA

Tuesday, April 30th, 2013

At a recent HIPAA seminar, the Office of Civil Rights (OCR) identified that they are evaluating HIPAA audit models. The present model requests certain records, reviews, cites errors/omissions and calls for corrective action. Privacy and security of Protected Health Information (PHI) is of primary concern especially in light of social media and mandated Electronic Medical Record creation in healthcare.

Presently, organizations are reviewing their privacy and security programs. How compliant is your Compliance and HIPAA programs? Perhaps you should conduct a gap analysis.

Getting started

To conduct a review and analysis of your agency’s compliance program you must know if your program covers the required elements?

  • Complete written policies and procedure
  • Designation of a Corporate Compliance Officer
  • A training and education program regarding confidentiality, commitment to preventing fraud and abuse, and other elements of compliance
  • Communication lines to the Corporate Compliance Officer
  • Identification of compliance risk areas and a plan to mitigate risk
  • Responding to non compliance issues
  • Policy of non-intimidation and non-retaliation against employees who identify non compliance
  • Disciplinary policies regarding non compliant behavior

Consider the re-signing of the organization privacy policies annually by employees. This act can become a reminder of the importance of privacy and confidentiality in the organization. Identify who will conduct regular internal audits. Conduct this present review and analysis as if it were a surveyor visit, only this time, you get to be the surveyor.

Audit the HIPAA Program

As part of the compliance audit process, be certain to evaluate the HIPAA program. Are there plan objectives? Is an audit and monitoring system in place? Who has the responsibility for completion?  Identify the audit checklist. Is it inclusive? Is there a documentation process to record findings?

Are there annual goals to improve on privacy and security in the organization? How are audit findings reviewed? How does follow up occur?

The Audit

The following checklist should be considered a guideline (not necessarily all inclusive) and would require agency individual application.

  • Is the Compliance plan, particularly the HIPAA portion, in compliance with the HIPAA Security Rule? Has an assessment been conducted regarding environmental/operational impact on PHI?
  • Can the organization identify how it protects access to information? Is there a policy re access to PHI and “need to know?”
  • Can patients obtain their information in a timely manner? Can information be provided in electronic format, as required by HITECH. Has a security risk analysis been conducted?
  • Have security measures been implemented to reduce the risk? What are those measures?
  • Have the Compliance, Privacy, and Security risk analysis available for an OCR audit or questions from an accrediting surveyor.
  • At the very least, for privacy, look at the following:
  • Can patients/guests view PHI? See computer screens? Is there any place on the premises that PHI is readily available?
  • Are PHI posted on wall boards where those who have “no need to know” have access to the info?
  • Is PHI left on desks? Are computer screens left on when the user steps away?
  • Are recycling bins used? Is there a BAA with that recycling vendor?
  • Are all BAAs in place with all vendors and in compliance with HIPAA HITECH?
  • Communication:
  • Is PHI faxed? Is there a confidentiality/disclosure statement on each fax coversheet?
  • Does the online system require level logins?
  • Are screen savers activated in a short period of time?
  • Are emails used with PHI? Are the emails encrypted?
  • Are phone calls used to give and receive PHI? How is the individuals receiving or giving info identified and confirmed?
  • Responsibility:
  • Can each employee identify when PHI enters there area of responsibility?
  • Who handles PHI? Where is it stored? What is the back up process? What is the length of storage? Is it secure? How do you know it is secure?
  • Have all employees been trained in privacy? Has security at the specific employee level been conducted? Is compliance training mandatory? Is it conducted annually?
  • Is there a protocol for new employees? Is there a protocol regarding confidentiality upon employee departure?
  • Are BAAs in place holding contractors accountable for PHI protection. Have you seen their policies, procedures, and processes?
  • Reports:
  • Are reports created that have confidential information? Are they circulated to only those with “need to know”
  • Have the reports been reviewed to reduce the amount of sensitive information, if possible? Could de-identified information be substituted?
  • Is transmission of report information secure?
  • Security:
  • Is there a written policy to protect PHI? Is there policies re computer screens in view with PHI? Are there policies re passwords?
  • Are there policies re storage of data and how backup tapes and storage devices are accounted for and monitored?
  • Has every station been evaluated as to protection of PHI and view and accessibility to information by those who do not have clearance to that station.
  • How are SmartPhones used? Are they ever used to capture pictures of patient wounds?
  • Technical Security:
  • Does the technical team periodically verify the technological security is in place and working appropriately? Can the technical team identify if an unauthorized user has accessed PHI? What safeguards are in place to protect against unauthorized access?
  • Is technology in place to verify identity of users?
  • Are passwords and IDs routinely changed per a schedule?

OCR Investigations and Review:

If you have a breach that triggers an investigation by OCR, be certain to promptly respond as to what happened, how it happened, what was done to mitigate outcomes, and what has been implemented to prevent a future occurrence.  Be certain to identify the fact you have a full Compliance Program in place. Identify that all employees have routine education re Compliance and HIPAA.

If documents are requested, your counsel may request confidentiality for those documented being sent to OCR. Create and maintain a log of events, completes with dates, times, and people involved throughout the entire investigation process. Save all electronic documents. Keep statements by all employees involved in the incident and the investigation. Obtain counsel’s advice as to phone conversations with OCR as written correspondence maintains an investigation trail.

Focus on internal compliance. If there is a HIPAA breach, there must be remediation/education regarding the process and the prevention of a reoccurrence.

Summary:

  • Keep your plan objectives current.
  • Identify who is responsible for the audits and establish times and how findings will be transmitted.
  • Have corrective action plans in place.
  • Include documentation of audits, results, and remediation/corrective action/education
  • Report findings to the BOD, leadership, and counsel.
  • If there is an OCR audit/investigation have a team established to quickly respond, pull data, analyze, and report.
  • Have an ongoing risk analysis performed as specified by policy. Be certain the risk analysis encompasses the technical requirements of the Security Rule.
  • Be certain the Risk Analysis is well documented. Be certain the plan for mitigation of any adverse findings is in place.

Like the clinical documentation rule, “if it wasn’t documented you did not do it,” so it is true here also. Document each step of the plan. If ever there is an audit, the fact a full compliance plan is in place in your agency including a HIPAA Privacy and Security review, can speak volumes about you and your organization.

Ethics and Accountability in an Electronic Age: 2012

Wednesday, December 28th, 2011

You are a leader or have interests in home healthcare and hospice, so you are aware of the challenges and opportunities presented in this electronic age.

Are you conducting your HIPAA Risk Analysis?

Do you have your Disaster Preparedness and Recovery Policies and Procedures current?

Do you have a policy regarding use of social media in the workplace?

Are you allowing nurses to take pictures of wounds with their personal cell phones?

Are you employing etechnology ethics ?

Technology and Change:

Today, we all use a GPS, an iPhone, a Droid or some brand of cell phone, and touched our iPad or other tablet,  powered up a laptop or computer to send email, or completed status updates to Facebook,  Linkedin, or Twitter or accessed the Internet for  patient information, financial or clinical reports and benchmarks, or budgets. Technology has not necessarily made life easier. It certainly has increased its constraints on time.

Technology has impacted how we do banking, make purchases, conduct transactions, complete travel reservations, attend conferences, provide healthcare schedules, teach patients and personnel, automate revenue cycle management, and generate personnel schedules and  agency reports.

The negative effects include:

5/19/11 57 hard drives from the servers at the Blue Cross Blue Shield Tennessee Call Center were stolen with 1 million individuals impacted.

9/29/11  4.9 million Tricare beneficiaries affected after data stolen.

10/11 McAfee demonstrated how they could hack into a Medtronic Insulin Pump and could have lethally increased the dose.

2010 File boxes of patient records found in two major cities.

The world is changing. The workforce is changing. Remote workers need special policies re PHI and protection of patient data. Be certain they attend sessions regarding HIPAA HITECH, privacy, and security. You may have a policy that addresses ‘view only’ access to data with no printing of data.

HIPAA HITECH

The American Recovery and Reinvestment Act of 2009 (ARRA) was signed into law on February 17, 2009.  Title XIII of ARRA is the Health Information Technology for Economic and Clinical Health Act (HITECH Act). HITECH legislation is meant to affect health care delivery

  • One way to affect change is to provide financial stimulation to create and have physicians and hospitals adopt electronic health records (EHR)

The Federal operating plan can be found at http://www.hhs.gov/recovery/reports/plans/onc_hit.pdf

This act includes $20 billion in funding for health information technology projects.

These projects include reimbursement incentives for health care providers to acquire electronic health record technology.  Hospitals are being encouraged to move toward becoming paperless.

HITECH has TEETH

The HITECH Act has given the HIPAA Privacy and Security Rules real teeth by strengthening business associates agreements.  One of the major goals of the HIPAA  Privacy Act was and is  “to assure that individuals’ health information is properly protected  while allowing the flow of health information  needed to provide and promote high quality health care and to protect the public’s health and well being.” HIPAA ensures that personal health information  given to covered entities is protected, even information shared with home health agencies, physicians, hospitals, third party billing providers, coding specialists, and others who provide or pay for healthcare services. But Business Associates were not held to the same standards as covered entities. HIPAA HITECH moved to correct this weakness.

BUSINESS ASSOCIATES

  • The BAA states that the Business Associate is obligated to:
    Use/disclose PHI only as permitted or required by the agreement and by law.
    Use appropriate safeguards to prevent use or disclosure of PHI other than as permitted by the BAA.
  • Report to the healthcare entity any use or disclosure of PHI not permitted. Require all subcontractors and agents that create, receive, use, disclose, or have access to PHI to agree, in writing tobe held to the same restrictions and conditions on use or disclosure of PHI.

HIPAA HITECH imposed breach notifications on both covered entities and business associates and increased individual rights with respect to PHI maintained in EHRs. In addition, there is increased enforcement of, and penalties for HIPAA violations..

The Department of Health and Human Services (HHS) has published a notice of proposed rulemaking that would modify the HIPAA Privacy, Security, and Enforcement Rules. The Proposed Rule implements the requirements of the HITECH Act as well as expands upon the statutory provisions of the HITECH Act.  On March 15, 2010 HHS stated that other than the security breach notification rule and new penalty levels, the new regulation would be enforced. The compliance date for all provisions of the Proposed Rule is 180 days after publication of the Final Rule. HHS accepted comments on the Proposed Rule through September 13, 2010. As of January, 2012, the final rule has not yet arrived, but is expected soon.

Prior to the HITECH Act, a Business Associate (BA) was not directly subject to HIPAA privacy and security requirements.  The BA obligations were to the CE under the terms of the agreement. The BA was subject to contractual remedies only for any breach of the business associate agreement (BAA).

  • Prior to ARRA, HITECH Business Associates were not required to meet the obligations for Administrative, Physical, and Technical safeguards, and Procedure and Documentation Requirements.
  • NOW the BAA must clearly require the BA to comply with HIPAA regulations just as the CE.

Penalties for the BA are the same as the CE. That is a huge responsibility for the BA and the CE.

The HITECH Act and the Proposed Rule require business associates to comply with the requirements of the HIPAA Security Rule and implement policies and procedures in the same manner as the CE. Also, subcontractors to business associates must develop Security Rule compliance programs. Rules to be followed include:

Security and Incident response policies

  • Breach Log
  • Every employee must understand they have personal responsibility for intentional breaches
  • Email with PHI is to be encrypted

Breach:

A breach is an unauthorized acquisition, access, use, or disclosure of protected health information relating to failure to comply with organizational security or privacy policies, or violation of federal or state privacy and security regulations. Accessing information by an employee of a covered entity, in good faith, is not considered a breach.

However, HITECH strengthens the specifics of privacy and security, significantly increasing penalties, establishing a heightened enforcement scheme giving state attorneys general enforcement authority. Individuals may now be held accountable for wrongful disclosure (HITECH Act section 13409).

Under the new law, when a breach is learned, a covered entity (CE) should notify each individual whose unsecured PHI has been, or believed to have been, accessed or disclosed.  Business associates must notify the CE of the breach.  Note the understanding that the breach has been evaluated to have caused harm to the individual.  CE and BAs must notify individuals about a breach as soon as possible but, no later than 60 days following discovery of the breach.

If a breach involves 500 or more individuals, the department of Health and Human services should be immediately notified. They will post the covered entity on their website. DHHS began posting names on March 1, 2010. Breaches of below 500 must be recorded on a log and annually sent to DHHS.

UCLA Medical Center recently was fined $865,000 and required to submit(and have approved) a corrective action plan after allowing workers to access records who should have had more  limited access and a higher level authorization. This is an organization with a sophisticated compliance plan and still had this breach.

The EHR

The Privacy Rule gives individuals the right to obtain copies of their paper PHI from a CE. The HITECH Act expanded those access rights to PHI maintained in an EHR.

ARRA prepares for the government goal of establishing electronic health records for all Americans by 2014

  • to accomplish this goal, privacy rules have been strengthened and the requirements for breach notification and responsibilities of business associates have been greatly increased.

CEs must prepare processes in response to the requirements and have updates to the BAA.

At Select Data,

  • We believe in Corporate Compliance
  • We have a strong HIPAA Awareness and Corporate Compliance Plan which assertively strives to protect PHI.
  • We notify the Corporate Compliance Officer of suspected or actual incidents of PHI disclosure

We want to comply with the regulations and we want to protect health information because, not only is it the law, but, it is the right thing to do.

57 million US consumers have accessed their medical information. Another 40 million want to do so states Cyber Citizen Health US, 2011 survey.

DISASTER PREPAREDNESS

The Security Plan: Each CE must plan and document how they will operate during a disaster and how ePHI will be secured. HIPAA 2005 required a Data Backup Plan. That plan requires the backup plan for accessing protected data in case the original data has been destroyed.

The Plan must show regular duplication of patient files that are stored in a secure location. The Plan also required an inventory of software and hardware used so key systems can be restored quickly, if a disaster occurs. It is not acceptable to merely store information on a cell or smartphone. Have a clear concise, complete backup plan.

The Security Plan is expected to show ways of protection from access to the premises by employees. It also requires records and how each employee can access data. In addition, levels of access are to be delineated.  There should be power on authentications and auto-locks. CEs are expected to test and revise their contingency plans taking steps to identify and mitigate areas of weakness.

Employees should be aware that not just patient names are identifiers. PHI also includes addresses, phone numbers, drivers license numbers, medical record numbers, policy and account numbers, VIN numbers, health plan numbers, and relative name and identifiers.

Lastly, the HIPAA Security Plan must be in writing and the industry standard is an annual review (though there is no frequency statute). The Plan should have detailed policies and procedures with all incidents recorded, identifying a Disaster Plan with contingencies and technological interventions planned.

To read more about HITECH, please refer to Federal Register/Vol 75, No. 134/Wednesday, July 14, 2010/Proposed Rules

Department of Health and Human Services, Office of the Secretary

45 CFR Parts 160 and 164

Modifications to the HIPAA Privacy, Security, and Enforcement Rules Under the Health Information Technology for Economic and Clinical Health Act

Agency: Office for Civil Rights

Social and Professional Media

Social media is one of the most dangerous of risks. What an interesting dichotomy: on one hand we, in health care, are operating under increasing rigid privacy restrictions and on the other, individuals are posting the most intimate or the most mundane information about themselves and others on the internet for the world to read and see forever.

Agencies that allow clinicians to use their personal smart phones to take pictures of wounds and upload them to a patient record may need to be concerned about patient information stored on a personal cell phone. Who owns the data? Who will protect the data? Is texting a safe way to transport patient data? Experts say, “No.”

Should clinicians worry that their party and beer drinking pictures could be used against them if they are involved in a med error or a law suit?

At the VA, a new social media directive covers the use of Facebook pages, Twitter feeds, blogs, and YouTube channels. They use examples of these sites to educate personnel re personal and professional responsibilities.

100% of the Top 100 firms employ personnel to monitor social media. Every person interviewed has their social media investigated. Hiring is dependent upon the findings. Law firms, banks, accounting firms use social media investigators. Garner Consulting and TechCrunch Blog state “the new social media customer relationship management market (CRM) is expected to reach over $1 billion in revenue by the end of 2012, up from approximately $625 million in 2010. World-wide social CRM is projected to total $820 million in 2011.”

What are the ethics of making negative comments about a present or prior employer? Many organizations, especially banks, hospitals, and academic institutions are monitoring what is said about them and their clients or patients. They have clear policies reflecting training as to HIPAA. If an employee or former employee breaches a confidence, they may be sanctioned or sued.

WHAT Can You Do?

Encrypt email with patient or other sensitive data!

Be certain your organization has a strong corporate compliance plan in place. Have a strong Corporate Compliance Officer who reports to the CEO and Board of Directors. Consider the CCO having direct access to corporate counsel.

Have compliance policies and procedures that also address disaster preparedness, social media, data protection and backup. Annually, minimally, review the Corporate Compliance Plan. Keep a copy of the presentation with an attendance sheet to demonstrate corporate wide support of the plan. Be clear as to internal audits conducted as well as a corporate wide risk analysis conducted annually.

Review the American Nurses Association’s Principles for Nurses re Social Media and Social Networking. Draw from the ANA’s Code of Medical Ethics. Review the American Physical Therapy Association Code of Ethics. Many clinical associations can provide ethical guidelines that can assist with policy development.

Mayo Clinic has refined policies on social media well worth reading. Protect your agency. Be certain your employees know your agency’s ethical stance. Review regulations frequently:

http://www.govinfosecurity.com

http://www.mobilhealthnews.com

http://www.hhs.cms.gov

http://www.healthdatamanagement.com

Expect clinicians to adhere to their Standards of Practice. Expect everyone to adhere to the best practices in ethical protection of patient data.  Password  protect and change them frequently.

Be serious and state your ethical beliefs, in front of employees, frequently. Encourage employees that when in doubt…don’t. Don’t send data that causes them to hesitate. Encourage them to double check what is being sent to whom.

Ethics and Compliance have become the watchwords for a safer healthcare environment. Remember agencies with similar beliefs seek each other out. The ethical industry leader wants to work with other industry organizations that share the concern to protect, care, and achieve expected patient outcomes in a compliant ethical manner. Have a great 2012.