Vocabulary

Breach:  A prohibited disclosure or use of protected health information (PHI), which compromises the security or privacy of the information.

Confidentiality: A legally protected right of patients. An ethical duty of designated healthcare professionals to keep patient information private.

Electronic health record (EHR):  A computerized software system that maintains patient health information, which can be created, managed, and consulted by authorized healthcare professionals and providers from more than one healthcare organization.

Healthcare providers:  Also called providers; includes doctors, nurse practitioners, midwives, and physician assistants.

Liable:  Legally responsible

Malware: Malicious computer software that affects the functioning of a computer. It can gather and send a person’s private information to unauthorized parties over the internet.

Policies:  Written plan of activities or behaviors that provide goals for the facility and the healthcare employees.

Privacy:  The condition of being private or secret.

Procedures:  Detailed steps that describe how to perform specific tasks.

Protected health information (PHI): Includes a patient’s identifiable demographic information, physical and/or mental health information and conditions and related payment information. Under HIPAA, the security, privacy, and confidentiality of PHI must be safeguarded.

Risk management:   Techniques used to lower the risk of accidental loss to a business.

Electronic Medical and Health Records

When patients’ paper medical records were moved to digital versions, they were called electronic medical records (EMRs). The EMR contained the patient’s medical and treatment information for that specific healthcare facility. Digitizing the medical records allowed healthcare providers to have quicker access to the patient’s information and track data over time. Providers in the same facility could review the chart at the same time, which was not possible when the records were in paper form.

A disadvantage of EMRs was the difficulty to share the information with other healthcare providers outside of the facility. For instance, if a patient was initially seen by their provider and then referred to a specialist outside of the facility, the patient’s electronic medical record needed to be printed out and mailed or faxed to the specialist.

As technology advanced, electronic health records (EHRs) were created. EHRs contained the patient’s total health information. The record was shared with healthcare providers and professionals outside of the facility and information from those visits were added to the EHR. Thus the EHR was accessed and managed by more than one healthcare facility. For instance, a patient recently discharged from the hospital is being seen by their provider. The doctor can access the x-ray report and medical laboratory reports from the hospital’s EHR. This allows for better patient care.

Information in an EHR

A patient’s EHR contains demographic information, such as name, address, phone numbers, email addresses, date of birth, and social security number. It also contains administrative and billing information, including insurance account numbers and claims. The EHR can contain correspondence from other providers, along with forms signed by the patient.

The largest collection of information in an EHR relates to the patient’s health information, which includes:

• Personal history: Includes past and current diseases, health concerns, and medications taken; surgeries and hospitalizations
• Family history: Includes diseases/conditions that the patient’s family members were diagnosed with
• Progress notes: Written by healthcare providers and include the patient’s signs, symptoms and  concerns; and findings from the physical exam and tests, diagnosis, and treatment plan
• Vital signs: Includes the patient’s heart rate, respiration rate, blood pressure, temperature, weight, and height
• Allergies: Includes medications, environmental, and food allergies
• Immunizations dates: Includes the vaccine type and the date it was administered
• Medical laboratory tests: Includes blood tests, urine tests, etc.
• Radiology images: Includes x-rays, ultrasounds, computerized tomography (CT) scan, magnetic resonance imaging (MRI), etc.
• Other tests results

Patient Portal

Many EHRs include patient portal software.  The patient portal is a secure website that allows the patient to interact with their EHR and their healthcare team.  Many patient portals allow patients to view test results, read visit and medication summaries, add and revise personal and family health information, and view immunization status.  Some patient portals allow patients to message their healthcare team, request prescription refills, make payments, update personal information, schedule appointments, read educational health information, and complete forms.

Privacy and Confidentiality of Health Information

In healthcare, a patient’s records are private and confidential. Privacy and confidentiality of their records give patients the freedom to share their health concerns with their provider (e.g., doctor, nurse practitioner, or physician assistant). Healthcare professionals can only read a patient’s chart if they are working with the patient and/or need information for their job.

Federal and state laws address privacy and confidentiality of patients’ health records. Two important federal laws that address these topics include:

• Health Insurance Portability and Accountability Act (HIPAA)
• Health Information Technology for Economic and Clinical Health (HITECH) Act

Health Insurance Portability and Accountability Act

In the 1980s and early 1990s, billing and payment processes in healthcare moved slowly. It was typical that payments for services provided were delayed for four to six months. During this time, healthcare technology increased, and many software companies were creating electronic healthcare records (EHRs).

Due to the changing times, Congress passed the Health Insurance Portability and Accountability Act of 1996 (HIPAA). HIPAA is a set of national standards that healthcare organizations, providers, and professionals must follow.  This law is enforced by the U.S. Department of Health and Human Services (HHS) Office for Civil Rights (OCR). One of the important goals of HIPAA was to safeguard the security, privacy, and confidentiality of protected health information (PHI). Protected health information includes identifiable demographic information. It also includes physical and/or mental health information and conditions and related payment information.

Two important Standards to be aware of as a healthcare professional include:

• Standard 2 – Privacy Rule: This standard requires healthcare facilities (e.g., clinics, hospitals, pharmacies, nursing homes, etc.) to protect patient health information.
• Standard 3 – Security Rule: This standard requires healthcare facilities to protect patient information when it is electronically transmitted and stored.

The following sections provide a brief summary of these two Standards. For more information see: https://www.hhs.gov/hipaa/for-professionals/index.html

Standard 2: Privacy Rule

The formal name for the “Privacy Rule” is  the Standards for Privacy of Individually Identifiable Health Information.  The Privacy Rule protects all individually identifiable health information, which includes a patient’s:

• Demographic data (name, address, phone numbers, email addresses, date of birth, and social security number)
• Past and present health information (e.g., physical and mental health information, surgeries and procedures, medications)
• Payment for past and present health services.

The Privacy Rule protects patient information that is transmitted to other healthcare facilities and services, whether in writing (paper), electronically, or orally.  This information is called protected health information (PHI). The Privacy Rule specifies situations when the PHI can be used or disclosed with and without the patient’s written authorization.

A patient’s written authorization is required when the patient requests PHI to be disclosed to a third party, such as another person or healthcare facility.  For instance, Tom gives written authorization for the doctor to talk to Jane, his daughter, about Tom’s diagnosis. Susie is moving and wants to see a new doctor.  She needs to provide a written authorization to have her records transferred to the new healthcare facility.

No written authorization is required for the following activities:

• To the individual: Patients can see their health information, without completing a written authorization (record release form).
• Treatment, payment, and healthcare operations (TPO): Treatment relates to the actions taken to care for the patient.  Payment refers to the reimbursement for the services provided. Healthcare operations relates to the healthcare facility’s activities required to run their business. This may involve such activities as legal services and quality improvement.
• Uses and disclosures with an opportunity to agree or object: When asked, the patient can give informal permission for another to hear their information. For instance, a patient is accompanied by their significant other. The patient gives permission for the significant other to remain in the room during the examination.
• Incidental use and disclosure:  Healthcare professionals must always take reasonable precautions, so patients’ information is not overheard. If an incidental disclosure occurs, no written authorization is required from the patient.
• Public interest and benefit activities: Local and state laws may require the release of PHI in certain situations that involve law enforcement and public health activities. PHI can also be given to coroners, medical examiners, and funeral directors.

De-identifying Protected Health Information

HIPAA’s direct patient identifiers can be used to link protected health information back to a specific person. Direct patient identifiers include:

• Names
• Addresses
• Dates (e.g., treatment, admission, and discharge dates; birth and death dates)
• Social security number
• Telephone and fax numbers
• Medical record numbers
• Biometric identifiers (e.g., finger, retinal, and voice prints)
• Health insurance beneficiary numbers
• Account information
• Full-face photographs and any comparable images
• License plate number and drivers’ license numbers
• Device identifiers and serial numbers
• Web universal resource location (URLs), Internet Protocol (IP) addresses, and email addresses
• Device attributes or serial numbers

Many times the direct patient identifiers are removed from the PHI, for research, healthcare operations, and public health purposes. Once the PHI has been deidentified (e.g., the direct patient identifiers have been removed), HIPAA does not restrict the disclosure of the information. For instance, the county health department requests all hospitals in the area to provide information on the patient deaths within the last month. The hospitals would remove all of the patients’ identifying information and just provide a list of reasons of death to the county. There would be a low risk of the information being linked back to the patients involved.

Standard 3: Security Rule

The Security Rule focuses on the protection of the electronic protected health information (ePHI).  The Security Rule contains administrative, physical, and technical safeguards important to ensuring the security of the ePHI.

Administrative Safeguards

One of the focuses of the administrative safeguards is to identify and prevent potential risks to the ePHI. Today, the greatest threat to ePHI are cyberattacks.

The administrative safeguards category includes administrative policies, procedures, and actions to protect ePHI. Typically, a security officer or an appointment person is responsible for ensuring the Security Rule requirements are implemented and followed in the facility.  Administrative safeguards used in healthcare facilities include:

• Written policies and procedures for identifying and reducing the risk to ePHI
• Security risk analysis that identifies potential threats with corrective action plans.
• Risk management program to prevent unauthorized disclosure of ePHI
• Employee training on privacy and security practices

Physical Safeguards

The physical safeguards focus on the protection of the computer network and the computer equipment. Healthcare facilities use surveillance cameras and alarms. Computer equipment should be labeled with identification numbers and security cables to prevent theft. Additional physical safeguards include:

• Inventory of all workstation equipment, portable devices, and medical devices that use, collect, or store ePHI. It’s important to know what equipment is being used, the location of the equipment, and who is using it.
• Staff members must only have access to the part of the software they need to complete their job. So a provider would have greater access to a patient’s EHR than the receptionist, for example.
• Workstations must have security features to prevent unauthorized individuals from accessing or viewing the EHR. These security measures include:
  • Unique strong network passwords for each staff member
  • Monitor filters, privacy screens, or privacy filters, which allow visualization of the information only to those directly in front of the screen
  • Network log-out procedures

Technical Safeguards

Technical safeguards focus on protecting the ePHI through the use of technology, policies, and procedures. Technical safeguards include:

• Using audit trails, which record a user’s activity in the software.
• Using authentication, which is a process of confirming the person logging into the computer. This may include behavioral biometrics such as voice, signature, or keystroke recognition. It may also include physiological biometrics such as facial, fingerprint, iris, or hand geometry recognition.
• Monitoring the log-in process and identifying if multiple login attempts are being made. This can indicate an unauthorized person is attempting to get into the network or EHR.
• Having the computer automatically log-off the network or EHR after a period of inactivity.
• Backing up the network at least once a day. The data backup process means the network files are copied and the copy of the files are stored offsite. If a disaster, cyberattack, or other type of situation occurs that impacts the integrity of the network files, the copied files can be used to restore the network.
• Using encryption software, which changes the ePHI to non-readable or encrypted data (ciphertext). To read the information, the user needs to enter a password for the decryption to occur.
• Using a firewall, which is hardware or software that act as a filter between the internet and the network. Firewall protects what data from the internet can enter the network.
• Installing and using antivirus, anti-malware, or virus protection software to identify and remove malware from the network.

Health Information Technology for Economic and Clinical Health Act

The Health Information Technology for Economic and Clinical Health (HITECH) Act was passed in 2009 as part of the American Recovery and Reinvestment Act.  This law is enforced by the U.S. Department of Health and Human Services (HHS) Office for Civil Rights (OCR).  The HITECH Act helped to enforce HIPAA by:

• Increasing the penalties for privacy and security violations. The penalty increases based on the gravity of the violation. Penalties range from $100 to 1.5 million per calendar year. Healthcare facilities or businesses and individuals can be penalized and fined.
• Making healthcare facilities or businesses personally liable for compliance with HIPAA.
• Selling a patient’s PHI without their written authorization is prohibited.

Learning Activities