Ensuring patient data protection, privacy, and security is essential for healthcare organizations and personnel, but is becoming increasingly pertinent as technology continues to evolve at a rapid pace.
The consequences of not adequately safeguarding and securing patient healthcare information are significant. It can lead to fines, reputational damage, or, in serious instances, a criminal case.
In this article, we outline five HIPAA violations and how you can avoid them.
HIPAA Rules Overview
The Health Insurance Portability and Accountability Act (HIPAA) of 1996 is a federal law safeguarding protected health information (PHI), which involves any information that can lead to the identification of a patient. The Department of Health and Human Services (HHS) published various rules under HIPAA that outline the handling, protection, and security of PHI.
The HIPAA Privacy Rule sets the standards for the protection of PHI. It defines how covered entities and business associates can appropriately use and disclose PHI. The main goal of the Privacy Rule is to ensure the protection of PHI without hindering the ability to provide high-quality healthcare.
The HIPAA Security Rule specifically focuses on the protection of electronic PHI (ePHI). All HIPAA-covered entities and their business associates are required to safeguard ePHI against threats to this information’s security.
The HIPAA Breach Notification Rule requires all HIPAA-covered entities and their business associates to inform patients when their unsecured PHI is impermissible, disclosed, or used in any way that compromises the security and privacy of this information.
The Enforcement Rule establishes procedures for investigations and hearings for violations of all the rules. It also specifies civil money penalties for HIPAA violations.
Covered entities and their business associates must follow these Rules to achieve and maintain HIPAA compliance.
What Is a HIPAA Violation?
A HIPAA violation is a failure to follow HIPAA Rules. It includes any action that results in the mishandling or unauthorized use of PHI.
Examples of Common HIPAA Violations
HIPAA violations span a wide range, from incidental to intentional breaches. Let's look at five common HIPAA violation categories and how to avoid them.
1. Failure to Secure and Encrypt Data
With the adoption of technology in healthcare, PHI has become an increased target of hacking, cyberattacks, and other breaches. Digital storage of patient records, telehealth, and devices and software that handle PHI are all susceptible to cyberattacks.
Failure to properly secure and encrypt data is the most common HIPAA violation, as intentional and accidental breaches can occur in many ways. Healthcare organizations mistakenly assume data encryption is unnecessary because HIPAA classifies it as “addressable” instead of “required.”
Examples of human error that may result in a data breach are listed below:
- Using unsecured messaging platforms to communicate with other providers
- Accessing patient files from an unsecured personal laptop
- Accidentally leaving patient files open on a screen in a public space and stepping away
- Downloading patient records onto unsecured mobile devices
Some best practices to protect data include encrypting all files that contain PHI, implementing two-factor authentication (2FA), and enforcing strict access controls. It’s also essential to always utilize secure communication platforms that meet HIPAA standards, such as HIPAA-compliant email for therapists or healthcare CRM software for medical providers.
2. Failure to Enter a HIPAA-Compliant Business Associate Agreement
When working with third-party organizations (business associates) that have access to PHI/ePHI, you are required to enter into a HIPAA-compliant Business Associate Agreement (BAA). A BAA outlines the responsibilities and expectations of the covered entity and business associate in handling PHI.
Once a HIPAA-compliant BAA is entered, the covered entity is liable for the business associate if they do not comply with HIPAA. Examples of some potential violations made by business associates include:
- Using or accessing PHI outside what is permitted in the BAA
- Neglecting to implement best practices to safeguard PHI
- Failing to notify their covered entity of a data breach involving PHI
- Failing to enter into a BAA with a subcontractor that will have access to PHI
The best way to avoid and protect your organization is to ensure you sign a BAA with every business associate as needed, all BAAs follow HIPAA standards, and the contracts are managed by trained staff.
3. Lack of HIPAA-Certified Employee Training
All covered entities are required to provide HIPAA-certified training to all relevant employees. A large number of unintentional violations occur due to human error. So, any employee that comes into contact with PHI must be thoroughly educated.
Examples of data breaches that may occur due to lack of training:
- Clicking on a phishing email
- Accessing PHI without a reason
- Sharing PHI with an unauthorized person
- Not maintaining the correct documentation required to be HIPAA compliant
HIPAA education and training should occur on the following basis:
- At least once per year
- During the onboarding and new hire process
- When organization security policies and procedures are changed or updated
- When an employee's job role and responsibilities change
- When HIPAA updates regarding security are released
Training and education best practices should be comprehensive to minimize the likelihood of an internal accidental or intentional breach and avoid penalties and fines.
4. Disclosing PHI on Social Media
Social media is a powerful tool for practitioners and healthcare organizations to communicate healthcare information to the general public. While there are no designated HIPAA social media rules, organizations subject to HIPAA and their employees must take care in how they utilize social media.
Common examples of social media HIPAA compliance violations include:
- Sharing photos or other forms of PHI without written consent from a patient
- Posting about patients on personal social media platforms, even if the patient's name is not disclosed
- Sharing seemingly innocent photos from work with a patient file in the shot
The best way to combat social media HIPAA violations is to establish best practices with detailed policies and procedures. Policies and procedures to ensure HIPAA compliance include:
- Specific guidelines that address both personal and professional use of social media
- Adequate employee training and education on company social media guidelines
- Periodic updates of these policies when new technology and circumstances occur
5. Denying Patients Access to Health Records
Although this is not a common HIPAA violation, denying a patient access to their health records is a major violation of HIPAA.
All providers are required to provide patients with their health records within 60 days of the patient requesting them. Any healthcare organization that does not comply and refuses patient access is liable to significant fines. This HIPAA violation occurs when a healthcare organization does the following:
- Charges patients extra for requesting copies of their medical records (more than the cost to obtain the records)
- Fails to complete the request for access to health records within 60 days.
- Denies (for any reason) a patient’s request for their medical records.
Conclusion
Grasping the intricacies of HIPAA is not merely a compliance requirement but a matter of ethical obligation towards patients. As physicians are entrusted with sensitive patient health information, it becomes your responsibility to ensure this information's security.
Uphold this trust and compliance by regularly reviewing HIPAA Rules, keeping abreast of updates and changes, and maintaining awareness of HIPAA-related news and violations.
From another perspective, a robust knowledge of HIPAA can considerably enhance employability. It is an essential asset in the increasingly complex arena of health information privacy. This could lead to various physician job opportunities, ranging from preferential hiring to faster career progression and potential salary increases.