You are the project manager for the health information exchange (HIE) project within your organization. You have been tasked with creating a presentation on privacy and security practices within the HIE for the workforce that will be using the HIE. Based on the recommendations from the textbook on training requirements for HIE use within an organization, create a slide deck presentation that provides training and education on the use of the HIE as it relates to privacy and security of PHI.
As the new HIM supervisor, one of the areas of responsibility is the release of information department. Upon reviewing the releases being processed through the department, it was determined that the release of information staff do not understand the basic requirements of an authorization and what makes an authorization valid. You are responsible for educating the release of information staff on what must be filled out on an authorization to make it valid.
a. Determine the main elements that must be completed on the authorization to make it valid and the six reasons an authorization would be considered defective.
The organization that you work for just concluded an investigation of a USB thumb drive that was lost and contained a file with the information of 765 patients on it, including their name, address, telephone number, and Social Security number. As the privacy officer, you are required to manage the notification process for the data breach. Complete the following as it pertains to the above data breach:
a. Describe who would need to be notified of the data breach based and the timeline for the notification requirement.
b. Compile a list of what should be included in the letter to send to the individuals impacted.
Slide 2: HIE: The New Standard of Care
Objective: Understand the legal and ethical necessity of protecting patient information within the HIE.
What is an HIE? A secure electronic network that allows healthcare providers to share patient Protected Health Information (PHI) across different systems and organizations.
The Power: Improves continuity of care, reduces duplicate tests, and supports rapid treatment decisions.
The Responsibility: Every user is a data steward. Increased access means increased responsibility for privacy and security compliance under HIPAA and organizational policy.
Slide 3: Core HIE Privacy Principle: Minimum Necessary
Training Requirement: Reinforce the "Minimum Necessary" standard.
The Rule: When accessing, using, or disclosing PHI for treatment, payment, or healthcare operations, you must make reasonable efforts to limit PHI to the minimum necessary amount to accomplish the intended purpose.
HIE Application: Do not browse records "just in case." Only access the specific parts of the patient record you need for your current role and task (e.g., if you only need lab results, don't view mental health notes).
Key Distinction: The Minimum Necessary rule generally does not apply to disclosures among providers for treatment purposes, but it remains the ethical standard for access and use within the HIE.
Slide 4: Security Protocols: Protecting the HIE Gateway
Training Requirement: Educate on security safeguards for HIE access.
Unique User IDs & Strong Passwords: Never share your login credentials. Your access is your digital signature; you are accountable for all actions taken under your ID.
Regular Password Changes: Follow the organization's policy (e.g., every 90 days).
No Unauthorized Access: Do not access the HIE for curiosity, research unrelated to your duties, or for family/friends' information (Snooping is a terminable offense).
Secure Workstations: Always log off the HIE when stepping away from your terminal to prevent unauthorized access.
Slide 5: Patient Rights & Consent (Opt-In vs. Opt-Out)
Training Requirement: Explain patient rights regarding data sharing.
Patient Control: HIPAA grants patients the right to control their PHI. The HIE operates under a specific consent model, which varies by state, but our organization follows the Opt-Out Model (most common).
Opt-Out Model: Patient information is included in the HIE unless the patient explicitly states they do not want their data shared.
CRITICAL WORKFLOW: Always check the patient's record at registration/check-in for a "Do Not Share" or "Restriction" flag. If a patient has opted out, you MUST NOT access or share their data via the HIE.
Restriction Requests: Patients have the right to request a restriction on the sharing of certain information (e.g., a specific mental health encounter). You must be aware of and abide by these restrictions.