HIPAA: Health Insurance Portability and Accountability Act

This initiative is designed to bolster healthcare providers' adherence to the Health Insurance Portability and Accountability Act (HIPAA) mandates, which are paramount for the protection and confidentiality of patient information. Amid the evolving healthcare landscape, this program addresses the complexity of HIPAA regulations, critiqued for their intricate nature and the minimal perceived direct benefits by patients. Strategic revisions and elimination of certain regulatory components are underway, with the Office for Civil Rights (OCR) focusing on refining privacy notices to improve stakeholder comprehension.

The urgency for this training has been amplified by the evolving PHI landscape catalyzed by the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009, underscoring the importance of adopting electronic health records (EHRs) and enhancing the security and privacy of health information technology. This act has highlighted the critical need for healthcare professionals to be well-versed in HIPAA and HITECH regulations to navigate the digital transformation in healthcare effectively (American Recovery and Reinvestment Act of 2009, § 13001-13424).

In 2023, the Department of Health and Human Services (HHS) escalated its enforcement efforts against HIPAA violations, marking a notable increase in penalties from an average of $50,000 to $75,000, emphasizing the heightened financial consequences of non-compliance (Alder, 2024). This rigorous amendment process includes comprehensive reviews, stakeholder consultations, and detailed committee deliberations before approving changes.

Healthcare providers are obligated to proactively recognize and address potential breaches of HIPAA regulations to protect the integrity of patient data and minimize compliance risks. Additionally, healthcare providers need to comprehend the severe repercussions of HIPAA violations, which can lead to substantial fines or termination of employment (Alder, 2019b).

Healthcare professionals must comprehend key terms because the passage of HIPAA has created new language and abbreviations that must be mastered.

HIPAA is the Health Insurance Portability and Accountability Act of 1996. HIPAA is a federal law that gives individuals rights over health information. HIPAA is a set of rules that limits who can access health information.  The law contains two main sections: the privacy rule and the security rule. The security rule sets standards for protecting information (Tariq & Hackert, 2023). The Privacy Rule applies to all forms of individuals' protected health information, whether electronic, written, or oral (HHS, 2010).

• PHI is Protected Health Information that identifies a patient or client, including past, present, or future diagnoses, conditions, outcomes, care plans, and billing statements. Eighteen elements comprise PHI (Tariq& Hackert, 2023). PHI excludes individually identifiable health information in education records covered by the Family Educational Right and Privacy Act (U.S. Department of Education, 2012). Unused documents containing PHI should be shredded. Throwing PHI in the trash is never permissible.
• ePHI is Protected Health Information in electronic form. Examples include online billing systems, electronic medical records and reports, a server with health insurance enrollments, a case manager’s laptop with patient assessment records, patient scheduling calendars, and patient videotapes.
• IIHI is Individually Identifiable Health Information (IIHI) that can be linked to a patient or client, including demographics, social security numbers, diagnoses, zip codes, and email addresses.
• PTO is payment, treatment, and healthcare operations, which are the three areas where PHI can be disclosed. Treatment refers to providing, managing, and coordinating care. Payment includes various activities related to billing, utilization review, and coverage determination. Operations cover maintaining medical records, exchange of data for care coordination, and billing.
• A Privacy Officer is a HIPAA-required position for every organization that falls under the law (Moore & Fryre, 2020). Privacy officers play a pivotal role in ensuring the organization's compliance with privacy laws and regulations, such as the Health Insurance Portability and Accountability Act (HIPAA) in the United States, through developing and implementing policies and procedures, training and education, compliance monitoring, investigating, and reporting breaches, risk management, and more.
• A Security Officer is a HIPAA-required position for every organization that falls under the law (Moore & Fryre, 2020). Security officers are responsible for overseeing the development, implementation, and enforcement of security measures to protect electronic health information (ePHI) and ensure compliance with the HIPAA Security Rule.
• A Business Associate is a business associate, entity, or person with access to a covered entity's Protected Health Information (PHI) or ePHI. This written document outlines each party’s responsibilities to protect PHI. Examples include companies that process claims for hospitals or physician practices, utilization review companies, case management companies, medical transcriptionist companies, and quality improvement organizations.
• Business Associate Agreement (BAA) is a legally binding document required by the Health Insurance Portability and Accountability Act (HIPAA) of 1996 that sets forth the safeguards that a business associate must implement to protect electronic Protected Health Information (ePHI) when it is handled, transmitted, or processed on behalf of a covered entity or another business associate. The agreement ensures that business associates comply with HIPAA's privacy and security rules and the HITECH Act’s provisions regarding the confidentiality and security of protected health information.
• Office of Civil Rights (OCR) is a branch of the Health and Human Services Department (HHS) that investigates HIPAA allegations and imposes fines and penalties.
• A Covered Entity is any business or individual with access to Protected Health Information (PHI). Covered entities include health plans, case management companies, medical research organizations, medical record copy services, and billing companies.
• Risk Analysis/Assessment is an entity’s written assessment of the potential risks and vulnerabilities to its protected data's confidentiality, integrity, and availability. A risk management plan outlines protections and measures to countermand risks. Both the risk analysis and risk management plans are cost-effective compliance mechanisms.
• Technical Safeguards are electronic security measures that covered entities use to secure ePHI. This can include following policies and procedures that protect and control access to ePHI.
• Security Rules refer to the Security Standards for the Protection of Electronic Protected Health Information. Security Rules are found in 45 CFR Part 160 and Part 164, Subparts A and C.

Healthcare professionals will likely encounter many situations in their careers that can be potential or actual HIPAA violations. An analysis of nine scenarios provides examples of areas where HIPAA rules are violated or could be violated. Healthcare professionals must take proper action to ensure that patient's privacy is protected and that the risk of HIPAA violations for their organization is lowered.

You are a nurse in a bustling outpatient clinic linked to a prominent healthcare system. One day, your manager apprises you of an upcoming promotional campaign by a renowned pharmaceutical company in the clinic. The campaign aims to showcase their latest medication for a chronic condition, including filming patient consultations, interviews, and treatment procedures to highlight its efficacy. Your manager assures you that the company has completed HIPAA training and confidentiality agreements.

Expressing concern about patient privacy, you inquire whether patients will have the choice to consent to filming. Surprisingly, your manager dismisses your worries, highlighting the campaign's benefits for the clinic's reputation and patient education. However, you recall a recent incident where a similar campaign led to HIPAA violations and patient complaints in another clinic. You also remember that an ABC news documentary, Save My Life: Boston Trauma, resulted in large fines because patient permission was not obtained before filming. While the hospital administrators required that news crew members and reporters complete HIPAA training and sign confidentiality agreements, the Office of Civil Rights (OCR) said that all patients needed to give written consent and have the opportunity to withdraw consent at any time (Cotter, 2018; U.S. Department of Health & Human Services [HHS], 2018e). Again, you object.

Despite your reservations, your manager insists on proceeding with the campaign as planned, stressing the importance of maintaining positive relationships with pharmaceutical companies for future collaborations.

What should you do next?

Your options are:

1. Comply with your manager’s suggestions without saying another word.
2. Make an appointment with the hospital’s HIPAA privacy office.
3. Ask to see the consent forms that the patients have signed.
4. File a complaint with the OCR.
5. Send an email to the hospital administrator outlining the situation.

Option 1 may seem convenient to avoid conflicts with your manager and preserve workplace harmony. However, remaining silent risks involvement in potential HIPAA violations, resulting in monetary penalties and undermining patient trust (Alder, 2023).

Option 2 involves proactively seeking guidance from the hospital’s HIPAA privacy office. By scheduling an appointment, you can discuss your concerns with experts in patient privacy and receive ethical guidance. This would be your first course of action.

Option 3 could put you at odds with management, and your inquiry may be dismissed.

Option 4 entails a formal approach by filing a complaint with the OCR. While this may escalate the situation, it ensures regulatory authorities are aware of potential violations and can investigate further. This would be your second course of action should your appointment with the HIPAA privacy officer fail to spur an investigation.

Option 5 enables you to escalate the issue directly to higher management by emailing the hospital administrator. This demonstrates your commitment to upholding patient privacy and holding the clinic accountable for ethical standards. Talking is better than email; while you can make an appointment with the administrator, your first stop should be the privacy officer.

Your decision will influence patient care integrity and confidentiality within the clinic. Further, your decision to weigh the potential consequences of each option and prioritize patient privacy is crucial.

Your lunch break takes an unexpected turn in the bustling long-term care facility where you are employed as an occupational therapist. While enjoying your meal in the cafeteria, you overhear a troubling conversation among some employees from the housekeeping office. They seem to be discussing how they gained access to a neighbor's medical records through the facility's online system, which immediately raises red flags.

You are aware that as a covered entity, your long-term care facility is subject to HIPAA security rules (HHS, 2005). You recall that security rules must be reasonable and appropriate (HHS, 2019c). You remember that access controls must ensure authorized users only have access to the minimum necessary information to perform job functions.

As someone who has received training on HIPAA regulations, you understand the gravity of such breaches in patient confidentiality. HIPAA rules dictate that access to protected health information (PHI) should be restricted to only those individuals who genuinely require it for specific job-related purposes, referred to as “need to know,” such as treatment or operations. Information technology systems and security must be in place to ensure that housekeeping employees cannot access PHI or ePHI.

Given the situation, you are confronted with a dilemma:

1. Approach the housekeeping staff discreetly and inform them of their violation of HIPAA rules.
2. Report the incident to the company’s HIPAA privacy officer for further investigation (Alder, 2018).
3. Bring the issue to the attention of the housekeeping manager and direct her to take disciplinary action against the staff involved.
4. Disregard the matter and resume your lunch as if nothing happened.

Options 1, 3, and 4 are not appropriate.  As an occupational therapist, you cannot direct housekeeping staff.

Ignoring the situation is not an option, as it significantly risks exposing the organization to potential fines and penalties for HIPAA non-compliance. As a covered entity, the case long-term care facility must adhere to the minimum necessary standard by law, allowing employees access only to the data they "need to know" for their roles (HHS, 2019d). This necessitates implementing information technology and security measures to prevent unauthorized access to Protected Health Information (PHI) or electronic PHI by non-essential personnel, such as housekeeping staff (HHS, 2019d).

Option 2 - By escalating the matter to the company's HIPAA privacy officer, you ensure a thorough investigation and implementation of measures to prevent future breaches, reflecting a commitment to stringent access controls(HIPAA, 2019c).

Implementation measures maintain the organization's integrity and compliance with HIPAA. These include creating unique usernames for each employee’s entry into the computer systems, limiting access based on job roles, and employing encryption to protect patient information.

The investigation process outlines the specific access needs of various organizational roles. For instance, while physicians, nurses, rehabilitation professionals, and case managers might require comprehensive access to medical records, access should be restricted for those whose roles do not necessitate viewing patient records.

Learning from the resolution agreements of companies that have breached HIPAA rules helps us comprehend the critical nature of compliance. The case of Fresenius Medical Care of North America, which was fined $3.5 million for failing to secure patients' PHI, highlights the consequences of non-compliance. The Office for Civil Rights (OCR) required Fresenius to conduct a risk analysis, implement a risk management plan, revise access control policies, enhance encryption, and provide employee education on HIPAA policies and procedures, addressing issues of unauthorized access, data tampering, and theft (HSS, 2018c).

The Security Rule mandates Access Control Standards to prevent similar violations, including creating unique usernames to monitor access, adjusting visibility settings to limit access to necessary PHI, and establishing emergency access procedures. These standards, alongside automatic logoff features and encryption/decryption processes, are designed to minimize unauthorized PHI access and ensure digital protection of sensitive information (HSS, 2018c).

In 2023, the U.S. Department of Health and Human Services’ Office for Civil Rights (OCR) announced a settlement with iHealth Solutions addressing potential HIPAA violations following a data breach involving an unsecured network server containing the PHI and IIHI of 267 individuals. The breach highlighted the need for stringent cybersecurity measures to protect ePHI from unauthorized access.

The resolution agreement between HHS, OCR, and iHealth Solutions involves a payment of $75,000 by iHealth Solutions to OCR and implementing a corrective action plan (CAP). This plan requires iHealth Solutions to conduct a comprehensive risk analysis, develop and implement a risk management plan to address and mitigate identified security risks, evaluate environmental and operational changes affecting ePHI security, and update their written HIPAA policies and procedures accordingly. The CAP also requires iHealth Solutions to submit regular reports to OCR. It will subject iHealth Solutions to two years of monitoring by OCR to ensure compliance with the HIPAA Security Rule (HSS, 2023a).

This settlement underscores the critical responsibility of HIPAA business associates in maintaining the privacy and security of health information. It highlights the consequences of failing to implement adequate security measures, the importance of conducting thorough risk analyses, and management plans to protect ePHI from potential breaches.

You are a nurse manager at a reputable rehabilitation center specializing in comprehensive addiction treatment services. The facility is known for its commitment to patient care and privacy, offering support to individuals navigating the challenging journey of addiction recovery. One day, amid the clinic's bustling activities, a local news reporter contacts you, expressing keen interest in interviewing staff members and patients. The reporter wants to illuminate prevalent challenges associated with addiction recovery within the community and hopes to capture firsthand accounts of individuals undergoing treatment at the center. The reporter also wants to interview you about how nurses help recovering patients.

What should you do?

1. Politely decline the interview at the clinic and suggest meeting at a neutral location without patients.
2. Decline the interview and inform the HIPAA privacy officer about the request.
3. Direct the reporter to contact the Media Officer designated for the clinic.
4. Agree to the interview and arrange for patients to participate.
5. Ask patients if they want to do it first and request an honorarium.

Given the sensitive nature of patient information and the importance of HIPAA compliance, the most appropriate action is option 2, to decline the interview and promptly notify the HIPAA privacy officer. Alternatively, directing the reporter to the designated Media Officer for the clinic may also be appropriate to ensure adherence to privacy protocols, but it is not your first action.

The same rules apply to friends who are concerned about a patient. Private information should not be divulged to friends or visitors without the proper consent of the patient.

Your decision is guided by HIPAA regulations and previous instances where patient privacy was compromised. For example, a violation occurred when a healthcare provider disclosed patient information to the media without proper consent, resulting in significant repercussions and fines (HHS, 2016).

Upholding patient confidentiality and adhering to regulatory standards is paramount, even when facing media inquiries. By following proper procedures and promptly addressing potential breaches, you contribute to maintaining the trust and integrity of patient care within the rehabilitation center.

The settlement between the U.S. Department of Health and Human Services (HHS), Office for Civil Rights (OCR), and Saint Joseph’s Medical Center highlights the importance of patient privacy and adherence to the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule (HHS, 2023b). Saint Joseph’s Medical Center, a prominent non-profit academic medical institution located in New York, was found to have violated HIPAA regulations due to the unauthorized disclosure of COVID-19 patients' protected health information to a national media outlet (HHS, 2023b).

The OCR initiated an investigation following an article published by the Associated Press, which brought attention to the medical center's response to the COVID-19 public health emergency (HHS, 2023b). The article, accompanied by photographs and patient details, including diagnoses, medical statuses, and treatment plans, raised concerns about potential breaches of patient privacy laws.

OCR's investigation revealed that Saint Joseph’s Medical Center had disclosed the protected health information of three patients to the Associated Press without obtaining written authorization, thereby violating the HIPAA Privacy Rule (HHS, 2023b). According to the HIPAA Privacy Rule, healthcare providers are prohibited from disclosing such information to the media without explicit written consent from the patients or their legal representatives.

Saint Joseph’s Medical Center agreed to pay OCR $80,000 as part of 2019 the settlement agreement and committed to implementing an encompassing corrective action plan (HHS, 2023b). This plan includes the development of written policies and procedures aligned with the HIPAA Privacy Rule requirements. Additionally, the medical center pledged to conduct extensive training sessions for its workforce to ensure full compliance with HIPAA regulations.

Under the terms of the settlement, OCR will closely monitor Saint Joseph’s Medical Center for a duration of two years to ensure adherence to the corrective action plan, reoccurrence prevention, and continued compliance with HIPAA regulations (HSS, 2018a; 2021; 2022; 2023b). This enforcement action underscores OCR's commitment to safeguarding patient privacy and holding healthcare entities accountable for maintaining the confidentiality of protected health information.

Imagine you serve as a clinical administrator overseeing a network of outpatient clinics affiliated with a regional hospital system. As part of your role, you evaluate potential vendors for electronic health record (EHR) systems to streamline patient documentation and billing processes across the clinics.

Under the Payment, Treatment, and Operations (PTO) rule, companies can relay information to an internal or external billing office with a properly documented BAA on file. However, during your vendor selection process, you encounter the website of a reputable EHR software company known for its wide-ranging solutions and user-friendly interface. While exploring their website, you notice a section showing client testimonials and case studies. Reviewing a case study featuring a clinic like yours, you come across a document link labeled "Sample Patient Encounter Report."

Curious about how the software handles patient data, you click the link and discover that the sample report contains identifiable patient information, including names, dates of birth, medical record numbers, and diagnostic codes. Concerned about the potential exposure of sensitive patient data, you realize the severity of the situation and carefully consider your next steps.

What should you do?

1. Inform the EHR software company's administrator about the exposed patient information.
2. Report the unauthorized disclosure of patient data to the Office for Civil Rights (OCR).
3. Seek advice from your organization's HIPAA Privacy Officer to address the security breach and mitigate risks.
4. Document the incident and make a note to exclude the EHR software company from further consideration due to the exposed patient data.

The best option in this scenario would be to report the incident to the OCR, which will investigate it. You do not know this company or the officers; therefore, you must report the violation. When you report to the OCR, provide detailed information about the incident and your contact information for a follow-up investigation.A second option is to seek guidance from your organization's HIPAA Privacy Officer, who will likely tell you to report the incident to the OCR. The EHR software company is responsible for its actions and future risk mitigation efforts.

If you submit your complaint anonymously, the OCR might not investigate it. Most complaints can be filed online using the complaint portal assistant at the following website.

Those who need help filing a complaint can email the office at OCRMail@hhs.gov or call 1-800-368-1019.

The OCR can impose financial penalties for HIPAA violations that occur through negligence. This happened when ACH, a company providing contracted physicians to hospitals and nursing homes, hired a billing company. In early 2014, hospital personnel discovered patient names, dates of birth, and social security numbers exposed on the internet. Initially, ACH filed an OCR breach notification report testifying that 400 patients were affected. After further investigation, ACH filed a supplemental breach report, avowing that an additional 8,855 patients could have been affected (HHS, 2018d).

The OCR examination revealed the following:

1. ACH shared protected health information with a vendor without a Business Associate Agreement (BAA) as HIPAA requires.
2. ACH lacked written HIPAA policies and procedures.
3. ACH did not conduct a risk analysis or implement security measures required by HIPAA rules.

A hospital's IT administrator recently uncovered unauthorized access to sensitive patient records by a former nursing staff member. Subsequent investigation revealed that the nurse, who had been laid off due to organizational downsizing, had been illicitly retrieving patient records without proper authorization. Additionally, it was discovered that the nurse had been monetizing patients' medical information by selling it to third-party entities for financial gain.

Consequences stemming from these actions may include:

1. Criminal repercussions: The nurse could face criminal charges for unlawfully accessing and disclosing patient information, potentially resulting in incarceration based on the severity of the offenses.
2. Civil liabilities: The hospital and affected patients might pursue civil litigation against the nurse to seek damages resulting from the unauthorized access and disclosure of their medical records.
3. Revocation of nursing credentials: The nurse's license may be revoked due to violations of patient privacy laws and breaches of healthcare professional ethics.
4. Monetary penalties: Regulatory bodies may levy substantial fines against the nurse for violating confidentiality agreements and patient privacy laws.

Case precedence was set when a former cardiothoracic surgeon, Zhou, who was fired from UCLA School of Medicine for performance issues unrelated to HIPAA, accessed the medical records of his supervisors, coworkers, and celebrities such as Arnold Schwarzenegger, Drew Barrymore, Leonardo DiCaprio, and Tom Hanks. The courts found that Zhou broke the rules to get back at those who terminated him. Zhou pleaded guilty. While he did not sell or misuse the information, he viewed the records illegally. Zhou was sentenced to 4 months in federal prison for the HIPAA violation (Federal Bureau of Investigations, 2010). The nurse researcher went one step further than Zhou because she sold the information for personal monetary gain.

While not quite as severe, another incident illustrates what can happen when an organization does not cease access to ePHI for a nurse or another medical worker who is no longer employed. A medical center’s information technology leader failed to stop access to ePHI after a hospital employee resigned and separated from service. The failure resulted in the former employee having access to the protected health information of 557 patients.

Additionally, the hospital used a Google-based patient scheduling calendar and did not have a business associate agreement with Google. The hospital paid $100 per patient in fines each time patient information was released inappropriately (HHS, 2018b).

You work as a nurse clinical researcher for a medical device company conducting trials in hospitals across different states. During a visit to a hospital in Texas, you realize that you misplaced your company-issued laptop, which contains detailed patient data and trial information. Despite retracing your steps, you cannot locate the computer.

What should you do?

1. Report the incident to your supervisor and the hospital's designated privacy officer immediately to initiate the protocols for handling a potential data breach.
2. Notify your company's IT department to remotely lock and track the tablet to prevent unauthorized access to sensitive patient information.
3. Collaborate with the hospital's IT security team to assess the extent of the data breach and identify any potential risks to patient privacy.
4. Provide full transparency about the incident to all relevant stakeholders, including patients enrolled in the trial, and offer appropriate support and resources.
5. Review company policies and protocols regarding the handling and safeguarding of sensitive patient data to prevent similar incidents in the future.

Your initial course of action involves promptly notifying your supervisor of the incident and the privacy officer of your medical device company. Both will provide guidance and ensure compliance with company policies related to potential or actual data security breaches. Subsequently, your privacy officer will contact HIPAA privacy officers associated with the hospital.

The business associate agreement will be reviewed since the medical device company is a business associate in this scenario. This document outlines the roles and responsibilities concerning protecting and managing sensitive patient information and ensuring alignment with HIPAA regulations (HHS, 2019d).

Consider a real-life scenario. A New York research institute paid a fine close to $4 million for a breach of research data. The data included 13,000 participants’ full names, addresses, dates of birth, medical diagnoses, laboratory test results, prescribed medications, medical study particulars, and social security numbers. The breach occurred when an unencrypted laptop was left in full view on the backseat of an employee’s automobile and was stolen (HHS, 2016).

Another research center, this time in Texas, suffered a similar fine and breach. Unencrypted data for 33,500 research patients were exposed when an unencrypted laptop and two flash drives were stolen.

In both cases, the following violations occurred:

1. The absence of technical safeguards by the research institute to prevent data theft and unauthorized individuals from accessing ePHI (HHS, 2019d).
2. Lack of policies and procedures governing removing equipment used to store ePHI (HHS, 2019e).
3. Failure to encrypt data or use another reasonable security measure to safeguard it (HHS, 2019f).

Since many healthcare professionals collect research data and may carry laptops into patient homes, hospitals, or clinics, they must adequately safeguard the data. Proper safeguarding measures mean locking briefcases and coding patient data, using numbers or coding instead of names. Company laptops should be stored in a secure room or cabinet when not in use.

You work as a physical therapist at a reputable rehabilitation center in Los Angeles. Despite undergoing HIPAA training during your initial onboarding a decade ago, you have not received any refresher courses. One day, a well-known public figure is admitted to the rehabilitation center for speech therapy following a recent accident. Intrigued by the celebrity presence, you succumb to curiosity and access the individual's medical records without a legitimate "need to know." Later, during a casual conversation in the break room, you inadvertently disclose details from the patient's chart to a colleague. Concerned about potential repercussions, your colleague promptly reports the incident to the facility's Privacy Officer by calling the compliance hotline.

In response to the report, your supervisor will likely take decisive action to address the HIPAA violation. This could entail placing you on probation with a closely monitored corrective action plan to ensure adherence to hospital policies and HIPAA regulations. As part of the corrective action plan, additional HIPAA training sessions may be scheduled, and your activities may be closely supervised to prevent future breaches of patient confidentiality.

Given the severity of the violation, the Privacy Officer may suspend you from your duties or even terminate your employment. Alternatively, they might implement a probationary period with strict monitoring to track your compliance with privacy protocols. While the patient may become aware of the breach, it is important to note that HIPAA violations do not typically result in private lawsuits against individual healthcare providers.

This situation underscores the importance of ongoing HIPAA training and the necessity for healthcare professionals to always adhere to strict guidelines regarding patient confidentiality (HHS, 2023b).

This scenario is similar to a situation at Chicago Northwestern Memorial Hospital, where at least 50 employees reviewed an actor’s medical records without the “need to know” his condition (Alder, 2019a; Quraishi, 2019).

The consequences of healthcare professionals violating HIPAA are many, including any or all of the following:

1. Being reported to your professional board and facing disciplinary actions
2. Employment discipline
3. Employment termination
4. Fines and penalties

Disciplinary action by a Board of Nursing for a HIPAA violation can be stiff. For example, when Martha Smith-Lightfoot, a nurse practitioner, left employment at the University of Rochester Medical Center (URMC), she took a detailed spreadsheet of 3,000 patients with PHI to her new employer. She did this without the consent of the patient or her employer. The breach was discovered when several patients complained about being contacted by Martha’s new employer. The New York Board of Nursing imposed a one-year suspension and three years of probation for Smith-Lightfoot. In addition, the New York Attorney General fined URMC and instituted a detailed corrective action plan, which included a policy review and further training (Donovan, 2018; Wofford, 2019).

Imagine you work at a community health clinic, and many of your colleagues are also your friends on Instagram. One day, you come across a series of posts by a coworker detailing a patient's struggles with a rare medical condition. The posts provide detailed information about the patient's age, symptoms, family dynamics, and the care received at your clinic. Despite not mentioning the patient's name, the posts identify the clinic, the specific unit, and the healthcare professional who originated the posts.

What is your initial step?

1. Contact the coworker who made the posts and request their removal.
2. Print the posts and bring them to the clinic's HIPAA Privacy Officer.
3. Unfollow the coworker and deactivate your Instagram account.
4. Report the incident to your state's medical board.
5. Take no action since the coworker did not disclose the patient's name.

The most appropriate response is to print out the posts and bring them to the clinic's HIPAA Privacy Officer. Printing the posts ensures that they are documented and can be reviewed. This action prioritizes protecting patient privacy and ensures compliance with HIPAA regulations.

Consider the adverse outcomes when healthcare providers post about their patients on social media. Even though the patient names may not be mentioned, other information could link the post to the case.

For example, one nurse posted about a child who became extremely sick with measles. The child had not been vaccinated, which is unusual in the community. While the nurse did not post the child’s name, she gave enough details so that others could identify the family. Because of her post, the family got hate mail.

In addition to posting about the child’s condition, the nurse posted her opinions about parents who do not vaccinate their children. The nurse was suspended by the Board of Nursing and her employer while an investigation took place. During the suspension, she removed many of the posts. Eventually, she was fired for breach of privacy and unprofessional behavior (Alder, 2018; Morgan, 2018).

In 2021, a neonatal intensive care nurse working at Jackson Memorial Hospital was put on administrative leave and subsequently terminated after investigations into privacy violations revealed that she posted images of a newborn with a rare diagnosis of gastroschisis (Acevedo, 2021).

The lesson learned in these cases is that healthcare professionals should never post about patients or display their photos on social media and should never give their opinions about prevention or treatment.

Correspondingly, there might be instances where a patient reaches out to you via social media inquiring about their Protected Health Information (PHI), including test outcomes. However, it's crucial to remember that electronic PHI (ePHI) and PHI must not be communicated through unsecured channels like social media, regardless of the patient's request.

Nurse Jackson, who works in a lively city hospital's emergency department, receives a document that appears to be a subpoena demanding the release of medical records for a patient treated for a sensitive condition two months prior. The document, delivered via courier, lacks an official court letterhead, case number, and the signature of a judge or attorney. The request specifies detailed patient information, including treatment records, notes, and personal identifiers. Nurse Jackson recalls HIPAA training sessions emphasizing the importance of safeguarding patient information and becomes suspicious of the document's authenticity.

Her options are:

Option 1 - Nurse Jackson complies with the request immediately, fearing legal repercussions for not adhering to a subpoena.

Option 2 - She contacts the patient directly to inform them of the request and seeks permission to release the records.

Option 3 - Nurse Jackson disregards the document, considering its dubious appearance and lack of proper identification as sufficient reason to ignore it.

Option 4 - She consults the hospital's legal department to thoroughly review the document to verify its legitimacy and ensure compliance with legal and HIPAA requirements.

The most appropriate course of action for Nurse Jackson is option 4 (HHS, 2022). Consulting the hospital’s legal department ensures that any response to the subpoena is legally sound and HIPAA-compliant. The legal team can quickly ascertain the document's authenticity, advise on the proper course of action, and take necessary steps to protect the patient's privacy and the hospital's compliance with the law. This approach safeguards patient information and ensures that the nurse and the hospital do not inadvertently engage in illegal or unethical behavior by releasing sensitive information improperly.

Under HIPAA regulations, healthcare providers must protect patient health information (PHI) with stringent measures. HIPAA provides clear guidelines surrounding subpoenas to ensure that PHI is disclosed only following the law. Not all subpoenas qualify for the release of medical records without explicit patient authorization. For a subpoena to compel the disclosure of PHI without patient consent, it must be a court-ordered subpoena or comply with specific requirements that protect the patient's privacy (45 CFR 164.512(e)). These requirements include demonstrating that reasonable efforts have been made to notify the patient of the request or to secure a qualified protective order for the information (HHS, 2022).

Healthcare providers must scrutinize subpoenas to ensure they meet HIPAA standards and are issued by a court or a legally authorized entity. Questionable subpoenas should raise immediate red flags, prompting nurses to seek legal counsel. This protective measure ensures that any release of PHI complies with legal requirements and upholds the patient's right to privacy. Legal departments or privacy officers within healthcare facilities play a crucial role in this process, offering expertise in verifying the legitimacy of such requests and guiding appropriate responses.

This diligence in handling subpoenas reflects the broader commitment required under HIPAA to protect patient information against unauthorized disclosure. Ensuring that subpoenas stand up to HIPAA's privacy rules is essential to maintaining trust between patients and healthcare providers, reinforcing the integrity of the healthcare system's commitment to confidentiality and legal compliance.

1. Healthcare Professionals should never comment on social media about patients or their conditions. Even if the patient’s name is not used, information such as the rarity of the disease or other information could make it possible to identify the patient.
2. Organizations must develop security systems to ensure employees have access to protected health information on a “need to know” basis. Policies need to be written and audited to ensure access management. Healthcare professionals must be aware of these policies and follow them consistently.
3. Companies must perform risk assessments to ensure compliance with HIPAA.
4. Failure to perform a risk assessment can lead to a breach deemed as “willful neglect,” which carries high monetary fines.
5. Procedures must be established, enforced, and audited to safely handle PHI and ePHI within institutions and data maintained on laptops. Healthcare professionals must follow all privacy protection procedures and report others that do not.
6. Healthcare professionals may use laptops or tablets in their work. Laptops or any device with ePHI must be encrypted. Professionals need to store equipment containing ePHI according to company policy.
7. The OCR can impose financial penalties and institute compliance plans for HIPAA violations for healthcare professionals and organizations.
8. HIPAA rule violators pay fines and must comply with corrective action plans, which are reviewed and monitored by the OCR and/or the Board of Nursing.
9. Under HIPAA, covered entities must secure a business associate agreement with all vendors with patient data access. A healthcare professional working for a business associate must be well-informed about protecting PHI and ePHI.
10. Employee access to PHI and ePHI must be revoked after employment ends.
11. Anyone who files an OCR complaint and wants action to be taken should provide a name and contact information.
12. Healthcare professionals may file complaints about HIPAA rule violations with the OCR. Most complaints can be filed online using the OCR complaint portal assistant.
13. Healthcare organizations cannot retaliate against individuals who report a HIPAA violation in the workplace.
14. HIPAA training should occur during the onboarding process for new employees and annually for all employees to ensure compliance, although there is no regulation mandating annual education.
15. The scenario with Nurse Jackson emphasizes the critical need for healthcare professionals to verify the authenticity of subpoenas and consult with legal experts to ensure compliance with HIPAA regulations, safeguarding patient information, and adhering to legal and ethical standards.

The primary purpose of the HIPAA law is to protect patients and healthcare clients from unauthorized or inappropriate use and access to their health information by instituting multiple processes and safeguards. Throughout this course, you explored scenarios surrounding potential breaches of HIPAA regulations and patient privacy within healthcare settings. Here are the main points discussed:

1. PHI encompasses all forms of patient information, while ePHI specifically refers to electronic information.
2. HIPAA Violations: Various situations highlighted unintentional or intentional breaches of HIPAA rules by healthcare professionals, including unauthorized access to protected health information (PHI) and inappropriate disclosure of patient data.
3. Consequences: Violating HIPAA regulations can lead to severe repercussions such as legal actions, hefty fines, loss of professional licenses, and disciplinary measures by regulatory bodies.
4. Reporting Procedures: Clear reporting channels are vital for addressing suspected or confirmed HIPAA violations. Healthcare professionals should promptly report incidents to supervisors, HIPAA Privacy Officers, or relevant regulatory authorities to ensure compliance and protect patient confidentiality.
5. Training and Education: Ongoing training and education on HIPAA regulations and privacy protocols are essential for healthcare staff to understand their obligations and prevent inadvertent breaches of patient confidentiality.
6. Privacy and Confidentiality: Maintaining the privacy and confidentiality of patient information is of utmost importance in healthcare. Professionals must adhere to strict protocols to safeguard patient data and prevent unauthorized access or disclosure.
7. Ethical Considerations: Upholding ethical standards is crucial, and healthcare professionals must prioritize patient confidentiality over personal curiosity or convenience.

Compliance with HIPAA regulations and protecting patient privacy are fundamental responsibilities in healthcare practice. Achieving this requires diligence, vigilance, and adherence to established protocols and ethical guidelines.

• Acevedo, N. (2021, October 2). Florida nurse fired after posting photos of baby born with birth defect on social media. NBC News. Visit Source.
• Alder, S. (Ed.). (2018, September 13). Texas nurse fired for social media HIPAA violation. HIPAA Journal. Visit Source.
• Alder, S. (Ed.). (2023, December 1). What to do if you discover a HIPAA violation in the workplace. HIPAA Journal. Visit Source.
• Alder, S. (Ed.). (2019a, March 8). Dozens of Northwestern Memorial Hospital employees fired for accessing Jussie Smollett’s medical records. HIPAA Journal. Visit Source.
• Alder, S. (Ed.). (2019b, January 3). Summary of 2018 HIPAA fines and settlements. HIPAA Journal. Visit Source.
• Alder, S. (Ed.). (2024, January 6). New HIPAA regulations in 2023-2024. HIPAA Journal. Visit Source.
• American Recovery and Reinvestment Act of 2009, Pub. L. No. 111-5, § 13001-13424, 123 Stat. 115 (2009).
• Cotter, S. P. (2018, September 21). ABC News documentary leads to HIPAA violation fines against Boston hospitals. Boston Herald. Updated November 8, 2019. Visit Source.
• Donovan, F. (2018, June 11). New York suspends nurse for HIPAA violation affecting 3K patients. Intelligent Healthcare Media. Visit Source.
• Federal Bureau of Investigation. (2010, January 8). Ex-UCLA healthcare employee pleads guilty to four counts of illegally peeking at patient records. Federal Bureau of Investigation. Visit Source.
• Moore, W., & Frye, S. (2020). Review of HIPAA, Part 2: Limitations, rights, violations, and role for the imaging technologist. Journal of Nuclear Medicine Technology, 48(1), 17–23. Visit Source.
• Morgan, S. (2018, August 29). Texas Children’s Hospital nurse fired after social media post. Fox 26 Houston. Visit Source.
• Quraishi, A. (2019, March 8). At least 50 Northwestern Hospital employees fired for accessing Smollett’s profile, records: sources. NBC Chicago. Visit Source.
• Tariq, R. A., & Hackert, P. B. (2023). Patient confidentiality. In StatPearls. StatPearls Publishing. Visit Source.
• U.S. Department of Education. (2012). Family Educational Right and Privacy Act regulations (FERPA). Federal Registry, 34, Subparts S and B. Codified at 34 CFR §§ 99.1 - 99.8.
• U.S. Department of Health and Human Services. (2005). 4 Security standards: Technical safeguards. Visit Source.
• U.S. Department of Health and Human Services. (2010). Public welfare: General provisions and procedures for hearings. Federal Registry, 2, Subparts A and E. Codified at 45 CFR §160.
• U.S. Department of Health and Human Services. (2016, March 17). Improper disclosure of research participants’ protected health information results in $3.9 million HIPAA settlement. Visit Source.
• U.S. Department of Health and Human Services. (2018a). Allergy practice pays $125,000 to settle doctor’s disclosure of patient information to a reporter. Visit Source.
• U.S. Department of Health and Human Services. (2018b). Colorado hospital failed to terminate former employee’s access to electronic protected health information. Visit Source.
• U.S. Department of Health and Human Services. (2018c). Five breaches add up to millions in settlement costs for entity that failed to heed HIPAA’s risk analysis and risk management rules.Visit Source.
• U.S. Department of Health and Human Services. (2018d). Florida contractor physicians’ group shares protected health information with unknown vendor without a business associate agreement. Visit Source.
• U.S. Department of Health and Human Services. (2018e). Unauthorized disclosure of patients’ protected health information during ABC television filming results in multiple HIPAA settlements totaling $999,000. Visit Source.
• U.S. Department of Health and Human Services. (2019fa). Public welfare: Security and privacy. Federal Registry, 2, Subpart E. Codified at 45 CFR §164.514(d).
• U.S. Department of Health and Human Services. (2019b). Public welfare: Security and privacy. Federal Registry, 2, Subpart E. Codified at 45 CFR §164.502(b).
• U.S. Department of Health and Human Services. (2019c). Public welfare: Security and privacy. Federal Registry, 2, Subpart C. Codified at 45 CFR §164.306(b).
• U.S. Department of Health and Human Services. (2019d). Public welfare: Security and privacy. Federal Registry, 2, Subpart C. Codified at 45 CFR §164.310(c).
• U.S. Department of Health and Human Services. (2019e). Public welfare: Security and privacy. Federal Registry, 2, Subpart E. Codified at 45 CFR §164.310(d).
• U.S. Department of Health and Human Services. (2019f). Public welfare: Security and privacy. Federal Registry, 2, Subpart E. Codified at 45 CFR §164.312(a)(2)(iv).
• U.S. Department of Health and Human Services. (2021). HIPAA for professionals. Visit Source.
• U.S. Department of Health and Human Services. (2022). Summary of the HIPAA Privacy Rule. Visit Source.
• U.S. Department of Health and Human Services. (2023a, ). HHS Office for Civil Rights settles HIPAA investigation with iHealth Solutions regarding disclosure of Protected Health Information on an unsecured server for $75,000. Visit Source.
• U.S. Department of Health and Human Services. (2023b). HHS’ Office for Civil Rights settles HIPAA investigation of St. Joseph’s Medical Center for disclosure of patients’ protected health information to a news reporter. Visit Source.
• Wofford, P. (2019). Jussie Smollett case: 50 Hospital workers fired for alleged HIPAA violations. Visit Source.