Are you responsible for training staff on HIPAA compliance? If so, you know it can be a daunting task. There are so many regulations to remember, and new information is released all the time. But don't worry, we've got you covered. In this guide, we'll walk you through everything you need to know about HIPAA training. We'll cover topics like required content, methods of delivery, and how to keep your staff up-to-date on the latest rules. So whether you're just starting out or looking for ways to improve your current program, read on for tips and advice from the experts!
What is HIPAA?
HIPAA stands for Health Insurance Probability and Accountability Act 1996. It is a federal law that includes the standards to protect sensitive information related to patient health. It prohibits the disclosure of such information without the consent of patients. This act is further divided into two rules that are HIPAA Security Rule and HIPAA Privacy Rule.
HIPAA Privacy Rule
It deals with the privacy concerns of individuals' health information. The privacy rule went into effect on April 14, 2003. It addresses the use and disclosure of this information (protected health information PHI). PHI may include patients' demographics, physical or mental health conditions, patient's payment details, or any kind of patient's medical record. This information is used only by individuals or organizations authorized by patients which are also called covered entities (CEs). The patients have the right to control the use of their information and protect their well-being.
HIPAA Security Rule
This rule was made to protect the health information of patients that present as electronic data. This rule went into effect on April 21, 2005. It includes all the identifiable health information which are created by a covered entity, received, and transmitted in an electronic form. Such type of protected information is also known as electronically protected health information (e-PHI).
The HITECH Act 2010
HITECH is an acronym of The Health Information Technology for Economic and Clinical Health. It is a subset of the American Recovery and Reinvestment Act 2009. It was made to promote the adoption of secure use of health information technology. This act expands HIPAA privacy rule requirement to business associates (BAs) who will now be required to report to the covered entities.
Omnibus Rule 2013
It is another regulation that affects HIPAA Privacy and security rule and HITECH. It implements new regulations.
Breach Notification Rule
This rule states that covered entities and business associates are required to notify about a breach within 60 days after its discovery.
What does HIPAA protect?
HIPAA protects different types of patient’s data. Written documents and all paper records including; prescriptions, X-ray, referral forms, encounter forms, progress notes, charts, etc.), Spoken, or verbal information including; in-person discussion, phone calls, voice mail messages.
Electronic database or any electronic information that includes research information, photographic images, audio or video recordings, patients protected health information stored on a computer, smartphone, memory card, USB drive, or any other electronic device.
HIPAA also involves the protection of computer hardware or electronic devices that contain protected health information in any form i.e., computer, laptops, PDAs, pagers, fax machines, servers, smartphones, etc.
What is the importance of HIPAA training?
There are many different types of covered entities and business associates that are involved in creating, receiving, analyzing, and transmitting the patient’s health information. So, HIPAA training is mandatory and required for the individuals and organizations which are dealing with patient’s health information. This training is necessary for all workforce in a healthcare organization to avoid any kind of breach of sensitive patient information.
HIPAA privacy and security training is important for individuals and organizations. It outlines the ways to prevent any accidental and intentional misuse of protected health information. Whenever an individual or organization comes in contact with a patient's information or any kind of protected health information (PHI), they become involved with some facet of regulations.
It is the requirement of the privacy and security rule to train ourselves and the employees. The training is important to ensure the understanding of HIPAA Privacy and Security Rules. It facilitates secure PHI with minimal impact to staff, business processes, and organization. The employees must be well trained and committed to managing electronically protected health information as it is their responsibility to keep it confidential.
Generally, it is thought that HIPAA protects patient's privacy and security. However, HIPAA training not only protects the patients' rights but also empowers the employees. Because if your company handles sensitive information about your clients then you are required by law to protect this information. The more you are compliant with HIPAA the more trust your organization will earn. This training will also show your efforts towards keeping your client’s information secretive.
The HIPAA training should be made mandatory for the employees. Continuous refresher HIPAA training programs should also be provided annually. It will help to revise the HIPAA training content periodically and update your employee about the new rules and regulations.
What should the training include?
There is no specified training material and duration provided by HIPAA. However, HHS has provided the training resources which can help to design the training course. The training should include the topics according to your work and exposure to the PHI. Some topics that the training must contain are discussed below.
What should we protect?
The training should educate the trainees that what is protected under HIPAA. It should identify all the sensitive patient health information (PHI) which comes under HIPAA.
Why are we protecting PHI?
The training should also provide the reasons for protecting PHI. The employees should know that it is always the patient’s choice to share their information or not. Sometimes medical identity theft may also occur due to a breach of PHI. Someone can use the medical identity of a patient and can submit false Medicaid or Medicare claims. It can lead to financial loss for taxpayers and can also disrupt quality care.
How can we protect PHI?
The training also must include what the law tells us about protecting the information. CEs or BAs should make efforts by ensuring the confidentiality, availability, integrity, of all ePHI they create, maintain or transmit. They should identify and protect ePHI against anticipated security or integrity threats. Any anticipated, impermissible uses or disclosures of ePHI should also be protected. Compliance with HIPAA should be ensured by the workforce.
Employers should evaluate their HIPAA-compliant security and privacy training protocols and ensure their implementation. Risk assessments should also be performed. It will help to identify their weaknesses so that they can address and rectify them. The ultimate goal of HIPAA compliance training is to protect your patient and also fulfill the regulatory requirements. HIPAA training and annual refreshers can help you to achieve this goal and keep your employees up to date.
Who needs HIPAA compliance training?
HIPAA training is required for the individuals and organizations on which HIPAA regulations are applicable. These organizations are called in legislative terms as Covered Entities and Business Associates.
Covered Entities (CEs)
Covered Entities are the organizations that provide treatment to the patients, receive payments from them, and work for the provision of healthcare. Covered Entities are directly in contact with protected health information (PHI). Covered Entities may include; doctors, clinics, psychologists, hospitals, healthcare agencies, health insurance companies, healthcare clearinghouses. According to the Department of Health and Human Services (HHS), there are three categories of Covered Entities.
Healthcare providers
Healthcare providers are the individuals that transmit a patient's health information electronically. According to HIPAA, healthcare providers include; hospitals, clinics, doctors, nurses, psychologists, dentists, chiropractors, pharmacies, home healthcare agencies, nursing homes, and any other healthcare workers who have access to PHI. Healthcare providers are the covered entities who should receive HIPAA compliance training to maintain the privacy and security of protected healthcare information.
Healthcare clearinghouses
Healthcare clearinghouses work as a bridge between healthcare providers and insurance companies or payers. They check the medical insurance claims and ensure that they are correctly processed by the payers. These include; billing services, repricing companies, community health information systems, health management systems, etc. As these companies receive and transmit electronically protected healthcare information (ePHI) so they should be trained for HIPAA compliance.
Health insurance plans
These include health insurance companies, health maintenance organizations (HMO), Government health programs (Medicare, Medicaid, etc.). These companies are directly dealing with patient's financial information and their insurance plans so they should be HIPAA compliant and provide their staff regular training to prevent any PHI breach.
Business Associates (BAs)
Business associates help the covered entities to help them in carrying out their activities and functions for example; transcriptionists, cloud service providers, physical and electronic data storage companies, claim processors, pharmacy benefit managers, information technology companies, etc. Therefore, it’s the responsibility of covered entities to have a written agreement or contract with their BAs to comply with the provisions of HIPAA and its rules. To get HIPAA compliant the business associates should provide HIPAA compliance training to their staff on a regular basis.
According to the law, all the covered entities and their business associates should provide HIPAA compliance training to their staff at regular intervals, and perform a risk analysis to check the effectiveness and gaps in compliance. They are required to get HIPAA compliant to prevent any PHI breach or HIPAA violation. HIPAA violation can result in monetary to criminal penalties and may cost the loss of trust and credibility of the organization.
Health Insurance Probability and Accountability Act 1996 (HIPAA) is a law that requires the protection of sensitive patient data. HIPAA training provides awareness and knowledge about the requirements of HIPAA compliance. HIPAA training for employees is intended to make them compliant with the law and protecting sensitive patient health information (PHI). Being a regulatory requirement each employee of a covered entity or their business associates is required to provide HIPAA training.
How to provide HIPAA Training to your employees
Training Medium
There are several ways and levels of HIPAA training. HIPAA training can be provided in person in an organization. Individual training can also be provided according to the specified role of employees in the organization. the organization can also provide training as a group if all the employees of the covered entity need a basic awareness. Some online training resources are also available you can also avail them if you have any issues related to in-person training.
Objectives of HIPAA training
- To provide awareness and understanding in employees about HIPAA
- Introduction to HIPAA and its rules including a brief overview, main aspects, and objectives.
- Introduction to technical terms included in HIPAA such as covered entities, business associates, protected health information (PHI), etc.
- The responsibilities of covered entities and their business associates to protect PHI
- Patients right under HIPAA
- PHI uses and disclosure
- The reasons for protecting PHI
- Security awareness and the possible threats to privacy
- Consequences and penalties for non-compliance
When should we provide HIPAA training?
The HIPAA training should be provided to the employees immediately after hiring. The employee should be trained according to their work and exposure to PHI. After the first training refresher training sessions should be arranged for employees periodically. These sessions will help them to revise the concepts and update them about the new laws and requirements. A training policy should be designed about how frequently these refresher training should be provided. The law has not provided any duration for refresher training. Ideally, the refresher HIPAA training should be provided on annual basis.
Risk Analysis
Whenever there is a change in policies, processes, or electronic devices, the analysis should be performed. It will show the impact of the new policy, process, or system on the HIPAA compliance of the organization. If the impact is assessed then additional training should be provided to the employees.
Dos and don’ts of Training
- Training should be comprehensive and short so that employees can retain the knowledge.
- Short training sessions after a short period are better than a long training session. It will help employees to learn about different aspects of law and compliance.
- Regular refresher training sessions should be arranged. Employees should be kept updated about the rules.
- Employees should be informed about the consequences of a breach. It will help understand the importance and need for HIPAA compliance.
- Refresher training should be provided to all levels of employees. Everyone should be reminded and updated about HIPAA compliance.
- Training content must be concise and engaging. Employee’s involvement and questions must be appreciated.
How long does it take to do HIPAA Training?
The amount of time needed for HIPAA compliance training will depend on the size and complexity of your organization. Generally, however, most companies spend around providing basic HIPAA training to employees. This may include an introduction to HIPAA basics, patient rights and responsibilities under HIPAA, PHI uses and disclosures, the need for PHI protection, threats to PHI security and privacy, the consequences and penalties for non-compliance, and key objectives of HIPAA compliance training. If your organization has a more complex or specialized regulatory environment then you may require additional time for your training initiatives. Additionally, depending on the size of your organization, you may also need to provide ongoing refresher courses every so often.
How can I best ensure my employees complete HIPAA Training?
In order to best ensure that your employees have completed their HIPAA training, it is important to design a comprehensive and effective training program that meets the needs of each employee. This may include providing an online training course or e-learning modules in addition to live instruction and discussion. Additionally, you can provide incentives for employees to complete the training and emphasize its importance as part of your organization’s culture. Lastly, it is also important to keep track of who has completed their HIPAA training and when they have done so in order to ensure that all relevant personnel are up-to-date on compliance requirements.
What to cover in your HIPAA training
Whether your employees work on the front line of healthcare, or your organization handles patient data in an office environment, you’ll need to provide HIPAA awareness training.
Not only is HIPAA training required by law, but it’s also vital for protecting your business from expensive lawsuits and data breaches. Regardless of how large your business is, you need to provide regular HIPAA training to ensure every employee stays up to date with the latest rules and regulations updates.
But what, exactly, should your HIPAA awareness training achieve? Here are the nine key things you need to cover in your training program.
Awareness of HIPAA
First of all, every employee must understand what the Health Insurance Portability and Accountability Act is. You can’t assume that new hires will have undertaken HIPAA compliance training before, so you must explain why this training is mandatory. You should also explain that after their initial training, employees will be expected to complete refresher training throughout their careers.
HIPAA and its Rules
Once your employees have context, you can begin to explain the reason why HIPAA is vital in a healthcare setting. At this stage, you should introduce the concept of patient health information, why it needs to be protected by data privacy laws, and the potential consequences a lack of compliance may have. The primary HIPAA Rules are:
Privacy Rule
The HIPAA Privacy Rule protects the privacy of individually identifiable health information. The rule covers various mechanisms by which an individual is identified, including date of birth, social security number, driver's license or state identification number, telephone number, or any other unique identifier.
Additionally, the covered entity cannot use the information for purposes other than those for which it was collected without first providing patients with a clear notice informing them of their right to opt-out of such use and how they may do so.
Security Rule
The HIPAA Security Rule requires that all covered entities have procedures in place to protect the integrity, confidentiality, and availability of electronic protected health information.
Protected Health Information is defined as:
"individually identifiable health information electronically stored or transmitted by a covered entity."
That includes "all forms of technology used by a covered entity that are reasonably likely to contain records that are protected health information."
The Security Rule also provides standards for ensuring that data are properly destroyed when no longer needed.
Additionally, the rule provides for sanctions for violations of provisions within the Security Rule.
Breach Notification Rule
The HIPAA Breach Notification Rule requires that covered entities report any incident that results in the "theft or loss" of e-PHI to the HHS Department of Health and Human Services, the media, and individuals who were affected by a breach. The HHS Office for Civil Rights investigates all complaints related to a breach of PHI against a covered entity.
HIPAA’s Technical Terms
HIPAA covers a very specific subset of data privacy. So, you need to give your employees a glossary of terms and HIPAA rules they’ll need to know as part of their HIPAA compliance training. The main terms you should cover and explain are:
- Covered entity
- Business associates
- Protected Health Information (PHI)
Covered Entities
In HIPAA, a covered entity is defined as:
"A health plan, a health care clearinghouse or a health care provider who transmits any health information in electronic form in connection with a transaction referred to in section 1173(a)(1) of the Social Security Act." (An electronic transaction is one the U.S. government defines as "Any transmission between computers that uses a magnetic, optical or electronic storage medium." Read here for more information.)
HIPAA also stipulates that an organization does not have to be in the health care industry to be considered a covered entity - specifically, it can include schools, government agencies, and any other entity that transmits health information in electronic form.
Business Associates
A business associate is defined as:
"A person who creates, receives, maintains or transmits any health information on behalf of a covered entity and whose activities involve:
1) The use and/or disclosure of protected health information;
2) Performing functions or activities regulated by HIPAA;
3) Designing, developing, configuring, maintaining or modifying systems used for HIPAA-regulated transactions."
PHI
PHI stands for "protected health information" and is defined as:
"Individually identifiable health information that includes demographic data, medical history, mental or physical condition, or treatment information that relates to the past, present or future physical or mental health of an individual."
The HITECH Act defines PHI specifically as:
"(1) Individually identifiable health information that is transmitted by electronic media;
(2) Individually identifiable health information that is transmitted or maintained in any medium described in paragraph (1); and (3) Individually identifiable health information that is created or received by a health care provider, health plan, employer, or health care clearinghouse."
The HITECH Act expanded PHI to include information that does not meet the HIPAA definition of PHI but relates to the health, welfare or treatment of an individual.
PHI and Associated Responsibilities
Given that your company is a covered entity under HIPAA, you’ll need to explain the role that PHI plays in your business and what responsibilities your employees have to keep that information secure. This should include how much PHI your company’s business associates can access, and the responsibilities that your business associates have in handling that data.
Patients’ Rights and HIPAA
Under HIPAA, patients have the right to see and request copies of their PHI or amend any records in a designated record set about the patient. They also have the right to request that data is sent to a designated person or entity.
Covered entities can only deny these requests in very specific and rare circumstances, so your employees need to fully understand the HIPAA Right of Access clause and how it applies to your organization.
PHI Uses and Disclosures
HIPAA only permits for PHI to be disclosed in two specific ways. The first is under the Right of Access clause, as mentioned above. The second is if the Department of Health and Human Services (HHS) requests it as part of an investigation or enforcement action.
In addition, PHI can only be used without the patient’s consent if it’s needed for treatment and healthcare operations, or it’s being used to determine payment responsibilities.
As such, every employee should receive HIPAA compliance training in their specific job area regarding how they can access data and who is responsible for handling disclosure requests.
The Need for PHI Protection
Once employees understand how PHI is protected, they need to understand why. This should cover the reasons why PHI is considered sensitive information, and, if applicable, case studies that demonstrate how unauthorized use of PHI can cause significant harm.
PHI Security Awareness and Privacy Threats
Not only do your employees need to understand general security awareness concepts, but they should also be aware that many cyber security policies, like using multi-factor authentication, are mandatory under HIPAA.
This part of your training should cover how PHI presents a privacy threat both for patients and your company. Because this data is highly sought after by cybercriminals, you should train employees about the importance of good cybersecurity practices and the responsibilities they have in keeping their workspace secure.
Consequences and Penalties
Finally, your employees need to understand what consequences and penalties they and your company may face for non-compliance.
With penalties carrying fines of up to $50,000 per violation or potential jail time and criminal charges for Willful Neglect charges, employees need to understand the different levels of infractions and how they can affect both themselves and the company.
At this stage, it’s a good idea to use case studies to demonstrate fines and penalties delivered to healthcare businesses and how these infractions are incurred. You should also emphasize to employees that they have the right to speak up if they feel that HIPAA is being violated within your business.
Key Objectives of HIPAA Compliance Training
With HIPAA being an extensive, yet vital part of any healthcare business, you need to make sure you’ve covered all of the bases in your compliance training. By focusing on these objectives, you can deliver meaningful and engaging HIPAA training to ensure your employees and your business stays on the right side of the law.
How do you get HIPAA Certified?
In order to become HIPAA certified, you must have completed a course of study and/or certification program that covers all aspects of the Health Insurance Portability and Accountability Act (HIPAA). Generally, this will include topics such as patient rights and regulations, PHI security and privacy, data handling protocols, business associate agreements, enforcement actions, and more.
Typically, organizations that offer HIPAA certification programs include universities, technical schools and private training providers. The courses offered will vary in length and depth of content depending on the provider, so it is important to research each program carefully to determine which best meets your needs. Additionally, many states require individuals who handle PHI for employers to be certified, so it is a good idea to check with your state licensing board to determine any specific certification requirements.
Once you have completed the program and obtained the necessary certification, you will need to keep abreast of all changes in HIPAA regulations and laws. Many organizations offer yearly recertification programs for a HIPAA compliance officer that wishes to maintain their certification status.
It is also important to note that in addition to obtaining HIPAA certification, organizations handling PHI must also have appropriate policies and procedures in place regarding the use, management, and disclosure of PHI. Additionally, employees must receive ongoing training on HIPAA regulations and other related topics as well as participate in regular reviews to ensure that the organization remains compliant with HIPAA regulations.
Ultimately, obtaining HIPAA certification is an important step for any organization handling PHI and will provide employees with the knowledge and skills necessary to protect confidential information. Doing so will also help ensure that businesses meet applicable legal requirements and maintain a safe work environment.
HIPAA Security Awareness Training
In addition to HIPAA awareness training that focuses on PHI, Patient rights, etc., healthcare employees should also undergo cybersecurity awareness training which focuses more on cyber threats within the workplace.
Security awareness training should be an ongoing process and include topics such as identifying potential threats, how to protect confidential data, best practices for using passwords and security software, and more. Training must also address different types of threats such as phishing emails, ransomware attacks, malicious downloads, etc. Additionally, it's important that employees regularly review their own privacy practices, such as keeping personal devices locked when not in use and refraining from clicking on suspicious links or attachments.
Security awareness training should also be tailored to the specific environment and roles of individual employees in order to ensure that they understand the importance of HIPAA regulations and how to properly protect sensitive data. By providing ongoing security awareness training, organizations can ensure that their employees have the knowledge and skills needed to protect sensitive information and remain compliant with HIPAA regulations.
HIPAA Training from Hook Security
By far the easiest (and most entertaining) way to get high-quality HIPAA training to your employees is through Hook Security.
Hook Security provides a complete toolkit for companies to create a security-aware culture, including phishing simulations, cyber security awareness training, and compliance courses like HIPAA training.
Through our lightweight LMS, employees can complete our online HIPAA training course in about an hour
Preview our HIPAA Training here or book a demo with us today to learn more
