The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a federal law that required the creation of national standards to protect sensitive patient health information from being disclosed without the patient’s consent or knowledge.
Privacy is critical to all healthcare providers, much especially for midwives. Our patient entrusts their lives to us that is why trust becomes a huge part of patient- midwife relationship that should not be neglected. Ensuring that all patient data are properly collected and well protected is our huge responsibility. It comes with patient confidentiality that is important for both patients and midwives, and it preserves the integrity of the midwifery community.
The U.S. healthcare system has never had a shortage of problems – it has always dealt with several issues simultaneously. The exorbitant prices, the lack of price transparency, medical identity theft cases, lack of patient identification in hospitals, preventable medical errors, and archaic laws are just some issues that plague healthcare. Healthcare data breaches have unfortunately been growing at an exponential rate. With no signs of them stopping anytime soon, it becomes crucial that healthcare providers, `professionals, and everyone involved with patient information be vigilant regarding protecting the data.
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a federal law that required the creation of national standards to protect sensitive patient health information from being disclosed without the patient’s consent or knowledge. This is as important to the healthcare industry now more than ever — if not more. Hospitals, insurance companies and healthcare providers all need to ensure HIPAA compliance to safeguard private and sensitive patient data.
HIPAA introduced a number of important benefits for the healthcare industry to help with the transition from paper records to electronic copies of health information. HIPAA has helped to streamline administrative healthcare functions, improve efficiency in the healthcare industry, and ensure protected health information is shared securely.
The HIPAA legislation had four primary objectives:
- Assure health insurance portability by eliminating job-lock due to pre-existing medical conditions.
- Reduce healthcare fraud and abuse.
- Enforce standards for health information.
- Guarantee security and privacy of health information.
The Privacy Rule standards address the use and disclosure of individuals’ health information (known as “protected health information”) by entities subject to the Privacy Rule. These individuals and organizations are called “covered entities.” The Privacy Rule also contains standards for individuals’ rights to understand and control how their health information is used. A major goal of the Privacy Rule is to ensure that individuals’ health information is properly protected while allowing the flow of health information needed to provide and promote high quality health care and to protect the public’s health and well-being. The Privacy Rule strikes a balance that permits important uses of information while protecting the privacy of people who seek care and healing.
Your practice, not your electronic health record (EHR) vendor, is responsible for taking the steps needed to comply with HIPAA privacy, security standards, and the Centers for Medicare & Medicaid Services’ (CMS’) Meaningful Use requirements. Read up on laws governing the privacy and security of health information. You must comply with all applicable federal, state, and local laws.
Below are the steps how you and your practice become HIPAA compliant
- Create Privacy and Security Policies for the Practice
Becoming HIPAA compliant requires more than simply following HIPAA Security and Privacy Rules. Covered entities and business associates must also prove that they’ve been proactive about preventing HIPAA violations by creating privacy and security policies. These policies must be documented, communicated to staff, and regularly updated. Staff must be trained on HIPAA policies during orientation and at least once a year, and they must attest (in writing) that they understand all HIPAA policies and procedures.
Healthcare organizations are also required to create and distribute a Notice of Privacy Practices (NPP) form for patients to review and sign. The NPP should outline the covered entity’s privacy policies, including how PHI is handled, and notify patients of their right to access copies of their medical records.
- Name a HIPAA Privacy Officer and Security Officer
HIPAA legislation is complicated and ever-changing, so every healthcare organization needs its own internal HIPAA experts.
The HIPAA Security Rule requires covered entities to designate a Privacy Compliance Officer to oversee the development of privacy policies, ensure those policies are implemented and update them annually. HHS suggests that larger organizations also form a Privacy Oversight Committee to help guide policy creation and manage oversight. The Privacy Officer and Oversight Committee members must undergo regular training to stay abreast of changes to HIPAA regulation. The HIPAA Privacy Officer is also responsible for maintaining NPPs, managing and updating BAAs, scheduling training sessions and self-audits, and otherwise ensuring that the organization is compliant with the HIPAA Privacy Rule.
Covered entities are also required to have a HIPAA Security Officer to ensure there are policies and procedures in place to prevent, detect, and respond to ePHI data breaches. The Security Officer establishes safeguards required by the Security Rule and conducts risk assessments to gauge their effectiveness.
- Implement Security Safeguards
The Security Rule requires three types of safeguards that covered entities and business associates must have in place to secure ePHI — including:
Administrative Safeguards: Organizations must document security management processes, designate security personnel, adopt an information access management system, provide workforce security training, and periodically assess all security protocols
Physical Safeguards: Organizations must be able to control who has access to physical facilities where ePHI is stored. They must also secure all workstations and devices that store or transmit ePHI.
Technical Safeguards: Organizations must have access controls to secure ePHI in the EHR and other databases to ensure employees only see data they’re authorized to see. Data must be encrypted when it is at rest and during transit, which creates the need for secure email, HIPAA Compliant Texting, and HIPAA Compliant Messaging solutions. Organizations must also have audit controls for all hardware and software that manage or transmit ePHI to ensure they meet HIPAA network requirements. And there must be integrity controls to ensure ePHI is not improperly edited or deleted.
- Regularly Conduct Risk Assessments and Self-Audits
Becoming HIPAA compliant is not a one-and-done process. HHS requires covered entities and business associates to conduct regular (at least annual) audits of all administrative, technical, and physical safeguards to identify compliance gaps. Organizations must then create written remediation plans that clearly explain how they plan to reverse HIPAA violations and when this will happen.
- Maintain Business Associate Agreements
Before sharing PHI with business associates, covered entities must obtain “satisfactory assurances” that the business associate is HIPAA-compliant and can effectively safeguard the data, and the parties must enter a BAA. All BAAs must be reviewed annually and updated to reflect any changes in the nature of the business associate relationship.
- Establish a Breach Notification Protocol
A HIPAA violation doesn’t always get organizations into trouble, especially if they can prove the breach was unintentional and that they did everything in their power to prevent such breaches. But failing to report breaches makes the situation worse.
The HIPAA Breach Notification Rule requires covered entities and business associates to report all breaches to OCR and to notify patients whose personal data might have been compromised. HIPAA-beholden organizations are required to have a documented breach notification process that outlines how the organization will comply with this rule.
- Document Everything
Organizations must document all HIPAA compliance efforts — including privacy and security policies, risk assessments and self-audits, remediation plans, and staff training sessions. OCR will review all this documentation during HIPAA audits and complaint investigations.
HIPAA compliance is critical for healthcare organizations, not only to protect patient privacy but also to protect the bottom line. To keep data safe, healthcare providers need to know how to become HIPAA compliant, and they need technology partners who take it just as seriously as they do.
Our duty as midwives is not only to provide our client with quality care but protecting their information as well. We must comply these set of rules not only to follow the law, but to safeguard confidentiality and individuality.
Centers for Disease Control and Prevention. (2018, September 14). Health Insurance Portability and accountability act of 1996 (HIPAA). Centers for Disease Control and Prevention. Retrieved June 18, 2022, from https://www.cdc.gov/phlp/publications/topic/hipaa.html#:~:text=The%20Health%20Insurance%20Portability%20and,the%20patient’s%20consent%20or%20knowledge.
Gibson, M. (2021, July 2). How to protect patient data at your hospital. RightPatient. Retrieved June 18, 2022, from https://www.rightpatient.com/blog/how-to-protect-patient-data-at-your-hospital/
Health Insurance Portability & Accountability Act (HIPAA): Cutting edge document destruction. Cutting Edge Document Destruction |. (2011, November 24). Retrieved June 18, 2022, fromhttps://cuttingedgedd.com/legislation/health-insurance-portability-accountability-act-hipaa/
TigerConnect on June 17, 2020. (2022, January 14). How to become HIPAA compliant (step-by-step guide). TigerConnect. Retrieved June 18, 2022, from https://tigerconnect.com/blog/how-to-become-hipaa-compliant-step-by-step-guide/
Why is HIPAA important? HIPAA Journal. (2022, March 16). Retrieved June 18, 2022, from https://www.hipaajournal.com/why-is-hipaa-important/#:~:text=HIPAA%20helps%20to%20ensure%20that,who%20it%20is%20shared%20with.