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Don’t Get Run Over by the HIPAA Omnibus!

January 23, 2015 by Danika Brinda Leave a Comment

3d london bus on white backgroundHIPAA Compliance continues to be a HOT TOPIC in healthcare.  Everyday news and information is published about the lack of compliance, the struggles within organizations, data breaches occurring, and the HIPAA audits coming.  In 2013, the HIPAA Omnibus Rule was established which had many provisions on the HIPAA Privacy and Security Regulations.  With the compliance date of September 23, 2013, many healthcare organizations and business associates have not taken proper steps to get to climb onto the HIPAA Omnibus and assure compliance with the new regulations.   

A recent study conducted by NueMD in 2014 provided insight into compliance levels with the HIPAA Regulations and the HIPAA Omnibus Rule.  Over 1,000 Medical Practices and 160 Billing Companies were surveyed in regards to the current level of compliance with HIPAA and the changes with the HIPAA Omnibus Rule.  The results were SHOCKING and EYEOPENING!!!!  Check out some key findings:

  • 36% of respondents stated they didn’t know about the HIPAA Omnibus Rule
  • 68% of respondents stated they didn’t know of the HIPAA Audits
  • 23% of respondents stated they had no HIPAA Compliance Plan
  • 54% of respondents stated they didn’t have a Security Officer
  • 45% of respondents stated they didn’t have a Privacy Officer
  • 55% of respondents stated they had no process established for Breach Notification

Based on the findings, it is clear that healthcare organizations need to step up and establish HIPAA Compliance Programs and ensure they are updating their information to include the HIPAA Omnibus Requirements.  Jump on the HIPAA Omnibus and ensure that the organization has a joyful ride rather than being ran off the road. 

The major components of the HIPAA Omnibus Rule that healthcare organizations AND business associates need to evaluate and implement within their organization are:

  • Breach Notification
  • Business Associates Compliance Requirements
  • Sale of Protected Health Information
  • Marketing and Protected Health Information
  • Fundraising and Protected Health Information
  • Research Authorization Changes
  • Access to Immunization Data
  • Electronic copy of Protected Health Information
  • Access to Deceased Patient’s Records
  • Genetic Information Nondisclosure Act (ACT)
  • Restriction of Protected Health Information to Health Plans
  • Update to the Notice of Privacy Practices

Please note this is not an “end all be all” list of requirements.  Each organization needs to assess the regulatory changes and determine how and what applies to their specific organization.

With the HIPAA Delays – healthcare organizations are given the gift of time.  Use this time to get aboard the HIPAA Omnibus and assure that you have updated or established all appropriate policies and procedures for your organization.  Don’t delay any longer – the time is NOW! 

Danika

Source: NueMD Survey Findings: http://www.nuemd.com/hipaa/survey/practice-findings.html

Filed Under: Business Associates, HIPAA, HIPAA Compliance, Omnibus Rule, Privacy, Security

Going from 0 to HIPAA Compliant – Like Climbing Mt. Everest: Small Steps Take You a Long Way

January 15, 2015 by Danika Brinda Leave a Comment

evening view of Everest and Nuptse from Kala PattharMoving from 0 to HIPAA Compliant can be a lot like climbing Mt. Everest.  Starting from the bottom and staring up to try and see the peak of Mt. Everest is challenging just as starting the route to HIPAA compliance can be.  When climbing Mt. Everest, nobody sets to climb to the summit in one day.  Instead, they prepare themselves for the climb, and they break it up and take it in small steps – with a dream of reaching the summit.  The usual course of the climb is:

  • Ice Fall
  • Camp 1
  • Camp 2
  • Camp 3
  • Camp 4
  • Everest Summit (YES)!

Looks easy, right?  WRONG!  At times, climbers spend 4 – 8 weeks at the different camps trying to acclimate themselves to the altitude and prepare themselves for the next hike up the mountain.  The time spent moving between camps takes hours upon hours and can be treacherous and dangerous.  But the moment that the climbers walk the last few steps and make it to the summit, all the hard work and dedication pays off.  They can finally enjoy the success of the momentous task they just accomplished.   

BREATH, EXIST, and ENJOY the moment – because then they remember that they have to climb down AND the only way down – is the way that they came up.     

When first reviewing the HIPAA Privacy and Security Regulations, it can be SCARY and OVERWHELMING, similar to climbing Mt. Everest.  Between the two regulations, writing policies and procedures and establishing practices for an organization can take weeks, even months.  The challenge that HIPAA privacy and security practitioners face is that HIPAA usually is another added task to one’s already full plate, creating an even bigger hurdle in the path to the summit of HIPAA compliance.  With all the conflicting priorities and trying to meet so many deadlines, HIPAA tasks usually gets pushed off to the side or left for ‘tomorrow’ to do.  How many times has HIPAA come up on your ‘To-Do’ list and got pushed off until tomorrow?

Looking at the requirements under HIPAA – it is easy to see how it can be overwhelming when you are starting from scratch or reviewing what you already have in place (if you are unclear about the HIPAA requirements – contact me).

Take a new philosophy on HIPAA Compliance and Commit to 3 tasks daily.  Think of the movement towards HIPAA compliance as your movement toward the different camps that the climbers make it to as they take the challenge of climbing Mt. Everest.  This may sound silly or a little ‘too easy’ but when you take a complicated task and break it down to small daily tasks, it seems a little more achievable and not so overwhelming.    

A Sample Week of HIPAA Tasks (Privacy Rule):

Monday 1.   Update Notice of Privacy Practices 

2.   Update process for Notice Signatures

3.   Update P&P on Notice of Privacy Practices

Tuesday 1.   Review P&P on Uses and Disclosures of Protected Health Information 

2.   Observe processes for releasing health information

3.   Evaluate documentation received for disclosures of health information

Wednesday 1.   Review recent Request for Amendments of Medical Record Documentation 

2.   Evaluate and Update Amendment Policy and procedure

3.   Assure Amendment Request form is adequate are being process timely

Thursday 1.   Review all accounting of disclosure (AOD) requests 

2.   Evaluate and update AOD policy and procedure

3.   Assure AOD Request form is adequate and requests are being process timely

Friday 1.   Evaluate areas that need re-training and education on practices reviewed this week 

2.   Create a training plan for workforce members

3.   Evaluate and Update HIPAA Training Policy and Procedure

The one important item to remember is – YOU CAN’T GET IT DONE IN A DAY!  To truly evaluate your level of HIPAA compliance, create and implement privacy and security practices within your organization, and effectively train your workforce – you need to dedicate time and effort to the project.  And remember, once you get it all done – it is not time to sit back, relax and never worry again.  It is the time for evaluation and assurance that what has been established for HIPAA compliance with what is being practiced within your organization – similar to climbing back down Mt. Everest.

Remember the famous Spanish saying “Poco a Poco se va lejos” (Little by Little, One Goes a Long Way).  Small steps can make all the difference in the successful creation, evaluation, and execution of a solid and complete HIPAA Compliance Program!

Danika 

Filed Under: Business Associates, HIPAA, HIPAA Compliance, Other, Privacy, Protected Health Information, Security

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