Questions and Answers
Which of the following are common causes of breaches? (Select all that apply)
A Privacy Impact Assessment (PIA) is an analysis of how information is handled?
Under the Privacy Act, individuals have the right to request amendments of their records contained in a system of records.
True
Under HIPAA, a covered entity (CE) is defined as:
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The e-Government Act promotes the use of electronic government services by the public and improves the use of information technology in the government.
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Which of the following are categories for punishing violations of federal health care laws? (Select all that apply)
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What are technical safeguards?
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An incidental use or disclosure is not a violation of the HIPAA Privacy Rule if the covered entity (CE) has:
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A covered entity (CE) must have an established complaint process.
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What does the HIPAA Security Rule apply to?
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Which of the following are breach prevention best practices? (Select all that apply)
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Which of the following are examples of personally identifiable information (PII)? (Select all that apply)
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HIPAA provides individuals with the right to request an accounting of disclosures of their PHI.
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If an individual believes that a DoD covered entity (CE) is not complying with HIPAA, he or she may file a complaint with the:
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What is the minimum necessary standard?
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When must a breach be reported to the U.S. Computer Emergency Readiness Team?
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What are administrative safeguards?
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A breach as defined by the DoD is broader than a HIPAA breach.
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Which HHS Office is charged with protecting an individual patient's health information privacy and security through the enforcement of HIPAA?
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What are physical safeguards?
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HIPAA allows the use and disclosure of PHI for treatment, payment, and health care operations (TPO) without the patient's consent or authorization.
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Study Notes
Breach Causes
- Common breach causes include human error, improper disposal of PHI/PII, theft, lost devices, and stolen paper records.
- Electronic media like laptops, smartphones, and USB drives are frequently involved in breaches.
Privacy Impact Assessment (PIA)
- A PIA evaluates information handling for compliance with legal and policy requirements.
- It assesses risks from maintaining identifiable information and reviews protection measures and alternatives.
Privacy Act Rights
- Individuals can request amendments to their records within systems of records under the Privacy Act.
Covered Entities Under HIPAA
- A covered entity (CE) includes health plans, healthcare clearinghouses, and healthcare providers engaged in electronic transactions.
e-Government Act
- Promotes electronic government services and enhances information technology usage in government.
Punishments for Violations
- Violations of federal health care laws can result in criminal penalties, civil monetary penalties, and sanctions.
Technical Safeguards
- Encompasses IT policies and procedures designed to protect and control access to electronic PHI (ePHI).
Incidental Use or Disclosure
- Not considered a violation of HIPAA if CE implements minimum necessary standards and proper administrative, physical, and technical safeguards.
Complaint Process
- Covered entities are required to have a complaint process in place for issues related to HIPAA compliance.
HIPAA Security Rule
- Applies specifically to PHI that is transmitted electronically.
Breach Prevention Best Practices
- Access only necessary PHI/PII and promptly retrieve documents from printers; always lock or log off unattended workstations.
Personally Identifiable Information (PII)
- Examples include Social Security numbers, DoD IDs, home addresses, telephone numbers, date of birth, and personal medical and financial information.
Accounting of Disclosures
- HIPAA grants individuals the right to request an accounting of their PHI disclosures.
Filing HIPAA Complaints
- Individuals can file complaints with the DHA Privacy Office, HHS Secretary, and MTF HIPAA Privacy Officer regarding non-compliance.
Minimum Necessary Standard
- Limits PHI use and disclosures to the minimal necessary for intended purposes; exceptions exist for treatment requests and individual disclosures.
Breach Reporting Timeline
- Breaches must be reported to the U.S. Computer Emergency Readiness Team (CERT) within 1 hour.
Administrative Safeguards
- Include policies and procedures to manage ePHI security measures and workforce conduct regarding ePHI protection.
Definition of Breach
- The DoD defines a breach more broadly than HIPAA or HHS.
HHS Office for HIPAA Enforcement
- The Office for Civil Rights (OCR) is responsible for enforcing HIPAA privacy and security protections.
Physical Safeguards
- Involve physical measures for the protection of electronic information systems from hazards and unauthorized access.
Use and Disclosure of PHI
- HIPAA permits the use and disclosure of PHI for treatment, payment, and health care operations (TPO) without needing patient consent or authorization.
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Description
Test your knowledge on HIPAA regulations and the common causes of privacy and security breaches. This quiz will cover key terms and scenarios that relate to workforce errors, electronic media disposal, and unauthorized access. Prepare yourself for the challenges faced in the healthcare sector regarding PHI and PII.
