Podcast
Questions and Answers
Is Carla's time saving measure appropriate provided she only sends unencrypted emails on occasion?
Is Carla's time saving measure appropriate provided she only sends unencrypted emails on occasion?
A breach as defined by the DoD is broader than a HIPAA breach.
A breach as defined by the DoD is broader than a HIPAA breach.
True
Which of the following are common causes of breaches?
Which of the following are common causes of breaches?
Which of the following are breach prevention best practices?
Which of the following are breach prevention best practices?
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When must a breach be reported to the U.S. Computer Emergency Readiness Team?
When must a breach be reported to the U.S. Computer Emergency Readiness Team?
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Which of the following would be considered PHI? (Select all that apply)
Which of the following would be considered PHI? (Select all that apply)
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Under HIPAA, a covered entity (CE) is defined as:
Under HIPAA, a covered entity (CE) is defined as:
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The HIPAA Privacy Rule applies to which of the following? (Select all that apply)
The HIPAA Privacy Rule applies to which of the following? (Select all that apply)
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An incidental use or disclosure is not a violation of the HIPAA Privacy Rule if the covered entity (CE) has:
An incidental use or disclosure is not a violation of the HIPAA Privacy Rule if the covered entity (CE) has:
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Which of the following are true statements about limited data sets? (Select all that apply)
Which of the following are true statements about limited data sets? (Select all that apply)
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How should John advise the staff member to proceed?
How should John advise the staff member to proceed?
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Was this a violation of HIPAA security safeguards?
Was this a violation of HIPAA security safeguards?
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Which of the following are fundamental objectives of information security? (Select all that apply)
Which of the following are fundamental objectives of information security? (Select all that apply)
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Administrative safeguards are:
Administrative safeguards are:
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Physical safeguards are:
Physical safeguards are:
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Technical safeguards are:
Technical safeguards are:
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What enforcement actions may occur based on Janet's conduct? (Select all that apply)
What enforcement actions may occur based on Janet's conduct? (Select all that apply)
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Which of the following are categories for punishing violations of federal health care laws? (Select all that apply)
Which of the following are categories for punishing violations of federal health care laws? (Select all that apply)
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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:
If an individual believes that a DoD covered entity (CE) is not complying with HIPAA, he or she may file a complaint with:
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Which HHS Office is charged with protecting patient health information privacy and security through enforcement of HIPAA?
Which HHS Office is charged with protecting patient health information privacy and security through enforcement of HIPAA?
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A covered entity (CE) must have an established complaint process.
A covered entity (CE) must have an established complaint process.
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How should John respond regarding the Privacy Act?
How should John respond regarding the Privacy Act?
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Is Major Randolph able to obtain a copy of his records and request changes?
Is Major Randolph able to obtain a copy of his records and request changes?
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Under the Privacy Act, individuals have the right to request amendments of their records.
Under the Privacy Act, individuals have the right to request amendments of their records.
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The e-Government Act promotes the use of electronic government services by the public.
The e-Government Act promotes the use of electronic government services by the public.
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A Systems of Records Notice (SORN) serves as a notice to the public about a system of records and must:
A Systems of Records Notice (SORN) serves as a notice to the public about a system of records and must:
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A Privacy Impact Assessment (PIA) is an analysis of how information is handled:
A Privacy Impact Assessment (PIA) is an analysis of how information is handled:
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What is the appropriate course of action for George regarding overheard information?
What is the appropriate course of action for George regarding overheard information?
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Study Notes
PHI Definition and Examples
- PHI includes an individual's identifiable health information, such as names and medical diagnoses.
- Individually identifiable health information should not be disclosed in employment records by a covered entity (CE).
- PHI can exist in various forms: orally, in paper form, or electronically.
Covered Entities under HIPAA
- Covered entities (CEs) include health plans, health care clearinghouses, and health care providers engaging in standard electronic transactions.
- Compliance with the HIPAA Privacy Rule is mandatory for CEs regarding PHI transmission and maintenance.
Incidental Uses and Disclosures
- Incidental uses or disclosures of PHI are not violations of HIPAA if safeguards are in place.
- Covered entities must adopt minimum necessary standards and implement appropriate safeguards to protect PHI.
Limited Data Sets
- A limited data set excludes 16 specific identifiers to protect individual privacy.
- These sets are permitted for specific purposes such as research and health care operations, with required Data Use Agreements (DUAs) for disclosure.
Physical Safeguards
- Physical safeguards ensure secure access to areas where PHI is located.
- Policies must be established to deny access to unauthorized individuals, including proper identification procedures.
Violations and Enforcement
- Violations of HIPAA can result in criminal charges, civil penalties, and complaints filed with relevant authorities.
- Specific procedures are required for complaints regarding potential HIPAA violations, ensuring they are consistently managed.
Security Measures
- Three fundamental objectives of information security under HIPAA are confidentiality, integrity, and availability.
- Administrative, physical, and technical safeguards collectively protect electronic PHI (ePHI).
Systems of Records and Privacy Act
- Individuals can request access to their records and amendments under the Privacy Act.
- Systems of Records Notices (SORNs) must detail routine uses of data and be publicly recorded before operational usage.
Privacy Impact Assessments (PIAs)
- PIAs are necessary analyses that assess how information is handled concerning privacy regulations.
- They evaluate potential risks and protections related to personal identifiable information (PII).
Reporting Breaches
- Staff members are obligated to report any suspected breaches immediately to prevent further harm.
- Proper disposal of electronic devices is critical in preventing unauthorized access to PHI.
Email Security Practices
- Sending unencrypted emails containing PHI/PII is risky and can lead to security breaches; encryption is required when transmitting sensitive information.
- Best practices also include not sharing passwords and securing workstations properly.
Breach Definitions
- DoD defines a breach more broadly than HIPAA, focusing on unauthorized access or disclosure of personal information that may adversely affect individuals.### Breaches Overview
- A Department of Defense (DoD) breach encompasses a Health Insurance Portability and Accountability Act (HIPAA) breach but is broader in nature.
Common Causes of Breaches
- Theft and intentional unauthorized access are significant contributors to breaches involving Protected Health Information (PHI) and Personally Identifiable Information (PII).
- Human error, such as misdirected communications containing PHI/PII, frequently results in breaches.
- Lost or stolen electronic media devices (e.g., laptops, smartphones, USB drives) are prevalent causes of security incidents involving PHI/PII.
- Improper disposal of electronic devices containing sensitive information can lead to serious breaches.
- Physical records, like paper documents containing PHI/PII, are also commonly lost or stolen, contributing to breach occurrences.
Breach Prevention Best Practices
- Access only the minimum necessary amount of PHI/PII required for tasks to reduce exposure.
- Always log off or lock workstations when unattended to protect sensitive information.
- Promptly retrieve any documents containing PHI/PII from printers to mitigate risks associated with discarded or mislaid sensitive materials.
Reporting Breaches
- A breach must be reported to the U.S. Computer Emergency Readiness Team (CERT) within one hour of discovery to ensure timely response and mitigation efforts.
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Description
Explore the vital concepts surrounding Protected Health Information (PHI) and the regulations under HIPAA. This quiz covers covered entities, incidental uses, disclosures, and the importance of safeguard measures. Test your knowledge on how PHI should be managed and protected in healthcare settings.
