Understanding PHI and HIPAA Regulations

Questions and Answers

Is Carla's time saving measure appropriate provided she only sends unencrypted emails on occasion?

No, because unencrypted emails containing PHI or PII may be intercepted and result in unauthorized access (correct)

No, because sending PHI in an unencrypted email can always result in a security breach

Yes, because the security risks associated with an email transmission are minimal

Yes, because seeing patients in a timely manner is a priority for Carla and requires her to occasionally take shortcuts in other areas

A breach as defined by the DoD is broader than a HIPAA breach.

True

Which of the following are common causes of breaches?

Theft and intentional unauthorized access to PHI and personally identifiable information (PII)

Human error (e.g. misdirected communication containing PHI or PII)

Lost or stolen electronic media devices or paper records containing PHI or PII

All of the above (correct)

Which of the following are breach prevention best practices?

All of the above Signup and view all the answers

When must a breach be reported to the U.S. Computer Emergency Readiness Team?

Within 1 hour of discovery Signup and view all the answers

Which of the following would be considered PHI? (Select all that apply)

An individual's first and last name and the medical diagnosis in a physician's progress report Signup and view all the answers

Under HIPAA, a covered entity (CE) is defined as:

All of the above Signup and view all the answers

The HIPAA Privacy Rule applies to which of the following? (Select all that apply)

All of the above Signup and view all the answers

An incidental use or disclosure is not a violation of the HIPAA Privacy Rule if the covered entity (CE) has:

All of the above Signup and view all the answers

Which of the following are true statements about limited data sets? (Select all that apply)

All of the above Signup and view all the answers

How should John advise the staff member to proceed?

Both B and C Signup and view all the answers

Was this a violation of HIPAA security safeguards?

True Signup and view all the answers

Which of the following are fundamental objectives of information security? (Select all that apply)

All of the above Signup and view all the answers

Administrative safeguards are:

Administrative actions to protect electronic PHI. Signup and view all the answers

Physical safeguards are:

Physical measures to protect electronic information systems. Signup and view all the answers

Technical safeguards are:

Information technology policies for access control. Signup and view all the answers

What enforcement actions may occur based on Janet's conduct? (Select all that apply)

All of the above Signup and view all the answers

Which of the following are categories for punishing violations of federal health care laws? (Select all that apply)

All of the above Signup and view all the answers

If an individual believes that a DoD covered entity (CE) is not complying with HIPAA, he or she may file a complaint with:

All of the above Signup and view all the answers

Which HHS Office is charged with protecting patient health information privacy and security through enforcement of HIPAA?

Office for Civil Rights Signup and view all the answers

A covered entity (CE) must have an established complaint process.

True Signup and view all the answers

How should John respond regarding the Privacy Act?

Yes, Privacy Act Statements and a SORN should both be considered. Signup and view all the answers

Is Major Randolph able to obtain a copy of his records and request changes?

Yes, he may request to inspect and copy his records. Signup and view all the answers

Under the Privacy Act, individuals have the right to request amendments of their records.

True Signup and view all the answers

The e-Government Act promotes the use of electronic government services by the public.

True Signup and view all the answers

A Systems of Records Notice (SORN) serves as a notice to the public about a system of records and must:

All of the above Signup and view all the answers

A Privacy Impact Assessment (PIA) is an analysis of how information is handled:

All of the above Signup and view all the answers

What is the appropriate course of action for George regarding overheard information?

Report the possible breach to his supervisor. Signup and view all the answers

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.

Understanding PHI and HIPAA Regulations

Questions and Answers

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.

Which of the following are common causes of breaches?

Which of the following are breach prevention best practices?

When must a breach be reported to the U.S. Computer Emergency Readiness Team?

Which of the following would be considered PHI? (Select all that apply)

Under HIPAA, a covered entity (CE) is defined as:

The HIPAA Privacy Rule applies to which of the following? (Select all that apply)

An incidental use or disclosure is not a violation of the HIPAA Privacy Rule if the covered entity (CE) has:

Which of the following are true statements about limited data sets? (Select all that apply)

How should John advise the staff member to proceed?

Was this a violation of HIPAA security safeguards?

Which of the following are fundamental objectives of information security? (Select all that apply)

Administrative safeguards are:

Physical safeguards are:

Technical safeguards are:

What enforcement actions may occur based on Janet's conduct? (Select all that apply)

Which of the following are categories for punishing violations of federal health care laws? (Select all that apply)

If an individual believes that a DoD covered entity (CE) is not complying with HIPAA, he or she may file a complaint with:

Which HHS Office is charged with protecting patient health information privacy and security through enforcement of HIPAA?

A covered entity (CE) must have an established complaint process.

How should John respond regarding the Privacy Act?

Is Major Randolph able to obtain a copy of his records and request changes?

Under the Privacy Act, individuals have the right to request amendments of their records.

The e-Government Act promotes the use of electronic government services by the public.

A Systems of Records Notice (SORN) serves as a notice to the public about a system of records and must:

A Privacy Impact Assessment (PIA) is an analysis of how information is handled:

What is the appropriate course of action for George regarding overheard information?

Study Notes

PHI Definition and Examples

Covered Entities under HIPAA

Incidental Uses and Disclosures

Limited Data Sets

Physical Safeguards

Violations and Enforcement

Security Measures

Systems of Records and Privacy Act

Privacy Impact Assessments (PIAs)

Reporting Breaches

Email Security Practices

Breach Definitions

Common Causes of Breaches

Breach Prevention Best Practices

Reporting Breaches

Studying That Suits You

Description

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