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Chapter 1 Introduction to HIPAA and the Privacy and Security Rules 1
Introduction 2
What Is HIPAA? 3
The Privacy and Security Rules 7
Terminology 8
General Terminology in Healthcare 13
Significant Points 14
Compliance Deadlines 16
Chapter 2 The Privacy and Security Rules and Healthcare Documentation 21
Introduction 22
What Does the Privacy Rule Really Do? 23
What Does the Security Rule Really Do? 23
Privacy for Protected Health Information Is the Goal! 24
What Constitutes Protected Health Information? 25
Who Must Comply and How Does Compliance Impact the Work Setting? 25
State Laws 26
Application of the Privacy Rule in Healthcare Documentation 26
Policies and Procedures 27
Training 27
Use and Disclosure 28
Minimally Necessary Information 29
Access Control 29
De-identified Information 30
Confidentiality Agreements 32
Computer Security 32
Work Areas 33
Transfer of Data 33
Destruction of Hard Copy protected Health Information 34
Use of the Fax 34
Use of E-Mail 36
Disaster Recovery 37
Offsite Workers 37
Storage and Retention 38
Audit Trails 39
Termination Procedures 39
Recycling of Computers 40
Access to PHI for Educational Purposes 40
Vendors 41
Breaches 42
Complaints 43
Penalties 44
Enforcement 46
HIPAA for the Independent Contractor 46
Are You a Business Associate? 47
General Requirements 47
Chapter 3 A Blueprint for Compliance with the Privacy Rule 57
Introduction 58
Where Do I Start? 58
Gap Analysis Checklist 59
Vendor Compliance Checklist 63
Training Checklist 63
What Policies Do I Need? 65
Privacy Officer Policy 66
Policy for the Use of Protected Health Information 67
Policy for the Use of Protected Health Information in Quality Assurance and Educational Programs 67
Training Policy 69
Computer Security Policy 69
Policy for Confidentiality Agreements 73
Policy for Work Area Arrangements 74
Access Policy for Digital Dictation Systems 75
Policy for the Use of Hard Copy Protected Health Information 76
Policy for Use of the Fax Machine 77
E-Mail Policy 78
Disaster Recovery Policy 80
Policy for Offsite Workers 81
Termination Policy 84
Breaches and Sanctions Policies 86
Complaint Policy 87
Vendor Policy 88
Policies for Business Associates 88
Sample Contracts and Agreements 90
Policy for Subcontractors 99
Policy for Offshore Contractors 99
A Word About Disclosures 100
What About Indemnification? 100
Chapter 4 The Security Rule and Healthcare Documentation 109
Introduction 110
What Does the Security Rule Really Do? 110
What Constitutes Protected Health Information? 111
Who Must Comply and How Does Compliance Impact the Work Setting? 112
State Laws 112
Application of the Security Rule 113
Administrative Safeguards 113
Physical Safeguards 121
Technical Safeguards 125
Organizational Requirements 127
Policies and Procedures and Documentation Requirements 127
Penalties 128
Enforcement 129
HIPAA for the Independent Contractor 130
Are You a Business Associate? 130
Chapter 5 A Blueprint for Compliance with the Security Rule 137
Introduction 138
Administrative Safeguards 139
Security Management Process 139
Assigned Security Responsibility 145
Workforce Security 146
Information Access Management 148
Security Awareness and Training 150
Security Incidents 152
Contingency Plans 155
Evaluation 157
Business Associate Contracts and Other Arrangements 158
Physical Safeguards 162
Facility Access Control 162
Workstation Use 165
Workstation Security 166
Device and Media Controls 167
Technical Safeguards 169
Access Control 170
Audit Controls 172
Integrity 172
Person or Entity Authentication 173
Transmission Security 174
Organizational Requirements 175
Business Associate Contracts and Other Arrangements 175
Requirements for Group Health Plans 176
Policies and Procedures and Documentation Requirements 177
Policies and Procedures 177
Documentation 178
A Final Note on Security 179
Chapter 6 Frequently Asked Questions 185
Appendix A Industry Resources 199
Appendix B AAMT Paper on Special Considerations for Offsite Medical Transcriptionists 205
Appendix C Abbreviations and Acronyms 211
Glossary 213
Index 219
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