As the Privacy Officer, what types of monitoring procedures would you develop?
Patient confidentiality is a vital factor in medicine. Protecting patient details should be a priority for any healthcare institution (Fernandez-Aleman et al. 2013 p. 542). Patient confidentiality does not only entail moral respect but also important in creating a bond of trust between the healthcare provider and patient. The Health Insurance Portability and Accountability Act of 1996 contains the privacy , breach notification and security requirements that apply to health information created, received, maintained and transmitted by health care providers. A privacy officer is designated with the duty of handling patient health information by developing strategies and overseeing the health care’s institution’s compliance to the U.S. Health Insurance Portability and Accountability Act (HIPAA).
Monitoring procedures ensure that a health institution maintains privacy. The privacy officer would ensure that the staff is educated to establish a practice of awareness. It is important to conduct regular scheduled trainings and communication programs that target the medical staff, interns, employees and contractors. The training events are an opportunity to train staff on information related to health information safety. The communication programs involve sending regular remainder emails on compliance to privacy regulations to staff. It is important to monitor the use of electronic health records. The privacy officer would conduct regular privacy checks and physical monitoring of activities and buildings. The procedure is completed by conducting physical walks of the facility to monitor staff and reviewing the physical preventive measures put in place to avoid breach of security documents and proper disposal of white boards. The physical walk-throughs are also an opportunity to gauge the staff’s knowledge and understanding of privacy issues for instance, how to manage patient information and reporting procedures for breaches. Another monitoring procedure is baseline tracking and ongoing checks of incidents or strange activities. Tracking and trending gives valuable data that can be used to identify educational needs and build auditing information. Regularly observing the access to high profile patients’ health information is a vital monitoring procedure that can be achieved by creating a VIP records lockdown that only allows certain staff members to see their information. Performing random, periodic and continuous audits of electronic health records founded on case-by-case need. The audit procedure can be chosen based on the risk areas identified. Health institutions with advanced tools could audit several databases to diagnose issues. Monitoring the use of emergency electronic health record use prevents the unauthorized access to records (Terry 2012).
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What would you include in your sanctions for violations of the policy?
The sanction model depends on the nature of privacy violation or security incident. Categorizing incidents, helps standardize corrective measures determinations (Fernandez-Aleman et al. 2013 p. 558). There are certain factors that determine the correct disciplinary action. The first category would be an accidental violation where a member of staff reveals patient information unintentionally. For instance, the member of staff could reveal patient information by sending patient information to the wrong email. Second factor under determination is whether the staff failed to follow established rules. Whether the employer gave patient information with the intention of harming the patient or health institution is a fact to consider before deciding on disciplinary options. The extent of breach refers the magnitude of information exposed and the number of patients affected is an important aspect to consider before beginning investigations. Other factors to consider include the employee’s previous violation history, employee’s conduct during investigations, harm to breach victims and nature of breach (Terry 2012).
The sanction policy should include the disciplinary process that allow for investigations. A violation can be reported directly to the privacy officer or anonymously to the HIPPA privacy office. After reporting the violation, the privacy officer would investigate and assess the violation. The investigation process might require staff interviews, telephone logs review, and audit trails of the electronic health record system. The privacy officer would then determine if the sanctions are appropriate. The disciplinary actions are finally recorded in employee records.
As the Privacy Officer, how would you address the following?
Tracking each point of access of the patient's database, including who entered the data.
Electronic health records (EHR) have largely replaced paper medical records. With the latter, it was easy to identify who had accessed a patient’s health record since employees were required to initial the date and time of new entry (Silow-Carroll et al. 2012 p. 15). The handwriting and initials made it possible to identify any employer who accessed records. Basically, the identification of the employee who accessed the record time and date remained a matter of public record. In the age of EHR, it is becoming impossible to track employees who access patients’ databases since employees exploit the system’s ability to filter out such information (Terry 2012). That necessitated the need for the federal government to allow health care providers to record access information from an EHR system (Heisey-Grove et al. 2014 p. 146). The information is stored in form of audit logs. As a privacy officer, I would ensure that the health institution uses audit logs to track individuals who access the patient databases. Audit logs are chronological records that provide evidence of employees who accesses the database, the times, location and what they did for example print out, modify or remove existing data (Fernandez-Aleman et al. 2013 p 546). Audit logs are trails that are essential when tracking illegal disclosures of patient health records and an efficient evaluation tool for the effectiveness of an organization’s privacy rules.
Nurses in your hospital have an access code that only gives them access to their unit's patients. A visitor accidently comes to the wrong unit looking for a patient and asks the nurse to find out what unit the patient is on.
Nurses are often allowed access to information they need to perform their duties. For instance if a nurse works in Cardiology she is only allowed to access information on patients in the cardiology unit. Viewing information of patients from other units is considered a breach of security and privacy policies (Fernandez-Aleman et al. 2013 p 543). Giving user privileges is an important aspect of medical records history. Providing nurses with information needed to perform their responsibility ensures that they are responsible for the misuse of information they view. In an instance where a patient comes to the wrong unit and wants to know what unit their patient is on, the nurses in the unit should direct the patient to the privacy officer who would then log in to the patients database and direct he/she to the correct unit.
How does a privacy officer Encourage nurses to report privacy and security breaches?
Nurses often handle private patient information and are at risk of breach of confidential information (Terry 2012). A privacy officer should ensure that he/she creates an environment that ensures nurses feel they can report breaches rather than hide them. The privacy officer should create a culture of fair implementation of disciplinary actions to ensure that other nurses are not silenced by the punishments their peers receive. The officer should encourage self-reporting of breeches rather than set a precedence of people committing breeches keeping silent for fear of punishments. The privacy officer should ensure that he/she has trained the nurses on the importance of maintaining patient privacy and the importance of self-reporting to aid mitigation of the effects of breaches. Possessing appropriate knowledge on privacy issues ensure that nurses report security and privacy breeches since they would know the benefits of self-reporting. If a nurse self-reports breaches, the privacy officer should not discipline him/her but rather applaud her; that encourages other nurses to come forward. The act creates a feeling of mutual trust between the employee and privacy officer; a factor that is essential for future interactions. Educating nurses on the consequences of breaching patients’ privacy encourages them to report breeches; for instance, informing them that failure to report could result to fine and criminal penalties (Silow-Carroll et al. 2012 p. 12). The privacy officer should however evaluate each incident in a case-by-case basis; if employees reveal patient information with the intent to hurt the patient or institution they have to be disciplined regardless of whether they reported the breach. Self-reporting is not an opportunity to evade disciplinary action but can be used to encourage more nurses to report breaches (Silow-Carroll et al. 2012 p. 12)
References
Fernández-Alemán, J. L., Señor, I. C., Lozoya, P. Á. O., & Toval, A. (2013). Security and privacy in electronic health records: A systematic literature review: Journal of biomedical informatics , 46 (3), 541-562.
Heisey-Grove, D., Danehy, L. N., Consolazio, M., Lynch, K., & Mostashari, F. (2014). A national study of challenges to electronic health record adoption and meaningful use: Medical care , 52 (2), 144-148.
Silow-Carroll, S., Edwards, J. N., & Rodin, D. (2012). Using electronic health records to improve quality and efficiency: the experiences of leading hospitals. Issue Brief (Commonw Fund) , 17 , 1-40.
Terry, N. P. (2012). Protecting patient privacy in the age of big data: UMKC L. Rev. , 81 , 385.
