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Identification Card | Secure Area Card Access | Privacy/Confidentiality | Computer Use/Electronic Information | Retention and Destruction/Disposal of Private and Confidential Information | Use and Disclosure of Protected Health Information | Notice of Privacy Practices | Access to Designated Record Set | Accounting of PHI Disclosures | Patient/Consumer Complaints | Vendors | Fax Transmissions | Psychotherapy Notes | Facility Security | Conditions of Treatment Form | Informed Consent for UNMC Media | Transporting Protected Health Information | Honest Broker | Social Security Number | Third Party Registry | Information Security Awareness and Training | Patient Privacy Investigations and Levels of Violation | Use and Disclosure of PHI for Training Health Care Professionals | Disclosures of PHI as Permitted or Required by Law | Disclosure of PHI for Law Enforcement Purposes

Policy No.: 6045
Effective Date: 11/21/03
Revised Date: 10/28/22 draft
Reviewed Date:

Privacy, Confidentiality and Security of Patient and Proprietary Information Policy

Basis for Policy

Nebraska Medicine/UNMC implements reasonable and appropriate access controls in alignment with National Institute of Standards and Technology (NIST) standards and guidance to maintain the minimum necessary access. NIST Special Publication 800-53 and the HIPAA Security Rule outline considerations for the access control family of security controls.

Policy

It is the policy of Nebraska Medicine/UNMC to maintain strict confidentiality and security of protected health information (PHI) and proprietary information.

Procedures

1. Records containing confidential information, in any form, are the property of Nebraska Medicine/UNMC. The original medical record in any form shall not be released except in response to a valid search warrant, subpoena or court order requiring the release of the original record. A copy of the medical record should be offered first in such circumstances. If the original medical record must be released, a copy should be made prior to release if possible.
2. Individuals have the following rights with respect to their PHI: </b
   1. Right to request access to inspect or to obtain a copy of their PHI in a designated record set and to receive such access (where granted) within a reasonable amount of time and to request amendment (see UNMC Policy No. 6059, Access and & Amendment of Designated Record Set);
   2. Right to request restrictions of how their PHI is used and disclosed (see UNMC Policy No. 6057, Use & Disclosure of Protected Health Information);
   3. Right to request an accounting of disclosures (see UNMC Policy No. 6061, Accounting of Protected Health Information Disclosures);
   4. Right to receive a Notice of Privacy Practices (see UNMC Policy No. 6058, Notice of Privacy Practices); and
   5. Right to file a complaint internally with the Patient Relations Department or with the U.S. Department of Health and Human Services Office for Civil Rights (see UNMC Policy No. 6058, Notice of Privacy Practices, UNMC Policy No. 6062, Patient/Consumer Complaints and Nebraska Medicine Patient Complaint and Grievance Management policy needpolicy #
      Individuals shall not be asked to waive these rights as a condition of receiving treatment.
3. Nebraska Medicine/UNMC is responsible for safeguarding and protecting confidential information against loss, tampering and use by or disclosure to unauthorized individuals. The safeguarding of confidential information in any form includes when the information is stored and/or being transferred outside the facility (see UNMC Policy No. 6073, Transporting Protected Health Information).
4. Nebraska Medicine/UNMC workforce has a duty to protect confidential information. Breach of this duty includes but is not limited to the following:
   1. Accessing confidential information, in any form, without a current "need to know" to perform assigned duties. Workforce members may not access their own records. Workforce members may not access records of family members (including children), relatives, friends and others, unless access is necessary to perform assigned duties. Workforce members may obtain a copy of their medical records from the Health Information Management Department or via the online patient portal.
   2. Discussing or disclosing patient care events/PHI to individuals who do not have a “need to know” this information to perform assigned duties, even if the patient’s name is not mentioned. The facts surrounding patient care are confidential and can lead to the identity of the patient.
   3. Disclosing confidential information without proper authorization (see UNMC Policy No. 6057, Use and Disclosure of Protected Health Information);
   4. Accessing patient information via Health Information Exchange in a manner or for a purpose not permitted (see UNMC Policy No. 6057, Use and Disclosure of Protected Health Information);
   5. Discussing confidential information in the presence of individuals who do not have the "need to know" to perform assigned duties;
   6. Disclosing that a patient is receiving care (except for authorized directory purposes);
   7. Leaving confidential information unattended in a non-secure area;
   8. Improper disposal of confidential information (see policy, “Destruction of Confidential Information”);
   9. Using another person's user ID, password or other security codes;
   10. Assisting an unauthorized user to gain access to a secured information system;
   11. Transferring confidential information in any form without both parties having a need to know such confidential information.
5. Nebraska Medicine/UNMC shall mitigate or reduce, to the extent practicable, any harmful effects of a use or disclosure of PHI in violation of its policies and procedures that is known to Nebraska Medicine/UNMC.
6. All employees, the medical staff, allied health practitioners and members of the Workforce with access to confidential information shall sign Nebraska Medicine/UNMC Information Privacy, Confidentiality and Security Agreement upon initial employment/work/appointment/credentialing (need URL for attachment to link to the policy).
7. Workforce members who suspect a privacy or information security violation must report it immediately. Such reports may be made to their respective manager and the Privacy and/or Information Security Office. Alternatively, staff who wish to remain anonymous may report the suspected violation to the Compliance Hotline at 800-822-8310. A full investigation of the suspected violation shall be conducted. Sanctions shall be imposed for substantiated breaches or failure to report suspected violations. The Medical Staff and allied health practitioners shall report suspected violations to the System Chief Medical Officer (how to contact that person??).
8. Sanctions for violations of privacy or information security may include revocation of medical staff privileges or allied health credentials, or employee corrective action up to and including termination of employment (see UNMC Policy No. 6302, Patient Privacy Investigations and Levels of Violation). Civil and criminal fines and penalties can also be levied under HIPAA.
9. Workforce members may not intimidate, threaten, coerce, discriminate against, or take other retaliatory action against any individual for reporting a suspected privacy or information security violation, or for filing of a complaint within Nebraska Medicine/UNMC or to the Office for Civil Rights (see Procedures, Section 2.2).
10. Access to patient information via Health Information Exchange shall be conducted in accordance with UNMC Policy No. 6057, Use and Disclosure of Protected Health Information.
11. Paper medical records shall be maintained in the Health Information Management Department.
    1. Records sent to clinic areas shall be returned to the Health Information Management Department within one working day.
    2. Records of discharged patients will remain on the units until the Health Information Management Department picks them up. Medical records of deceased patients scheduled for an autopsy may be sent to the morgue.
    3. Records signed out to the attending physician's office or other authorized areas shall be returned to the Health Information Management Department as soon as possible (preferably by 5:00 pm each working day).
12. Editing, authenticating and correcting the medical record.
    1. Please reference, policy, “Contents of Medical Record”, for editing and authenticating the medical record.(Nebraska Medicine Policy number??)
13. Business Associate agreements/addenda shall be executed with each Business Associate (
14. Human Subjects Research shall be conducted in accordance with UNMC’s Human Research Protection Program (HRPP) Policies and Procedures, including HRPP Policy 3.4, “Use of Protected Health Information in Research" and UNMC Policy No. 6057, Use and Disclosure of Protected Health Information.
15. Retention of the designated record set and other protected health information shall be in accordance with federal, state and local laws and regulatory association guidelines. Documents required to demonstrate HIPAA compliance shall be retained for a period of six years.

Definitions

Affiliated Covered Entity (ACE)

Legally separate covered entities that are affiliated and designate themselves as a single covered entity for the purpose of HIPAA Compliance. Current ACE members are: The Nebraska Medical Center, UNMC Physicians, UNMC, University Dental Associates, Bellevue Medical Center and Nebraska Pediatric Practice, Inc. d/b/a Children’s Specialty Physicians. ACE membership may change from time to time. The Notice of Privacy Practices lists current ACE members. Access and amendment rights apply to designated record sets throughout the ACE.

Business Associate

A third party who performs services on behalf of Nebraska Medicine/UNMC that involve the creation, receipt, maintenance or transmission of PHI. Some examples of such services include claims processing, data analysis, data processing, practice management, utilization review, quality assurance, patient safety activities, billing, benefit management and repricing.

Designated Record Set (DRS)

Includes medical records and billing records about Individuals maintained by or for UNMC/ACE and any other record used by an ACE entity to make decisions about Individuals. Exact duplicates of records maintained by business associates are not considered part of the DRS.

Individual

The person who is the subject of the PHI. Personal representatives of the patient have the same rights as the Individual under HIPAA (i.e., they “step into the shoes” of the Individual). Personal representatives include the legal guardian and anyone else authorized by law to act on behalf of the Individual. (See Nebraska Medicine Consents and Permits policy, MS14).

Protected Health Information (PHI)

Individually identifiable health information including demographic information, collected from an Individual, whether oral or recorded in any medium, that:

• is created or received by UNMC/ACE; and
• relates to the past, present or future physical or mental health or condition of an Individual; the provision of health care to an Individual; or the past, present or future payment for the provision of health care to an Individual and identifies the Individual or with respect to which there is a reasonable basis to believe the information can be used to identify the Individual.

PHI includes genetic information, which includes information about the following items (and excludes information about an Individual’s sex or age):

• an Individual’s genetic tests;
• the genetic tests of an Individual’s family members; or
• the manifestation of a disease or disorder in such Individual’s family members (i.e., family medical history); or
• any request for, or receipt of, genetic services (e.g., genetic test, genetic counseling, genetic education), or participation in clinical research which includes genetic services by the Individual or any family member of the Individual.

PHI excludes:

• individually identifiable health information of a person who has been deceased for more than fifty (50) years.
• education records covered by the Family Educational Rights and Privacy Act (FERPA); and
• employment records held by UNMC in its role as employer.

Workforce

Employees, medical staff, volunteers, trainees and other persons whose conduct, in the performance of work for Nebraska Medicine/UNMC, is under the direct control of Nebraska Medicine/UNMC, whether or not they are paid by Nebraska Medicine/UNMC.

In addition for purposes of this policy.

Information Security

The set of policies and practices designed to protect PHI from any unauthorized access, use, disclosure, modification, destruction or loss.

Proprietary Information

Information relating to Nebraska Medicine/UNMC business practices, including but not limited to financial statements, contracts, and business plans, employee records and meeting minutes.

Additional Information

• Note: Corresponds to Nebraska Medicine Policy IM06
• Contact the Chief Compliance Officer, 402-559-9576 or the UNMC Compliance Office at 402-559-6767
• Compliance Hotline - 800-822-8310
• Contact the Privacy or Information Security Officers
• Contact Human Resources – Records at 402-559-8962 or Human Resources - Employee Relations
• Statement of Understanding are these the same thing? if so, what is the correct name and URL? Nebraska Medicine/UNMC Information Privacy, Confidentiality and Security Agreement
• Exhibit B - Use of Student Social Security Number Exception
• Exhibit C - Use of Employee Social Security Number Exception
• UNMC Policy No. 1098, Corrective and Disciplinary Action
• UNMC Policy No. 6036, Reproduction of Copyrighted Materials Policy
• UNMC Policy No. 6052, Contract or Agreement for Student Training Policy
• UNMC Policy No. 6057, Use and Disclosure of Protected Health Information
• UNMC Policy No. 6058, Notice of Privacy Practices
• UNMC Policy No. 6059, Access and Amendment of Designated Record Set
• UNMC Policy No. 6061, Accounting of PHI Disclosures
• UNMC Policy No. 6062, Patient/Consumer Complaints
• UNMC Policy No. 6073, Transporting Protected Health Information
• UNMC Policy No. 6085, Social Security Number
• UNMC Policy No. 6302, Patient Privacy Investigations and Levels of Violation
• UNMC Policy No. 8000, Compliance Program
• UNMC Policy No. 8009, Contracts
• UNMC’s Human Research Protection Program (HRPP) Policies and Procedures, including HRPP Policy 3.4, “Use of Protected Health Information in Research
• Nebraska Medicine Consents and Permits policy, MS14
• UNMC Data Classification Procedure
• UNMC Privacy and Information Security Policies
• UNMC Human Resources Procedures
• Job Shadowing Procedures
• Information Security Plan
• Telehealth Procedures
• Privacy Incident Response and Breach Notification Procedures
• Copyright and Disclaimer
• Destruction of Private and Confidential Information Procedures
• Procedures for Obtaining Informed Consent for UNMC Audio-Visual Media Production and Distribution
• Human Resources Performance Management Procedures
• UNMC Faculty Handbook: Operating Procedures
• Student Handbook
• NIST Special Publication 800-53
• Health Insurance Portability and Accountability Act of 1996 (HIPAA)
• HIPAA Security Rule
• Gramm-Leach-Bliley Act (GLBA)
• Family Educational Rights and Privacy Act (FERPA)
• University of Nebraska Board of Regents Bylaws
• University of Nebraska Board of Regents Policies
• Executive Memorandum No. 16, Policy for Responsible Use of University Computers and Information Systems
• Executive Memorandum No. 22, Public Record Requests
• Executive Memorandum No. 26, Information Security Plan - Gramm Leach Bliley Compliance
• Executive Memorandum No. 27, HIPAA Compliance Policy
• Executive Memorandum No. 41, Policy on Research Data and Security
• Executive Memorandum No. 42, Policy on Risk Classification and Minimum Security Standards
• University of Nebraska Affiliated Hospital House Staff Manual 2022 – 2023
• Research Handbook
• Institutional Review Board Guidelines
• Protecting Controlled Unclassified Information (CUI)
• Security and Privacy Controls for Information Systems and Organizations

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