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Policy No.: '''6045'''<br /> | Policy No.: '''6045'''<br /> | ||
Effective Date: '''11/21/03'''<br /> | Effective Date: '''11/21/03'''<br /> | ||
Revised Date: ''' | Revised Date: '''08/01/23'''<br /> | ||
Reviewed Date: ''' '''<br /> | Reviewed Date: 08/01/23''' '''<br /> | ||
<br /> | <br /> | ||
<big>'''Privacy, Confidentiality and Security of Patient and Proprietary Information Policy'''</big><br /><br /> | <big>'''Privacy, Confidentiality and Security of Patient and Proprietary Information Policy'''</big><br /><br /> | ||
== Basis for Policy == | == Basis for Policy == | ||
To maintain the privacy, confidentiality and security of patient and proprietary information and comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and related regulations. For purposes of this policy, confidential information means protected health information and proprietary information. | |||
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. [https://csrc.nist.gov/publications/detail/sp/800-53/rev-5/final NIST Special Publication 800-53] and the [https://www.cdc.gov/phlp/publications/topic/hipaa.html#security-rule HIPAA Security Rule] outline considerations for the access control family of security controls. | 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. [https://csrc.nist.gov/publications/detail/sp/800-53/rev-5/final NIST Special Publication 800-53] and the [https://www.cdc.gov/phlp/publications/topic/hipaa.html#security-rule HIPAA Security Rule] outline considerations for the access control family of security controls. | ||
== Policy == | == Policy == | ||
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##Right to request an accounting of disclosures (see UNMC Policy No. 6061, [https://wiki.unmc.edu/index.php/Accounting_of_PHI_Disclosures Accounting of Protected Health Information Disclosures]); | ##Right to request an accounting of disclosures (see UNMC Policy No. 6061, [https://wiki.unmc.edu/index.php/Accounting_of_PHI_Disclosures Accounting of Protected Health Information Disclosures]); | ||
##Right to receive a Notice of Privacy Practices (see UNMC Policy No. 6058, [https://wiki.unmc.edu/index.php/Notice_of_Privacy_Practices Notice of Privacy Practices]); and | ##Right to receive a Notice of Privacy Practices (see UNMC Policy No. 6058, [https://wiki.unmc.edu/index.php/Notice_of_Privacy_Practices Notice of Privacy Practices]); and | ||
##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, [https://wiki.unmc.edu/index.php/Notice_of_Privacy_Practices Notice of Privacy Practices], UNMC Policy No. 6062, [[Patient/Consumer Complaints]] and | ##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, [https://wiki.unmc.edu/index.php/Notice_of_Privacy_Practices Notice of Privacy Practices], UNMC Policy No. 6062, [[Patient/Consumer Complaints]] and Nebraska Medicine Patient Complaint and Grievance Management policy ''RI23''. '''Individuals shall not be asked to waive these rights as a condition of receiving treatment.''' | ||
#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]]). | #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]]). | ||
#Nebraska Medicine/UNMC workforce has a duty to protect confidential information. Breach of this duty includes but is not limited to the following: | #Nebraska Medicine/UNMC workforce has a duty to protect confidential information. Breach of this duty includes but is not limited to the following: | ||
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##Transferring confidential information in any form without both parties having a need to know such confidential information. | ##Transferring confidential information in any form without both parties having a need to know such confidential information. | ||
#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. | #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. | ||
#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 | #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 or [https://www.unmc.edu/academicaffairs/_documents/compliance/statement_of_understanding.pdfv Statement of Understanding] upon initial employment/work/appointment/credentialing. | ||
#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 | #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 [https://now.nebraskamed.com/leadership/ System Chief Medical Officer]. | ||
#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. | #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. | ||
#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 [https://wiki.unmc.edu/index.php?title=Privacy/Confidentiality&action=edit#Procedures Procedures, Section 2.2]). | #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 [https://wiki.unmc.edu/index.php?title=Privacy/Confidentiality&action=edit#Procedures Procedures, Section 2.2]). | ||
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##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). | ##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). | ||
#Editing, authenticating and correcting the medical record. | #Editing, authenticating and correcting the medical record. | ||
## | ##See Nebraska Medicine Policy, “Contents of Medical Record”, MS22, for editing and authenticating the medical record. | ||
#Business Associate | #[https://wiki.unmc.edu/index.php/Business_Associate_Agreements_and_Addendums_Procedures A Business Associate Agreement or Addenda] shall be executed with each Business Associate | ||
#Human Subjects Research shall be conducted in accordance with UNMC’s [https://guides.unmc.edu/books/hrpp-policies-and-procedures 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]]. | #Human Subjects Research shall be conducted in accordance with UNMC’s [https://guides.unmc.edu/books/hrpp-policies-and-procedures 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]]. | ||
#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. | #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 == | == Definitions == | ||
===Affiliated Covered Entity (ACE)=== | ===Affiliated Covered Entity (ACE)=== | ||
Legally separate covered entities that | Legally separate covered entities that 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. | ||
===Business Associate=== | ===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. | A third party who performs services on behalf of Nebraska Medicine/UNMC that involve the creation, receipt, maintenance or transmission of PHI in any form, even if PHI is not accessed. Some examples of such services include storage, including cloud storage, claims processing, data analysis, data processing, practice management, utilization review, quality assurance, patient safety activities, billing, benefit management and repricing. | ||
===Designated Record Set (DRS)=== | ===Designated Record Set (DRS)=== | ||
Includes medical records and billing records about Individuals maintained by or for UNMC/ACE and any other record used by | Includes medical records and billing records about Individuals maintained by or for UNMC/ACE and any other record used by the ACE to make decisions about Individuals. | ||
===Individual=== | ===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). | 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). | ||
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'''''In addition for purposes of this policy.''''' | '''''In addition for purposes of this policy.''''' | ||
===Information Security=== | ===Information Security=== | ||
Policies and practices designed to control access and protect information from unauthorized access, alteration, destruction, loss or disclosure. | |||
===Proprietary Information=== | ===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. | Information relating to Nebraska Medicine/UNMC business practices, including but not limited to financial statements, contracts, and business plans, employee records and meeting minutes. | ||
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*Contact the [mailto:debrbishop@nebraskamed.com Privacy] or [mailto:libazis@nebraskamed.com Information Security] Officers | *Contact the [mailto:debrbishop@nebraskamed.com Privacy] or [mailto:libazis@nebraskamed.com Information Security] Officers | ||
*Contact Human Resources – Records at 402-559-8962 or Human Resources - Employee Relations | *Contact Human Resources – Records at 402-559-8962 or Human Resources - Employee Relations | ||
* | *[https://www.unmc.edu/academicaffairs/_documents/compliance/statement_of_understanding.pdf Statement of Understanding] | ||
*UNMC Policy No. 1098, [https://wiki.unmc.edu/index.php/Corrective/Disciplinary_Action Corrective and Disciplinary Action] | *UNMC Policy No. 1098, [https://wiki.unmc.edu/index.php/Corrective/Disciplinary_Action Corrective and Disciplinary Action] | ||
*UNMC Policy No. 6036, [ | *UNMC Policy No. 6036, [https://wiki.unmc.edu/index.php?title=Reproducing_Copyrighted_Materials Reproduction of Copyrighted Materials Policy] | ||
*UNMC Policy No. 6052, [ | *UNMC Policy No. 6052, [https://wiki.unmc.edu/index.php?title=Student_Training_Agreement Contract or Agreement for Student Training Policy] | ||
*UNMC Policy No. 6057, [[Use and Disclosure of Protected Health Information]] | *UNMC Policy No. 6057, [[Use and Disclosure of Protected Health Information]] | ||
*UNMC Policy No. 6058, [[Notice of Privacy Practices]] | *UNMC Policy No. 6058, [[Notice of Privacy Practices]] | ||
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*UNMC Policy No. 8000, [[Compliance Program]] | *UNMC Policy No. 8000, [[Compliance Program]] | ||
*UNMC Policy No. 8009, [[Contracts]] | *UNMC Policy No. 8009, [[Contracts]] | ||
*[https://wiki.unmc.edu/index.php/Business_Associate_Agreements_and_Addendums_Procedures Business Associate Agreements and Addendums Procedures] | |||
*UNMC’s [https://guides.unmc.edu/books/hrpp-policies-and-procedures Human Research Protection Program (HRPP) Policies and Procedures], including HRPP Policy 3.4, “Use of Protected Health Information in Research | *UNMC’s [https://guides.unmc.edu/books/hrpp-policies-and-procedures 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 | *Nebraska Medicine Consents and Permits policy, MS14 | ||
*UNMC [https://info.unmc.edu/its-security/policies/procedures/data-classification.html Data Classification Procedure] | *UNMC [https://info.unmc.edu/its-security/policies/procedures/data-classification.html Data Classification Procedure] | ||
*[ | *[https://wiki.unmc.edu/index.php?title=Privacy/Information_Security UNMC Privacy and Information Security Policies] | ||
*[ | *[https://wiki.unmc.edu/index.php?title=Human_Resources_-_Procedures UNMC Human Resources Procedures] | ||
*[https://info.unmc.edu/its-security/policies/plan.html Information Security Plan] | *[https://info.unmc.edu/its-security/policies/plan.html Information Security Plan] | ||
*[https://info.unmc.edu/its-security/policies/procedures/destruction-confinfo.html Destruction of Private and Confidential Information Procedures] | *[https://info.unmc.edu/its-security/policies/procedures/destruction-confinfo.html Destruction of Private and Confidential Information Procedures] | ||
*[ | *[https://wiki.unmc.edu/index.php?title=Informed_Consent_for_UNMC_Media_Production_and_Distribution_Procedures Procedures for Obtaining Informed Consent for UNMC Audio-Visual Media Production and Distribution] | ||
*[ | *[https://www.unmc.edu/human-resources/_documents/procedures/Procedures1097.pdf Human Resources Performance Management Procedures] | ||
*[ | *[https://info.unmc.edu/wiki/index.php/Faculty_Handbook UNMC Faculty Handbook: Operating Procedures] | ||
*[ | *[https://catalog.unmc.edu/general-information/ Student Handbook] | ||
*[https://csrc.nist.gov/publications/detail/sp/800-53/rev-5/final NIST Special Publication 800-53] | *[https://csrc.nist.gov/publications/detail/sp/800-53/rev-5/final NIST Special Publication 800-53] | ||
*[https://www.cdc.gov/phlp/publications/topic/hipaa.html Health Insurance Portability and Accountability Act of 1996] (HIPAA) | *[https://www.cdc.gov/phlp/publications/topic/hipaa.html Health Insurance Portability and Accountability Act of 1996] (HIPAA) | ||
*[https://www.cdc.gov/phlp/publications/topic/hipaa.html#security-rule HIPAA Security Rule] | *[https://www.cdc.gov/phlp/publications/topic/hipaa.html#security-rule HIPAA Security Rule] | ||
*University of Nebraska [https://nebraska.edu/-/media/unca/docs/offices-and-policies/policies/board-governing-documents/board-of-regents-bylaws.pdf?la=en Board of Regents Bylaws] | *University of Nebraska [https://nebraska.edu/-/media/unca/docs/offices-and-policies/policies/board-governing-documents/board-of-regents-bylaws.pdf?la=en Board of Regents Bylaws] | ||
*University of Nebraska [https://nebraska.edu/-/media/unca/docs/offices-and-policies/policies/board-governing-documents/board-of-regents-policies.pdf?la=en Board of Regents Policies] | *University of Nebraska [https://nebraska.edu/-/media/unca/docs/offices-and-policies/policies/board-governing-documents/board-of-regents-policies.pdf?la=en Board of Regents Policies] | ||
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*[https://nebraska.edu/-/media/unca/docs/offices-and-policies/policies/executive-memorandum/university-of-nebraska-information-security-plan.pdf Executive Memorandum No. 26, Information Security Plan - Gramm Leach Bliley Compliance] | *[https://nebraska.edu/-/media/unca/docs/offices-and-policies/policies/executive-memorandum/university-of-nebraska-information-security-plan.pdf Executive Memorandum No. 26, Information Security Plan - Gramm Leach Bliley Compliance] | ||
*[https://nebraska.edu/-/media/unca/docs/offices-and-policies/policies/executive-memorandum/hipaa-compliance-policy.pdf Executive Memorandum No. 27, HIPAA Compliance Policy] | *[https://nebraska.edu/-/media/unca/docs/offices-and-policies/policies/executive-memorandum/hipaa-compliance-policy.pdf Executive Memorandum No. 27, HIPAA Compliance Policy] | ||
*Executive Memorandum No. 41, [https://nebraska.edu/-/media/unca/docs/offices-and-policies/policies/executive-memorandum/policy-on-research-and-data-security.pdf Policy on Research Data and Security] | |||
*Executive Memorandum No. 42, [https://nebraska.edu/-/media/unca/docs/offices-and-policies/policies/executive-memorandum/policy-on-risk-classification-and-minimum-security-standards.pdf Policy on Risk Classification and Minimum Security Standards] | |||
*[https://www.unmc.edu/com/about/gme/housestaffmanual.pdf University of Nebraska Affiliated Hospital House Staff Manual 2022 – 2023] | *[https://www.unmc.edu/com/about/gme/housestaffmanual.pdf University of Nebraska Affiliated Hospital House Staff Manual 2022 – 2023] | ||
*[https:// | *[https://guides.unmc.edu/books/research-handbook Research Handbook] | ||
*[ | *[https://www.unmc.edu/irb/ Institutional Review Board Guidelines] | ||
*[https://csrc.nist.gov/publications/detail/sp/800-53/rev-5/final Security and Privacy Controls for Information Systems and Organizations] | *[https://csrc.nist.gov/publications/detail/sp/800-53/rev-5/final Security and Privacy Controls for Information Systems and Organizations] | ||
This page maintained by [mailto: | This page maintained by [mailto:mhurlocker@unmc.edu mh]. | ||