Difference between revisions of "Privacy/Confidentiality"

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width="20">[[Intellectual Property]]</td>
 
width="20">[[Intellectual Property]]</td>
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<td style="border-bottom:2px solid #A3B1BF" width="3">&#160;</td>
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<td style="padding:0.5em; background-color:#e5e5e5; font-size:90%; line-height:0.95em; border:1px solid #A3B1BF; border-bottom:solid 2px #A3B1BF"
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width="20">[[Faculty]]</td>
 
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<br />
 
<br />
[[Identification Card]] | [[Secure Area Card Access]] | [[Privacy/Confidentiality]] | [[Computer Use/Electronic Information]] | [[Confidential Information]] | [[Protected Health Information (PHI)]] | [[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]]
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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]]
 
<br /><br />
 
<br /><br />
 
Policy No.: '''6045'''<br />
 
Policy No.: '''6045'''<br />
 
Effective Date: '''11/21/03'''<br />
 
Effective Date: '''11/21/03'''<br />
Revised Date: '''08/17/07'''<br />
+
Revised Date: '''07/01/19'''<br />
Revised Date: '''08/20/08'''<br />
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Reviewed Date: '''06/17/19'''<br />
 
<br />
 
<br />
<big>'''Privacy, Confidentiality and Information Security Policy'''</big><br /><br />
+
<big>'''Privacy, Confidentiality and Security of Patient and Proprietary Information Policy'''</big><br /><br />
 
+
'''NOTE''': These guidelines are provided to assist UNMC workforce, including those in the patient treatment areas of the Munroe-Meyer Institute, the College of Medicine Optical Shop, the Lions Eye Bank and the College of Dentistry, as applicable, comply with HIPAA regulations. Those departments and clinics which fall under the jurisdiction of  The Nebraska Medical Center and/or University Medical Associates should consult the policies and procedures of those entities for authoritative guidance.<br />
+
<br />
+
== Introduction ==
+
University of Nebraska Medical Center (UNMC) workforce and business associates handle a variety of proprietary information concerning patients, colleagues, employees, students, alumni, donors or others associated with the University. This information includes, but may not be limited to:   
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* Protected Health Information (PHI) as defined by [http://www.unmc.edu/hippa HIPAA]
+
* Student Education Records as defined by [http://www2.ed.gov/policy/gen/guid/fpco/ferpa/index.html FERPA]
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* Protected Student Financial Information (PSFI) as defined by [http://business.ftc.gov/privacy-and-security/gramm-leach-bliley-act GLBA]
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* Employee records
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* Research data
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* Business plans
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* Financial data
+
 
+
It is the responsibility of all University workforce and business associates to respect the highest level of privacy for their patients, colleagues and other members of the University community.  Disclosure and discussion of confidential information obtained from University records, either during or after employment or association with the University, is impermissible unless such disclosure is a normal requirement of a workforce position and has been authorized.
+
 
+
UNMC shall require its workforce to adhere to another entity’s rules, regulations, policies and procedures while on the premises of the other entity as contracted workforce of that other entity.
+
 
+
 
== Basis for Policy ==
 
== Basis for Policy ==
 
+
To maintain the privacy, confidentiality and security of patient information in compliance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and other proprietary, confidential or regulated information.  
It is the policy of the University of Nebraska Medical Center (UNMC) to comply with all applicable federal, state, local regulations and University policies and procedures governing confidentiality, privacy and information security.  These regulations and guidelines include, but may not be limited to:   
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* [http://www.unmc.edu/hipaa Health Insurance Portability and Accountability Act of 1996] (HIPAA)
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* [http://www.ftc.gov/privacy/privacyinitiatives/glbact.html Gramm-Leach-Bliley Act] (GLBA)
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* [http://www.ed.gov/offices/OM/fpco/ferpa/index.html Family Educational Rights and Privacy Act] (FERPA)
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* Nebraska Free Flow of Information Act (§ 20-144, 20-145, 20-146, 20-147
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* Nebraska Rev. Statutes § 84-712, 84-712.01, 84-712.02, 84-712.03, 84-712.04, 84-712.05, 84-712.06, 84-712.07, 84-712.08, 84-712.09
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* [http://www.nebraska.edu/bylaws-and-policies.html Board of Regents Bylaws]
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* [http://www.nebraska.edu/board/board_policies.shtml Board of Regents Policies]
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* [http://www.nebraska.edu/docs/president/16%20Responsible%20Use%20of%20Computers%20and%20Info%20Systems.pdf Executive Memorandum No. 16, Responsible Use of Information Resources, Technology and Networks]
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* [http://www.nebraska.edu/about/exec_memo22.pdf Executive Memorandum No. 22, Public Record Requests]
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* [http://www.nebraska.edu/about/exec_memo26.pdf Executive Memorandum No. 26, Information Security Plan]
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* [http://www.nebraska.edu/about/exec_memo27.pdf Executive Memorandum No. 27, HIPAA Compliance Policy]
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* [http://wiki.unmc.edu/index.php?title=Compliance_Program UNMC Policy No. 8000, Compliance Program]
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* [http://wiki.unmc.edu/index.php?title=Privacy/Information_Security UNMC Privacy and Information Security Policies]
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* [http://wiki.unmc.edu/index.php?title=Reproducing_Copyrighted_Materials UNMC Policy No. 6036, Reproduction of Copyrighted Materials Policy]
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* [http://wiki.unmc.edu/index.php?title=Student_Training_Agreement UNMC Policy No. 6052, Contract or Agreement for Student Training Policy]
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* [http://info.unmc.edu/index.php?title=wiki/index.php/Faculty_Handbook UNMC Faculty Handbook]
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* [http://www.unmc.edu/studentservices/_documents/handbook.pdf UNMC Student Handbook]: Academic Policies
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* [http://wiki.unmc.edu/index.php?title=Human_Resources_-_Procedures UNMC Human Resources Procedures]
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* [http://www.unmc.edu/cctr/ Clinical Research Center Guidebook]
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* Eppley Cancer Center Scientific Review Committee Policies and Procedures
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* [http://www.unmc.edu/com/about/gme/gme-housestaff.pdf University of Nebraska Residency Program Policies and Procedures]
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* [http://www.unmc.edu/spa/ Sponsored Programs Administration Policies and Procedures]
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* [http://www.unmc.edu/irb/ Institutional Review Board Guidelines]
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* [http://www.unmc.edu/its/ Information Technology Services Procedures
+
 
+
 
== Policy ==
 
== Policy ==
It is the policy of University of Nebraska Medical Center (UNMC) to protect confidentiality and privacy through appropriate acquisition, storage, maintenance, use, and destruction of information gathered in the course of employment or other affiliation with UNMC or entrusted to UNMC for academic, research, patient care, or administrative purposes.  
+
It is the policy of UNMC to maintain the confidentiality of all regulated information, including but not limited to protected health information, controlled unclassified information and other regulated information, and all confidential proprietary information classified in accordance with UNMC's [https://info.unmc.edu/its-security/policies/procedures/data-classification.html Data Classification Procedure].
 +
== Definitions (as defined by HIPAA 45 CFR 164.501) ==
 +
*'''Affiliated Covered Entity (ACE)''' means University of Nebraska Medical Center, The Nebraska Medical Center, UNMC Physicians, University Dental Associates, Bellevue Medical Center and The Nebraska Pediatric Practice Plan as one covered entity for the purpose of sharing PHI under HIPAA.  ACE membership may change from time to time. The Notice of Privacy Practices lists current ACE members.
 +
*'''Business Associate''' means a third party who performs services on behalf of UNMC and has access to protected health information (PHI) when performing services; or provides one of the following services for UNMC involving access to PHI: claims processing, data analysis, data processing, practice management, utilization review, quality assurance, billing, benefit management, and repricing.
 +
*'''Designated Record Set''' is the medical record and billing record.
 +
*'''Individual''' means the person who is the subject of the protected health information (including ACE workforce who are patients).
 +
*'''Protected Health Information (PHI)'''  is individually identifiable health information. Health information means any information, whether oral or recorded in any medium that:
 +
:*is created or received by 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.
 +
*'''Workforce''' means employees, the medical staff, volunteers, trainees, and other persons whose conduct, in the performance of work for UNMC is under the direct control of UNMC, whether or not they are paid by UNMC.
 +
==Other Definitions==
 +
*'''Controlled Unclassified Information (CUI)''' as defined by U.S. Presidential Executive Order 13556 is information that requires safeguarding or dissemination controls pursuant to and consistent with applicable law, regulations and government-wide policies but is not classified under Executive Order 13526 or the Atomic Energy Act, as amended.
 +
*'''Employee Records''' refers to all information, records and documents pertaining to any person who is an applicant or nominee for any University personnel position described in the Board of Regents Bylaws, § 3.1, regardless of whether any such person is ever actually employed by the University, and all information, records and documents pertaining to any person employed by the University.
 +
*'''Information Security''' is the ability to control access and protect information from unauthorized alteration, destruction, loss or accidental or intentional disclosure to unauthorized persons.
 +
*'''Proprietary Information''' is information relating to business practices, including but not limited to financial statements, contracts, and business plans; employee records; student records; and meeting minutes.
 +
*'''Student Education Records''' means any information recorded in any way which directly relates to a student and is maintained by or on behalf of UNMC (education agency/institution). Student education record does not include a (i) sole possession record, (ii) law enforcement record, (iii) employee record of a person who is employed by UNMC by virtue of his or her status as a student at UNMC (e.g. work study, assistantships, resident assistants), (iv) alumni record and (v) medical record that is part of the common medical record shared by the Affiliated Covered Entity. Student education records are covered by the Family Educational Rights and Privacy Act (FERPA).
  
Department administration shall determine what information entrusted to their department is private and/or confidential; and shall communicate methods of protecting that information from acquisition through destruction, to appropriate persons associated with their department. UNMC workforce and business associates with access to private and/or confidential information will be held accountable for maintaining confidentiality.  
+
==Procedures==
 
+
===Patient Information===
For more detailed information, see  
+
*Records containing PHI, in any form, are the property of the ACE. 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.
* Privacy, Confidentiality and Information Security Procedures
+
*Individuals have the following rights with respect to their PHI:
* [http://www.unmc.edu/its/security/procedures/infosecurity-plan.html Information Security Plan]
+
:*Right to request access and obtain copies of their designated record set within a reasonable amount of time and to request amendment (see UNMC Policy No. 6059, [https://wiki.unmc.edu/index.php/Access_to_Designated_Record_Set Access and Amendment of Designated Record Set]);
* UNMC Policy No. 6056, Retention and Destruction/Disposal of Private and Confidential Information
+
:*Right to request restrictions of how their PHI is used and disclosed (see UNMC Policy No. 6057, [[Use and Disclosure of Protected Health Information]]);
 
+
:*Right to request an accounting of disclosures (see UNMC Policy No. 6061, [[Accounting of PHI Disclosures]]);
Breach of confidentiality may result in sanctions, civil or criminal prosecution and penalties, scholastic or employment corrective action which could lead to dismissal or, as it relates to health care professionals or others outside of UNMC, suspension or revocation of all access privileges.  
+
:*Right to receive a Notice of Privacy Practices (see UNMC Policy No. 6058, [[Notice of Privacy Practices]];
 
+
:*Right to file a complaint internally with the Nebraska Medicine Patient Relations Department, the Office of the Assistant Dean for Patient Services (College of Dentistry), or with the U.S. Department of Health and Human Services Office for Civil Rights. (See UNMC Policy Nos. 6058, [[Notice of Privacy Practices]] and 6062, [[Patient/Consumer Complaints]]).
Individuals who know or suspect that confidentiality has been breached by another person or persons have a responsibility to report the breach to Financial Controls and Compliance or to the Human Resources Employee Relations Department. Employees should not confront the individual under suspicion or initiate investigations on their own, as such actions could compromise any ensuing investigation. All individuals are to cooperate fully with those performing an investigation pursuant to this policy.  
+
*Individuals shall not be asked to waive these rights as a condition of receiving treatment.
 
+
*The ACE is responsible for safeguarding and protecting PHI against loss, tampering, and disclosure to unauthorized individuals. The safeguarding of PHI 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]]).
New hires and volunteers and first year students shall read this policy and sign the Statement of Understanding. Thereafter, all members of the workforce shall sign the agreement annually. The agreement is also available online through UNMC's Employee Self Service (ESS). The original document should be maintained in the department staff/faculty/student/volunteer file if completed manually and retained for six years.  
+
*ACE workforce have a duty to protect PHI. Breach of this duty includes the following:
 
+
:*Accessing PHI, in any form, without a "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 via the online patient portal.
== Definitions ==
+
:*Discussing or disclosing patient care events to individuals who do not have a “need to know” 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.
'''Employee records''' refers to all information, records and documents pertaining to any person who is an applicant or nominee for any University personnel position described in the Board of Regents Bylaws, § 3.1, regardless of whether any such person is ever actually employed by the University, and all information, records and documents pertaining to any person employed by the University.  
+
:*Disclosing PHI without proper authorization (see UNMC Policy No. 6057, [[Use and Disclosure of Protected Health Information]]);
 
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:*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]]);
'''Information''' is data presented in readily comprehensible form.  (Whether a specific message is informative or not depends in part on the subjective perceptions of the person who receives it.) Information may be stored or transmitted via electronic media, on paper or other tangible media, or be known by individuals or groups. Information generated in the course of University operations is a valuable asset of the University and belongs to the University.  
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:*Discussing PHI in the presence of individuals who do not have the "need to know" to perform assigned duties;
 
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:*Disclosing that a patient is receiving care (except for authorized directory purposes);
'''Information security''' is defined as the ability to control access and protect information from accidental or intentional disclosure to unauthorized persons and from alteration, destruction or loss.  
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:*Leaving PHI unattended in a non-secure area;
 
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:*Improper disposal of PHI;
'''Information technology''' resources include voice, video, data and network facilities and services and are intended for use in completing UNMC’s mission. Their use is governed by Executive Memorandum No. 16, Executive Memorandum No. 26, Information Security Plan, all applicable UNMC policies (see especially Policy No. 6051, Computer Use and Information Security), Information Technology Services policies and procedures and applicable federal, state and local laws.  
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:*Using another person's user ID, password, or other security codes;
 
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:*Assisting an unauthorized user to gain access to a secured information system;
'''Job Shadowing'''  is an opportunity for an individual, age 16 and older, to observe and learn aspects about the world of work in a health care setting. The experience permits the program participant to gain an understanding of a typical day for an employee, and the skills necessary to complete the work required. The job shadow program is designed to promote the health care professions while safeguarding patients’ privacy. Participants in the job shadowing program are considered UNMC workforce and are subject to this policy and related procedures.
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:*Transferring PHI in any form without both parties having a need to know.
 
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*The ACE shall reasonably mitigate or reduce any harmful effects that may result from privacy breaches.
'''Privacy''' is defined as the right of individuals to keep information about themselves from being disclosed.  
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*All employees, medical staff, allied health practitioners and members of the workforce with access to PHI shall sign UNMC [https://www.unmc.edu/academicaffairs/_documents/compliance/Statement_of_Understanding.pdf Statement of Understanding] upon initial employment/work/appointment/credentialing.
 
+
*Workforce members who suspect a privacy or information security violation must report it immediately to their respective manager and the Privacy and/or Information Security Office. A full investigation of the suspected violation shall be conducted. Staff who wish to remain anonymous may report the suspected violation to the Compliance Hotline at 844-348-9548. 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.
'''Proprietary information''' refers to information regarding business practices, including but not limited to, financial statements, contracts, business plans, research data, employee records and student records.  
+
*Sanctions for violations of privacy or information security may include revocation of medical staff privileges, allied health credentials, or employee corrective action up to and including termination of employment (see UNMC Policy No. 1098, [https://wiki.unmc.edu/index.php/Corrective/Disciplinary_Action Corrective and Disciplinary Action]). Civil and criminal fines and penalties can also be levied under HIPAA.
 
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*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 the organization or to the Office for Civil Rights.
'''Protected Health Information (PHI)''' is individually identifiable health information.  Health information means any information, whether oral or recorded in any medium, that:  
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*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]].
* is created or received by UNMC; and
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*Paper medical records shall be maintained in the Health Information Management Department.
* 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.
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:*Records sent to clinic areas shall be returned to the Health Information Management Department within one working day.
 
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:*Records of discharged patients will remain on the units until Health Information Management picks them up. Medical records of deceased patients scheduled for an autopsy may be sent to the morgue.
Records containing PHI, in any form, are the property of UNMC. The PHI contained in the record is the property of the individual who is the subject of the record.  
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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).
 
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*Editing, authenticating and correcting the medical record.
'''Protected Student Financial Information (PSFI)''' is information that UNMC has obtained from a student in the process of offering a financial product or service, or such information provided to UNMC by another financial institution. Offering a financial product or service includes offering student loans to students, receiving tax information from a student’s parent when offering a financial aid package and other financial services. Examples of student financial information include addresses, phone numbers, bank and credit account numbers, income and credit histories, and social security numbers in both paper and electronic format.  
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:*Please contact the One Chart Resource team.
 
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*Business Associate agreements/addenda shall be established with any individual or corporation who performs a function on behalf of UNMC involving the use or disclosure of PHI, other than as a member of the workforce or a healthcare provider providing treatment (see UNMC Policy No. 8009, [[Contracts]]).
Student education records means any information recorded in any way which directly relates to a student and is maintained by or on behalf of UNMC (education agency/institution). Student education record does not include a (i) sole possession record, (ii) law enforcement record, (iii) employee record of a person other than a student who is employed by UNMC by virtue of his or her status as a student at UNMC, (iv) alumni record and (v) medical record that is part of the common medical record shared by UNMC, The Nebraska Medical Center, UMA and UDA. (NOTE: HIPAA and GLBA privacy regulations do not apply to education records covered by FERPA.)
+
*Human Subjects Research shall be conducted in accordance with UNMC Human Research Protection Program (HRPP) Policies and Procedures, including [https://net.unmc.edu/rss/ HRPP Policy 3.4, Use of Protected Health Information in Research and Registries] and with 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.
Workforce refers to faculty, staff, volunteers, trainees, students (including job shadowing participants), independent contractors and other persons whose conduct, in the performance of work for UNMC, is under the direct control of UNMC, whether or not they are paid by UNMC.<br />
+
*The Privacy Officer shall be designated in writing and shall be responsible for developing and implementing written policies and procedures necessary to comply with the [https://www.hhs.gov/hipaa/index.html Health Insurance Portability and Accountability Act of 1996 (HIPAA)].
<br />
+
*All members of the workforce shall receive training on privacy and security of confidential information upon hire, and when policies and procedures relevant to their position change.
For more information, contact the Privacy or Information Security Officers, or see the following resources:
+
===Business Information===
* [http://www.unmc.edu/hipaa/_documents/6045-privacy-procedure.doc Privacy, Confidentiality and Information Security Procedures]
+
*Members of the workforce have a duty to protect proprietary business information. Breach of this duty includes, but may not be limited to, the following:
* [http://www.unmc.edu/its/security/procedures/infosecurity-plan.html Information Security Plan]
+
:*Disclosure of confidential financial information
* [http://info.unmc.edu/media/its/strohben/HIPAA/UNMCHIPAACompliancePlan_05%20review.pdf HIPAA Compliance Plan]
+
:*Disclosure of confidential contract/agreement information
* [http://www.unmc.edu/hipaa/_documents/telehealth-final.pdf Telehealth Procedures]
+
:*Disclosure of confidential business plans
* [http://www.unmc.edu/media/compliance/privacy_incident_response_and_breach_notification_procedures.pdf Privacy Incident Response and Breach Notification Procedures]
+
:*Disclosure of fundraising information
* [http://www.nebraska.edu/siteinfo/index.shtml Copyright and Disclaimer]
+
:*Disclosure of credit card information received in the course of business, whether or not such credit card information is covered by the Gramm-Leach-Bliley Act (GLBA).
* [http://www.unmc.edu/its/security/procedures/destruction-confinfo.html Destruction of Private and Confidential Information Procedures]
+
*Workforce members who suspect a breach of confidentiality regarding proprietary information shall report the breach to the Human Resources Employee Relations Department.
* [http://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]
+
*A full investigation of the breach shall be conducted by the Human Resources Employee Relations Department, as appropriate.
* [http://www.unmc.edu/hr/Proc/Procedures1097.pdf Human Resources Performance Management Procedures]
+
===Student Education Record Information===
* [http://info.unmc.edu/wiki/index.php/Faculty_Handbook UNMC Faculty Handbook: Operating Procedures]
+
*Members of the workforce have a duty to maintain the confidentiality of student education records. Breach of this duty includes, but is not limited to, release of student information that is not considered “directory information” under the guidelines of the Family Educational Rights and Privacy (FERPA) listed in the Student HandbookIt also includes, but is not limited to, protection of confidential student financial information protected under the Gramm-Leach-Bliley Act (GLBA).
* [http://www.unmc.edu/studentservices/_documents/handbook.pdf UNMC Student Handbook: Academic Policies]
+
*Employees shall verify FERPA restrictions placed on student records prior to release of student information.
 +
*The social security number of a student is considered confidential information and must not be used to identify a student.
 +
*Information Technology Services (ITS) shall be available to assist in identifying alternatives to use of social security number. Alternatives which should be considered, include but are not limited to Student Number.
 +
*Use of a student’s social security number in databases is prohibited. In the event that the social security number of a student must be maintained, an Exhibit B - [https://www.unmc.edu/hipaa/_documents/6045-Exhibit-B-SSN-Student.docx Use of Student Social Security Number Exception] must be completed and submitted to Academic Affairs for approval. If it must be used, the use of the student’s social security number must comply with [https://info.unmc.edu/its-security/policies/procedures/database-security.html ITS Database Security Procedures].
 +
*Workforce members who suspect a breach of confidentiality regarding Student Education Records shall report the breach to the Compliance Office or the Student Affairs Office.  
 +
*The student may file a complaint with the Family Policy Compliance Office, U.S. Department of Education, 400 Maryland Ave SW, Washington, DC 20202-4605.
 +
===Employee Information===
 +
*Employment records are confidential and will not be made publicly available, except upon written authorization signed by the individual to whom the records pertain or in response to a legal mandate. In this context, employment records are those of persons who are employees of UNMC, and persons who are or have been either applicants or nominees for employment. Such records include the entire employment process beginning with application or nomination for appointment, search committee evaluation, and appointing authority evaluation, through appointment and employment, and ending with separation from employment.  
 +
*The social security number of an employee is considered confidential information and should not be used to identify an employee unless legally mandated, see UNMC policy No. 6085, [[Social Security Number]].
 +
*ITS shall be available to assist in identifying alternatives to use of social security number. Alternatives which should be considered, include but are not limited to:
 +
:*Personnel (SAP) Number
 +
:*Last four digits of social security number 
 +
*In the event that the social security number of an employee must be maintained, an Exhibit C - [https://www.unmc.edu/hipaa/_documents/6045-Exhibit-C-SSN-Employee.docx Use of Employee Social Security Number Exception] must be completed and submitted to Human Resources for approval. In cases where the employee social security number must be stored in a database, the database use must comply with [https://info.unmc.edu/its-security/policies/procedures/database-security.html ITS Database Security Procedures].
 +
*The following are not confidential and are considered by UNMC as directory information:
 +
:*Employee Name
 +
:*Gross salary
 +
:*Dates of hire and separation
 +
:*Type of appointment(s) held and term of each appointment
 +
:*Title or academic rank
 +
:*UNMC employment address
 +
:*Post-secondary education degrees earned
 +
:*Awards or honors
 +
*Employee information other than directory information is accessible only to the employee, the department administrative personnel, UNMC Human Resources, and other University offices with a need to know.  Non-directory information should be released to others only with signed authorization from the employee or in response to a legal mandate.  
 +
*Departments have three options for responding to requests for reference checks:
 +
:*Refer to Human Resources – Records
 +
:*Provide directory information only
 +
:*With a signed release, respond to questions and provide information based only on what is documented in the employment file
 +
:*For more information about responding to reference checks, inquire at UNMC Human Resources – Records at 402-559-8962.
 +
*Members of the workforce have a duty to protect employee information. Breach of this duty includes but is not limited to the following:
 +
:*Disclosure of social security number
 +
:*Disclosure of Family Medical Leave information
 +
:*Disclosure of employee corrective action
 +
*Workforce members who suspect a breach of confidentiality regarding Employment Records shall report the breach to the Human Resources Employee Relations Department.
 +
===Controlled Unclassified Information (CUI)===
 +
Controlled Unclassified Information as defined by Executive Order 13556 and administered by the National Archives includes several categories of information, as detailed in the CUI Registry (https://www.archives.gov/cui/registry/category-list). That list includes:
 +
*Personally Identifiable Information (PII)
 +
*Personally Identifiable Health Information (PHI)
 +
*Defense/Technology related research and development for the US Government
 +
Guiding standards for the management and handling of CUI are:
 +
*[https://csrc.nist.gov/publications/detail/sp/800-171/rev-1/final Protecting Controlled Unclassified Information in Nonfederal Information Systems and Organizations]
 +
*[https://csrc.nist.gov/publications/detail/sp/800-53/rev-4/final Security and Privacy Controls for Federal Information Systems and Organizations]
 +
All personnel, including faculty, staff, research associates and fellows, visiting scholars, students, and all other persons retained by or working at the University of Nebraska Medical Center and its affiliates will comply with all applicable U.S. laws and regulations while teaching, conducting research or providing service activities at or on behalf of the university. As such, personnel are required to comply with the U.S. laws that regulate the transfer of items, information, technology, software, and funds to destinations and persons outside of the U.S., as well as in some cases, to non-U.S. citizens at the university.
 +
*Specific CUI are referenced elsewhere in this policy, reference applicable sections for additional information.
 +
*Workforce members who suspect a breach of confidentiality regarding controlled unclassified information shall report the breach to the Privacy Office and/or Information Security Office.  
 +
===Research Information===
 +
*PHI and other sensitive data, such as student information or business information, may be elements of authorized research. Members of the workforce have a duty to protect confidential information produced while performing research.  
 +
*Health outcomes and quality improvement projects performed with data from the Nebraska Medicine enterprise may be exempt from IRB review and approval but publication of those results will require IRB approval. Any questions should be directed to the IRB, and questions of ethical access to the data to specific individuals or groups can be referred to the privacy officer or IRB.
 +
*Research with PHI generated within Nebraska Medicine or other UNMC affiliated entities or received by UNMC from other entities. Research personnel need to follow all relevant policies for use of those records, including restrictions on sharing with any individuals that have not received human subjects training and/or authorization by IRB protocol.
 +
*De-identified data used for research is proprietary information and should still be stored and shared safely.  
 +
*Research PHI generated by other entities and sent to UNMC. When UNMC receives data containing PHI from another or a group of institutions for the purposes of analysis or storage, such as when UNMC serves as a coordinating center for a collaboration, a multicenter trial, or UNMC conducts data analysis, PHI received should be stored securely and shared only with those individuals approved by the IRB protocol and in accordance with the business contract.  
 +
*Breach of confidentiality includes the following:  
 +
:*Disclosure of PHI to unauthorized persons or entities not included in the Authorization for Release of Information, if requested for specific data sets OR
 +
:*Disclosure of research results linked to human subjects to persons or entities not authorized in the Institutional Review Board (IRB) approved protocol
 +
*Workforce members who suspect a breach of confidentiality regarding human subjects’ research information shall report the breach to the IRB office for research data sets sent to UNMC from outside entities and/or the Privacy Office for data sets generated within Nebraska Medicine or affiliated entities.
 +
==Additional Information==
 +
*Note: Corresponds to Nebraska Medicine Policy IM06
 +
*Contact the [mailto:sarah.glodencarlson@unmc.edu Chief Compliance Officer], 402-559-9576, or the UNMC Compliance Office at 402-559-6767
 +
*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
 +
*[https://www.unmc.edu/academicaffairs/_documents/compliance/Statement_of_Understanding.pdf Statement of Understanding]
 +
*Exhibit B - [https://www.unmc.edu/hipaa/_documents/6045-Exhibit-B-SSN-Student.docx Use of Student Social Security Number Exception]
 +
*Exhibit C - [https://www.unmc.edu/hipaa/_documents/6045-Exhibit-C-SSN-Employee.docx Use of Employee Social Security Number Exception]
 +
*UNMC Policy No. 1098, [https://wiki.unmc.edu/index.php/Corrective/Disciplinary_Action Corrective and Disciplinary Action]
 +
*UNMC Policy No. 6036, [http://wiki.unmc.edu/index.php?title=Reproducing_Copyrighted_Materials Reproduction of Copyrighted Materials Policy]
 +
*UNMC Policy No. 6052, [http://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. 6058, [[Notice of Privacy Practices]]
 +
*UNMC Policy No. 6059, [https://wiki.unmc.edu/index.php/Access_to_Designated_Record_Set 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. 8000, [[Compliance Program]]
 +
*UNMC Policy No. 8009, [[Contracts]]
 +
*UNMC [https://info.unmc.edu/its-security/policies/procedures/data-classification.html Data Classification Procedure]
 +
*[http://wiki.unmc.edu/index.php?title=Privacy/Information_Security UNMC Privacy and Information Security Policies]
 +
*[http://wiki.unmc.edu/index.php?title=Human_Resources_-_Procedures UNMC Human Resources Procedures]
 +
*[https://wiki.unmc.edu/index.php/Job_Shadowing_Procedure Job Shadowing Procedures]
 +
*[https://info.unmc.edu/its-security/policies/plan.html Information Security Plan]
 +
*[http://www.unmc.edu/hipaa/_documents/telehealth-final.pdf Telehealth Procedures]
 +
*[https://www.unmc.edu/hipaa/_documents/privacy-incident-response-and-breach-notification-procedures.pdf Privacy Incident Response and Breach Notification Procedures]
 +
*[https://nebraska.edu/offices-policies/general-counsel/practice-areas/intellectual-property Copyright and Disclaimer]
 +
*[https://info.unmc.edu/its-security/policies/procedures/destruction-confinfo.html Destruction of Private and Confidential Information Procedures]
 +
*[http://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]
 +
*[http://www.unmc.edu/hr/Proc/Procedures1097.pdf Human Resources Performance Management Procedures]
 +
*[http://info.unmc.edu/wiki/index.php/Faculty_Handbook UNMC Faculty Handbook: Operating Procedures]
 +
*[http://catalog.unmc.edu/general-information/ Student Handbook]
 +
*[https://aspe.hhs.gov/report/health-insurance-portability-and-accountability-act-1996 Health Insurance Portability and Accountability Act of 1996] (HIPAA)
 +
*[http://www.ftc.gov/privacy/privacyinitiatives/glbact.html Gramm-Leach-Bliley Act] (GLBA)
 +
*[http://www.ed.gov/offices/OM/fpco/ferpa/index.html Family Educational Rights and Privacy Act] (FERPA)
 +
*Nebraska Free Flow of Information Act (§ 20-144, 20-145, 20-146, 20-1470)
 +
*[http://nebraskalegislature.gov/laws/laws.php Nebraska Rev. Statutes] § 84-712, 84-712.01, 84-712.02, 84-712.03, 84-712.04, 84-712.05, 84-712.06, 84-712.07, 84-712.08, 84-712.09
 +
*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]
 +
*[https://nebraska.edu/-/media/unca/docs/offices-and-policies/policies/executive-memorandum/policy-for-responsible-use-of-university-computers-and-information-systems.pdf Executive Memorandum No. 16, Policy for Responsible Use of University Computers and Information Systems]
 +
*[https://nebraska.edu/-/media/unca/docs/offices-and-policies/policies/executive-memorandum/public-records-request.pdf Executive Memorandum No. 22, Public Record Requests]
 +
*[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://www.unmc.edu/com/about/gme/housestaffmanual.pdf University of Nebraska Affiliated Hospital House Staff Manual 2018 – 2019]
 +
*[https://www.unmc.edu/vcr/about/research-handbook-web.pdf Research Handbook]
 +
*[http://www.unmc.edu/irb/ Institutional Review Board Guidelines]
 +
*[https://csrc.nist.gov/publications/detail/sp/800-171/rev-1/final Protecting Controlled Unclassified Information in Nonfederal Information Systems and Organizations]
 +
*[https://csrc.nist.gov/publications/detail/sp/800-53/rev-4/final Security and Privacy Controls for Federal Information Systems and Organizations]  
  
 
This page maintained by [mailto:dpanowic@unmc.edu dkp].
 
This page maintained by [mailto:dpanowic@unmc.edu dkp].

Revision as of 14:12, July 16, 2021

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Policy No.: 6045
Effective Date: 11/21/03
Revised Date: 07/01/19
Reviewed Date: 06/17/19

Privacy, Confidentiality and Security of Patient and Proprietary Information Policy

Basis for Policy

To maintain the privacy, confidentiality and security of patient information in compliance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and other proprietary, confidential or regulated information.

Policy

It is the policy of UNMC to maintain the confidentiality of all regulated information, including but not limited to protected health information, controlled unclassified information and other regulated information, and all confidential proprietary information classified in accordance with UNMC's Data Classification Procedure.

Definitions (as defined by HIPAA 45 CFR 164.501)

  • Affiliated Covered Entity (ACE) means University of Nebraska Medical Center, The Nebraska Medical Center, UNMC Physicians, University Dental Associates, Bellevue Medical Center and The Nebraska Pediatric Practice Plan as one covered entity for the purpose of sharing PHI under HIPAA. ACE membership may change from time to time. The Notice of Privacy Practices lists current ACE members.
  • Business Associate means a third party who performs services on behalf of UNMC and has access to protected health information (PHI) when performing services; or provides one of the following services for UNMC involving access to PHI: claims processing, data analysis, data processing, practice management, utilization review, quality assurance, billing, benefit management, and repricing.
  • Designated Record Set is the medical record and billing record.
  • Individual means the person who is the subject of the protected health information (including ACE workforce who are patients).
  • Protected Health Information (PHI) is individually identifiable health information. Health information means any information, whether oral or recorded in any medium that:
  • is created or received by 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.
  • Workforce means employees, the medical staff, volunteers, trainees, and other persons whose conduct, in the performance of work for UNMC is under the direct control of UNMC, whether or not they are paid by UNMC.

Other Definitions

  • Controlled Unclassified Information (CUI) as defined by U.S. Presidential Executive Order 13556 is information that requires safeguarding or dissemination controls pursuant to and consistent with applicable law, regulations and government-wide policies but is not classified under Executive Order 13526 or the Atomic Energy Act, as amended.
  • Employee Records refers to all information, records and documents pertaining to any person who is an applicant or nominee for any University personnel position described in the Board of Regents Bylaws, § 3.1, regardless of whether any such person is ever actually employed by the University, and all information, records and documents pertaining to any person employed by the University.
  • Information Security is the ability to control access and protect information from unauthorized alteration, destruction, loss or accidental or intentional disclosure to unauthorized persons.
  • Proprietary Information is information relating to business practices, including but not limited to financial statements, contracts, and business plans; employee records; student records; and meeting minutes.
  • Student Education Records means any information recorded in any way which directly relates to a student and is maintained by or on behalf of UNMC (education agency/institution). Student education record does not include a (i) sole possession record, (ii) law enforcement record, (iii) employee record of a person who is employed by UNMC by virtue of his or her status as a student at UNMC (e.g. work study, assistantships, resident assistants), (iv) alumni record and (v) medical record that is part of the common medical record shared by the Affiliated Covered Entity. Student education records are covered by the Family Educational Rights and Privacy Act (FERPA).

Procedures

Patient Information

  • Records containing PHI, in any form, are the property of the ACE. 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.
  • Individuals have the following rights with respect to their PHI:
  • Individuals shall not be asked to waive these rights as a condition of receiving treatment.
  • The ACE is responsible for safeguarding and protecting PHI against loss, tampering, and disclosure to unauthorized individuals. The safeguarding of PHI 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).
  • ACE workforce have a duty to protect PHI. Breach of this duty includes the following:
  • Accessing PHI, in any form, without a "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 via the online patient portal.
  • Discussing or disclosing patient care events to individuals who do not have a “need to know” 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.
  • Disclosing PHI without proper authorization (see UNMC Policy No. 6057, Use and Disclosure of Protected Health Information);
  • 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);
  • Discussing PHI in the presence of individuals who do not have the "need to know" to perform assigned duties;
  • Disclosing that a patient is receiving care (except for authorized directory purposes);
  • Leaving PHI unattended in a non-secure area;
  • Improper disposal of PHI;
  • Using another person's user ID, password, or other security codes;
  • Assisting an unauthorized user to gain access to a secured information system;
  • Transferring PHI in any form without both parties having a need to know.
  • The ACE shall reasonably mitigate or reduce any harmful effects that may result from privacy breaches.
  • All employees, medical staff, allied health practitioners and members of the workforce with access to PHI shall sign UNMC Statement of Understanding upon initial employment/work/appointment/credentialing.
  • Workforce members who suspect a privacy or information security violation must report it immediately to their respective manager and the Privacy and/or Information Security Office. A full investigation of the suspected violation shall be conducted. Staff who wish to remain anonymous may report the suspected violation to the Compliance Hotline at 844-348-9548. 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.
  • Sanctions for violations of privacy or information security may include revocation of medical staff privileges, allied health credentials, or employee corrective action up to and including termination of employment (see UNMC Policy No. 1098, Corrective and Disciplinary Action). 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 the organization or to the Office for Civil Rights.
  • 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.
  • Paper medical records shall be maintained in the Health Information Management Department.
  • Records sent to clinic areas shall be returned to the Health Information Management Department within one working day.
  • Records of discharged patients will remain on the units until Health Information Management picks them up. Medical records of deceased patients scheduled for an autopsy may be sent to the morgue.
  • 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.
  • Please contact the One Chart Resource team.
  • Business Associate agreements/addenda shall be established with any individual or corporation who performs a function on behalf of UNMC involving the use or disclosure of PHI, other than as a member of the workforce or a healthcare provider providing treatment (see UNMC Policy No. 8009, Contracts).
  • Human Subjects Research shall be conducted in accordance with UNMC Human Research Protection Program (HRPP) Policies and Procedures, including HRPP Policy 3.4, Use of Protected Health Information in Research and Registries and with 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.
  • The Privacy Officer shall be designated in writing and shall be responsible for developing and implementing written policies and procedures necessary to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
  • All members of the workforce shall receive training on privacy and security of confidential information upon hire, and when policies and procedures relevant to their position change.

Business Information

  • Members of the workforce have a duty to protect proprietary business information. Breach of this duty includes, but may not be limited to, the following:
  • Disclosure of confidential financial information
  • Disclosure of confidential contract/agreement information
  • Disclosure of confidential business plans
  • Disclosure of fundraising information
  • Disclosure of credit card information received in the course of business, whether or not such credit card information is covered by the Gramm-Leach-Bliley Act (GLBA).
  • Workforce members who suspect a breach of confidentiality regarding proprietary information shall report the breach to the Human Resources Employee Relations Department.
  • A full investigation of the breach shall be conducted by the Human Resources Employee Relations Department, as appropriate.

Student Education Record Information

  • Members of the workforce have a duty to maintain the confidentiality of student education records. Breach of this duty includes, but is not limited to, release of student information that is not considered “directory information” under the guidelines of the Family Educational Rights and Privacy (FERPA) listed in the Student Handbook. It also includes, but is not limited to, protection of confidential student financial information protected under the Gramm-Leach-Bliley Act (GLBA).
  • Employees shall verify FERPA restrictions placed on student records prior to release of student information.
  • The social security number of a student is considered confidential information and must not be used to identify a student.
  • Information Technology Services (ITS) shall be available to assist in identifying alternatives to use of social security number. Alternatives which should be considered, include but are not limited to Student Number.
  • Use of a student’s social security number in databases is prohibited. In the event that the social security number of a student must be maintained, an Exhibit B - Use of Student Social Security Number Exception must be completed and submitted to Academic Affairs for approval. If it must be used, the use of the student’s social security number must comply with ITS Database Security Procedures.
  • Workforce members who suspect a breach of confidentiality regarding Student Education Records shall report the breach to the Compliance Office or the Student Affairs Office.
  • The student may file a complaint with the Family Policy Compliance Office, U.S. Department of Education, 400 Maryland Ave SW, Washington, DC 20202-4605.

Employee Information

  • Employment records are confidential and will not be made publicly available, except upon written authorization signed by the individual to whom the records pertain or in response to a legal mandate. In this context, employment records are those of persons who are employees of UNMC, and persons who are or have been either applicants or nominees for employment. Such records include the entire employment process beginning with application or nomination for appointment, search committee evaluation, and appointing authority evaluation, through appointment and employment, and ending with separation from employment.
  • The social security number of an employee is considered confidential information and should not be used to identify an employee unless legally mandated, see UNMC policy No. 6085, Social Security Number.
  • ITS shall be available to assist in identifying alternatives to use of social security number. Alternatives which should be considered, include but are not limited to:
  • Personnel (SAP) Number
  • Last four digits of social security number
  • In the event that the social security number of an employee must be maintained, an Exhibit C - Use of Employee Social Security Number Exception must be completed and submitted to Human Resources for approval. In cases where the employee social security number must be stored in a database, the database use must comply with ITS Database Security Procedures.
  • The following are not confidential and are considered by UNMC as directory information:
  • Employee Name
  • Gross salary
  • Dates of hire and separation
  • Type of appointment(s) held and term of each appointment
  • Title or academic rank
  • UNMC employment address
  • Post-secondary education degrees earned
  • Awards or honors
  • Employee information other than directory information is accessible only to the employee, the department administrative personnel, UNMC Human Resources, and other University offices with a need to know. Non-directory information should be released to others only with signed authorization from the employee or in response to a legal mandate.
  • Departments have three options for responding to requests for reference checks:
  • Refer to Human Resources – Records
  • Provide directory information only
  • With a signed release, respond to questions and provide information based only on what is documented in the employment file
  • For more information about responding to reference checks, inquire at UNMC Human Resources – Records at 402-559-8962.
  • Members of the workforce have a duty to protect employee information. Breach of this duty includes but is not limited to the following:
  • Disclosure of social security number
  • Disclosure of Family Medical Leave information
  • Disclosure of employee corrective action
  • Workforce members who suspect a breach of confidentiality regarding Employment Records shall report the breach to the Human Resources Employee Relations Department.

Controlled Unclassified Information (CUI)

Controlled Unclassified Information as defined by Executive Order 13556 and administered by the National Archives includes several categories of information, as detailed in the CUI Registry (https://www.archives.gov/cui/registry/category-list). That list includes:

  • Personally Identifiable Information (PII)
  • Personally Identifiable Health Information (PHI)
  • Defense/Technology related research and development for the US Government

Guiding standards for the management and handling of CUI are:

All personnel, including faculty, staff, research associates and fellows, visiting scholars, students, and all other persons retained by or working at the University of Nebraska Medical Center and its affiliates will comply with all applicable U.S. laws and regulations while teaching, conducting research or providing service activities at or on behalf of the university. As such, personnel are required to comply with the U.S. laws that regulate the transfer of items, information, technology, software, and funds to destinations and persons outside of the U.S., as well as in some cases, to non-U.S. citizens at the university.

  • Specific CUI are referenced elsewhere in this policy, reference applicable sections for additional information.
  • Workforce members who suspect a breach of confidentiality regarding controlled unclassified information shall report the breach to the Privacy Office and/or Information Security Office.

Research Information

  • PHI and other sensitive data, such as student information or business information, may be elements of authorized research. Members of the workforce have a duty to protect confidential information produced while performing research.
  • Health outcomes and quality improvement projects performed with data from the Nebraska Medicine enterprise may be exempt from IRB review and approval but publication of those results will require IRB approval. Any questions should be directed to the IRB, and questions of ethical access to the data to specific individuals or groups can be referred to the privacy officer or IRB.
  • Research with PHI generated within Nebraska Medicine or other UNMC affiliated entities or received by UNMC from other entities. Research personnel need to follow all relevant policies for use of those records, including restrictions on sharing with any individuals that have not received human subjects training and/or authorization by IRB protocol.
  • De-identified data used for research is proprietary information and should still be stored and shared safely.
  • Research PHI generated by other entities and sent to UNMC. When UNMC receives data containing PHI from another or a group of institutions for the purposes of analysis or storage, such as when UNMC serves as a coordinating center for a collaboration, a multicenter trial, or UNMC conducts data analysis, PHI received should be stored securely and shared only with those individuals approved by the IRB protocol and in accordance with the business contract.
  • Breach of confidentiality includes the following:
  • Disclosure of PHI to unauthorized persons or entities not included in the Authorization for Release of Information, if requested for specific data sets OR
  • Disclosure of research results linked to human subjects to persons or entities not authorized in the Institutional Review Board (IRB) approved protocol
  • Workforce members who suspect a breach of confidentiality regarding human subjects’ research information shall report the breach to the IRB office for research data sets sent to UNMC from outside entities and/or the Privacy Office for data sets generated within Nebraska Medicine or affiliated entities.

Additional Information

This page maintained by dkp.