Use and Disclosure of PHI for Training Health Care Professionals: Difference between revisions

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To establish guidelines for the use and disclosure of PHI for training health care professionals in accordance with HIPAA.   
To establish guidelines for the use and disclosure of PHI for training health care professionals in accordance with HIPAA.   
==Policy==
==Policy==
The University of Nebraska Medical Center (UNMC) shall use and disclose Protected Health Information (PHI) to train health care professionals in accordance with the requirements of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and UNMC policies to maintain confidentiality of PHI and protect patient privacy.
The University of Nebraska Medical Center (UNMC) shall use and disclose Protected Health Information (PHI) to train health care professionals in accordance with the requirements of the [https://www.cdc.gov/phlp/publications/topic/hipaa.html Health Insurance Portability and Accountability Act of 1996 (HIPAA)] and UNMC policies to maintain confidentiality of PHI and protect patient privacy.  
==Definitions==
'''Formal training''' as described in this policy includes learning that is delivered in an intentional way, and is guided by an instructor, supervisor, or other designated individual, versus casual, unstructured, and/or self-directed access to or disclosure of PHI (e.g., perusing the records/images/labs of patients you are curious about, sharing patient information with a colleague because it is “interesting”, etc.).<br />
 
'''Protected Health Information (PHI)''' is individually identifiable health information. Individually identifiable health information is a subset of health information, including demographic information, collected from an Individual, whether oral or recorded in any medium, that:
*is created or received by UNMC and/or Nebraska Medicine*; 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:
*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).
PHI excludes individually identifiable health information of a person who has been deceased for more than fifty (50) years.<br />
 
PHI excludes education records covered by the Family Educational Rights and Privacy Act (FERPA) and employment records held by UNMC in its role as employer.<br />
 
'''Research''' means a systematic investigation, including research development, testing and evaluation, designed to develop or contribute to generalizable knowledge.<br />
 
'''Workforce''' means employees, 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.
==Procedures==
==Procedures==
===Formal Training of Health Care Professionals===
===Formal Training of Health Care Professionals===
Formal training of healthcare professionals is a category of Healthcare Operations as defined by HIPAA and is subject to the minimum necessary standard.
Formal training of health care professionals is a category of Health Care Operations as defined by HIPAA and is subject to the minimum necessary standard.
*Staff may share minimum necessary PHI with students, residents, trainees and faculty supervising such individuals according to policy and/or pursuant to a clinical affiliation agreement between UNMC and the affiliated institution.
*Staff may share minimum necessary PHI with students, residents, trainees and faculty supervising such individuals according to policy and/or pursuant to a clinical affiliation agreement between UNMC and the affiliated institution.
*Individuals receiving training and faculty supervising such individuals shall be considered members of the Workforce for purposes of HIPAA.
*Individuals receiving training and faculty supervising such individuals shall be considered members of the Workforce for purposes of HIPAA.
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Individual descriptive case histories, even if published and/or presented at national or regional meetings or otherwise intended for an audience by individuals who are not members of the Workforce, are generally not considered research provided the case is limited solely to a description of the clinical features or findings and/or outcome of the individual patient. However, case series (generally involving more than three patients) where there is concomitant analysis and correlation of data as part of a systematic investigation are considered research and must be reviewed by the IRB. (See HRPP Policy 1.8 for additional information).
Individual descriptive case histories, even if published and/or presented at national or regional meetings or otherwise intended for an audience by individuals who are not members of the Workforce, are generally not considered research provided the case is limited solely to a description of the clinical features or findings and/or outcome of the individual patient. However, case series (generally involving more than three patients) where there is concomitant analysis and correlation of data as part of a systematic investigation are considered research and must be reviewed by the IRB. (See HRPP Policy 1.8 for additional information).
====Case Series====
====Case Series====
If cases are being sought for publication as part of a case series or a clinical study needing chart reviews, faculty and department staff will assist students in creating lists of possible diagnoses of interest along with possible International Classification of Diseases (ICD) codes. This list will be used by [https://www.unmc.edu/cctr/resources/crc/index.html Clinical Research Center] or [http://newintranet.nebraskamed.com/ AnalyticsRequest/ Analytics Work Request] to confirm the existence and number of such possible cases available for review within a specified timeframe. Following IRB approval, those designated by the IRB as being appropriate, including students, will be allowed to access the charts with the understanding of the need for full confidentiality in the handling and appropriate de-identification of any stored data onto a secure and HIPAA-compliant server. Individual cases may be reviewed prior to IRB consent only under supervision of the physician of record.  
If cases are being sought for publication as part of a case series or a clinical study needing chart reviews, faculty and department staff will assist students in creating lists of possible diagnoses of interest along with possible International Classification of Diseases (ICD) codes. This list will be used by [https://www.unmc.edu/cctr/resources/crc/index.html Clinical Research Center] or [http://newintranet.nebraskamed.com/AnalyticsRequest/ Analytics Work Request] to confirm the existence and number of such possible cases available for review within a specified timeframe. Following IRB approval, those designated by the IRB as being appropriate, including students, will be allowed to access the charts with the understanding of the need for full confidentiality in the handling and appropriate de-identification of any stored data onto a secure and HIPAA-compliant server. Individual cases may be reviewed prior to IRB consent only under supervision of the physician of record.  
===External Use of PHI for Educational Purposes===
===External Use of PHI for Educational Purposes===
Providers/faculty/staff/trainees/students or other members of the Workforce may not use PHI in case studies, Grand Rounds, community presentations, articles, industry conferences/lectures, posters, fliers or any other material or media that could be seen or accessed by individuals who are not a member of the Workforce unless:
Providers/faculty/staff/trainees/students or other members of the Workforce may not use PHI in case studies, Grand Rounds, community presentations, articles, industry conferences/lectures, posters, fliers or any other material or media that could be seen or accessed by individuals who are not a member of the Workforce unless:
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::*Patient name, MRN and/or SSN shall not be used without obtaining prior written patient authorization.
::*Patient name, MRN and/or SSN shall not be used without obtaining prior written patient authorization.
::*De-identified information should be used whenever possible (see [https://wiki.unmc.edu/index.php/Use_and_Disclosure_of_PHI_for_Training_Health_Care_Professionals#De-identification_of_PHI_for_Educational_Purposes 4.8 De-identification of PHI for Educational Purposes]).
::*De-identified information should be used whenever possible (see [https://wiki.unmc.edu/index.php/Use_and_Disclosure_of_PHI_for_Training_Health_Care_Professionals#De-identification_of_PHI_for_Educational_Purposes 4.8 De-identification of PHI for Educational Purposes]).
::*Patient’s or legal guardian’s written authorization is required to photograph or videotape a patient for training purposes. The patient or the patient’s legal guardian will complete the [ Education Authorization Form CON MR 1900] or other Privacy Office-approved form. Then, only the minimum amount of information shall be photographed/videotaped. (See [https://info.unmc.edu/its-security/policies/procedures/electronic-comm-phi.html Electronic Communication of Protected Health Information], Procedure for UNMC Policy No. 6051, for additional guidance.)
::*Patient’s or legal guardian’s written authorization is required to photograph or videotape a patient for training purposes. The patient or the patient’s legal guardian will complete the [ Education Authorization Form CON MR 1900] or other Privacy Office-approved form. Then, only the minimum amount of information shall be photographed/videotaped. (See Procedure for UNMC Policies No. 6051 and 6057, [https://info.unmc.edu/its-security/policies/procedures/electronic-comm-phi.html Electronic Communication of Protected Health Information], for additional guidance.)
*Individuals participating in clinical job shadowing shall follow [http://www.nebraskamed.com/careers/job-shadowing Nebraska Medicine’s job shadowing process] and visiting providers functioning as observers or trainees follow [Med Staff’s Visiting Staff policy, MS28].
*Individuals participating in clinical job shadowing shall follow [https://www.unmc.edu/student-success/pathway-programs/job-shadow.html Nebraska Medicine’s job shadowing process] and visiting providers functioning as observers or trainees follow [Med Staff’s Visiting Staff policy, MS28].
===Use/Disclosure of PHI for Research ===
===Use/Disclosure of PHI for Research ===
*Research is not considered training or education within the meaning of this policy.
*Research is not considered training or education within the meaning of this policy.
*All research requests using PHI must be submitted to the UNMC IRB for review and approval. See UNMC Human Research Protection Policies and Procedures. The IRB-approved consent also contains the HIPAA-compliant authorization when required under HIPAA. The UNMC IRB operates as UNMC’s Privacy Board and approves all waivers of authorization as permitted under HIPAA.   
*All research requests using PHI must be submitted to the UNMC IRB for review and approval. See UNMC [https://guides.unmc.edu/books/hrpp-policies-and-procedures Human Research Protection Program Policies and Procedures]. The IRB-approved consent also contains the HIPAA-compliant authorization when required under HIPAA. The UNMC IRB operates as UNMC’s Privacy Board and approves all waivers of authorization as permitted under HIPAA.   
Review of PHI Preparatory to Research. UNMC staff and students who wish to review PHI to prepare a research proposal must submit a "Request for Electronic Health Data" form to the [www.unmc.edu/cctr/ehr_research.html Electronic Health Record Core].
*Review of PHI Preparatory to Research. UNMC staff and students who wish to review PHI to prepare a research proposal must submit a "Request for Electronic Health Data" form at [https://unmcredcap.unmc.edu/redcap/surveys/?s=NMPNWMEA7W Electronic Health Data Request].
===De-identification of PHI for Educational Purposes===
===De-identification of PHI for Educational Purposes===
PHI may be used to create information that is not individually identifiable health information (de-identified). The HIPAA privacy rules do not apply to information that does not identify an individual and with respect to which there is no reasonable basis to believe that the information can be used to identify an individual. However, de-identification to HIPAA standards is challenging and is not always possible, which often results in the need for written Individual authorization to use/disclose the patient’s PHI. Beyond the removal of identifiers, the following considerations are required by the Privacy Office:
PHI may be used to create information that is not individually identifiable health information (de-identified). The HIPAA privacy rules do not apply to information that does not identify an individual and with respect to which there is no reasonable basis to believe that the information can be used to identify an individual. However, de-identification to HIPAA standards is challenging and is not always possible, which often results in the need for written Individual authorization to use/disclose the patient’s PHI. Beyond the removal of identifiers, the following considerations are required by the Privacy Office:
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*Is the case geographically uncommon? (E.g., a case that is common in Brazil, but rarely seen/treated in Nebraska)
*Is the case geographically uncommon? (E.g., a case that is common in Brazil, but rarely seen/treated in Nebraska)
*Is the case procedurally uncommon? (E.g., the first double lung transplant, etc.)  
*Is the case procedurally uncommon? (E.g., the first double lung transplant, etc.)  
Some cases and images would be unique without any indication of the injury or disease (e.g., physical structures that are unusual). However, any image/case combined with the treatment location (e.g., UNMC/Nebraska Medicine), the facts of the case (e.g., how the injury occurred or the disease process), and/or the facts of the treatment (e.g., the number of screws in the injured ankle) tips the image/case toward identifiability. Additionally, cases/images are rarely presented in a vacuum – while identifiers are commonly removed, the presenter generally provides some background (e.g., a story about how the injury happened) or applicable facts about the patient (e.g., place/type of employment; medical history), adding additional risk of identifiability.<br />
Some cases and images would be unique without any indication of the injury or disease (e.g., physical structures that are unusual). However, any image/case combined with the treatment location (e.g., UNMC/Nebraska Medicine), the facts of the case (e.g., how the injury occurred or the disease process), and/or the facts of the treatment (e.g., the number of screws in the injured ankle) tips the image/case toward identifiability. Additionally, cases/images are rarely presented in a vacuum – while identifiers are commonly removed, the presenter generally provides some background (e.g., a story about how the injury happened) or applicable facts about the patient (e.g., place/type of employment; medical history), adding additional risk of identifiability.<br />


See UNMC Policy No. 6057, [[Use and Disclosure of Protected Health Information]], for additional information regarding de-identification.
See UNMC Policy No. 6057, [[Use and Disclosure of Protected Health Information]], for additional information regarding de-identification.
==Definitions==
===Formal Training===
As described in this policy, formal training includes learning that is delivered in an intentional way, and is guided by an instructor, supervisor, or other designated individual, versus casual, unstructured, and/or self-directed access to or disclosure of PHI (e.g., perusing the records/images/labs of patients you are curious about, sharing patient information with a colleague because it is “interesting”, etc.).
===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.
===Research===
A systematic investigation, including research development, testing and evaluation, designed to develop or contribute to generalized knowledge. Generalized knowledge is knowledge that can be applied to populations outside the population served by the ACE.
===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.
==Additional Information==
==Additional Information==
*Contact the [mailto:privacy@nebraskamed.com Privacy Office] or at 402-559-5136.
*Contact the [mailto:privacy@nebraskamed.com Privacy Office] or at 402-559-5136.
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*UNMC Policy No. 6051, [https://wiki.unmc.edu/index.php/Computer_Use/Electronic_Information Computer Use/Electronic Information]
*UNMC Policy No. 6051, [https://wiki.unmc.edu/index.php/Computer_Use/Electronic_Information Computer Use/Electronic Information]
*UNMC Policy No. 6057, [https://wiki.unmc.edu/index.php/Use_and_Disclosure_of_Protected_Health_Information Use and Disclosure of Protected Health Information]
*UNMC Policy No. 6057, [https://wiki.unmc.edu/index.php/Use_and_Disclosure_of_Protected_Health_Information Use and Disclosure of Protected Health Information]
*[https://info.unmc.edu/its-security/policies/procedures/electronic-comm-phi.html Electronic Communication of Protected Health Information], Procedure for UNMC Policy No. 6051
*Procedure for UNMC Policies No. 6051 and 6057, [https://info.unmc.edu/its-security/policies/procedures/electronic-comm-phi.html Electronic Communication of Protected Health Information]
*UNMC [https://guides.unmc.edu/books/hrpp-policies-and-procedures Human Research Protection Program Policies and Procedures]
*[https://www.cdc.gov/phlp/publications/topic/hipaa.html Health Insurance Portability and Accountability Act of 1996 (HIPAA)]
*HRPP Policy 1.8
*HRPP Policy 1.8
*Med Staff’s Visiting Staff policy, MS28.
*Med Staff’s Visiting Staff policy, MS28.
*Education Authorization form CON MR 1900
*Education Authorization form CON MR 1900
*Request for Electronic Health Data Form
*[https://unmcredcap.unmc.edu/redcap/surveys/?s=NMPNWMEA7W Electronic Health Data Request] Form
*[http://www.nebraskamed.com/careers/job-shadowing Nebraska Medicine’s job shadowing process]
*[http://newintranet.nebraskamed.com/AnalyticsRequest/ Analytics Work Request]
*[https://www.unmc.edu/student-success/pathway-programs/job-shadow.html Nebraska Medicine’s job shadowing process]


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