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Information Systems
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Nov 24, 2024
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Uploaded by LieutenantGoose2748
Compliance Program Implementation and Ethical Decision-Making
Background
The health insurance and portability and Accountability Act (HIPAA) protect privacy and health information security through the
provision of rights to patients concerning their health information. It has the security rule whereby the covered entities and their
associates should withhold to protect their confidentiality, electronic health protected information availability and integrity of the
information. The privacy rule sets the guidelines for the use and disclosure of health information that is protected. In the scenario of a
breach of unsecured patient health information, it is a requirement by the breach notification rule for the entities who are covered to
alert the U.S Department of Health and Human Services, the individuals affected, and the media.
Problem Summary:
Privacy Breach—HIPAA Violation
Briefly Explain the Law, Regulation,
Standard, et cetera*
Briefly Explain How the Law, Regulation,
Standard, et cetera Applies to the Privacy
Breach/HIPAA Violation
Applicable Law(s)
These laws were enacted in 1996 and require the
secretary of HHS to make public the standards
required for electronic exchange, the security, and
privacy of health information (Summary of the
HIPAA Privacy Rule, 2013)
These laws establish the national standard required in
order to protect medical records of individuals and
their personal health information. The use and
disclosures that may be used of such information
without the authorization by the patient is limited.
Applicable Specific
Regulation(s)
The HIPAA privacy rule enables the patient to
control their PHI and how it is used (Summary of
the HIPAA Privacy Rule, 2013).
Unless authorized by the patient in written form or
allowed by the HIPAA, a covered entity is not allowed
to use or disclose PHI.
Disclosure
For a covered entity, they can only disclose their
protected health information in only two
scenarios, to the HHS when undergoing a
These instructions determine how information can be
divulged and that an individual’ permission should be
obtained before their health information is used in
1
Briefly Explain the Law, Regulation,
Standard, et cetera*
Briefly Explain How the Law, Regulation,
Standard, et cetera Applies to the Privacy
Breach/HIPAA Violation
compliance investigation or to their personal
representatives especially when they ask for
access to the PHI (
Department of Health and
Human Services Centers for Medicare and
Medicaid Services, 2016).
research, marketing or fundraising. Patients have the
right to conceal their information from insurance
companies if their care is privately funded
Applicable Human
Resource Law(s)
If a hospital or any covered entity wants to
publish the protected information of the patient,
the individual must be provided with an
opportunity for consent (Summary of the HIPAA
Privacy Rule, 2013)
The privacy rule applies to covered entities. So, if the
organizations that access, collect and use individually
identifiable information are not covered entities, there
will be a privacy breach.
These rules may also affect researchers and their
access to patient health information (PHI)
Applicable Industry
Accrediting Body
Standards
Only authorized users should have access to the
patients’ records (
Department of Health and
Human Services Centers for Medicare and
Medicaid Services, 2016).
The standards of privacy of individually identifiable
health information establish national standards for the
protection of PHI
Seven Essential Elements of an Effective Compliance Program
Numbe
r
Element of an Effective Compliance Program
(Federal Register) *
How Does This Element Apply to the Privacy Breach/HIPAA
Violation?
1.
Having a prompt response to detected offenses and
undertaking a corrective action (HIPAA Guide, All
About HIPAA Compliance, 2017)
After detection of an offense, reasonable steps should be
undertaken to prevent future similar occurrences. This concept of
integrative action is integrated with the privacy regulations
2.
Conducting essential education and training
Elements such as periodic security reminders, training in security
2
Numbe
r
Element of an Effective Compliance Program
(Federal Register) *
How Does This Element Apply to the Privacy Breach/HIPAA
Violation?
(Cascardo, 2016).
awareness, virus protection, monitoring discrepancies in logins
success and failures and password management form a major
detail in improving the security standards and preventing a
breach in privacy.
3.
Developing clear lines of communication (HIPAA
Guide, All About HIPAA Compliance, 2017).
This would be in accordance with the privacy regulations that
require the subject of PHI to submit complaints to the covered
entity without fear. Complaint procedures should be clearly
outlined.
4.
Conducting internal auditing and monitoring
(Cascardo, 2016).
It provides a view of the organization’s current compliance with
the regulations and also serves as a blue-print for the
development of HIPAA program.
5.
Publicizing of disciplinary guides so as to enforce
standards (HIPAA Guide, All About HIPAA
Compliance, 2017).
It is a requirement of the covered entities to administer sanctions
for violations of privacy, this affords protection in disputes that
are employment related and also creates an effective compliance
program to the HIPAA.
6.
Designation of a compliance committee and
compliance officers (HIPAA Guide, All About
HIPAA Compliance, 2017).
The responsibilities of these committees and officers will be to
oversee the access, disclosures, uses, and the disposition of
information that is protected. They will also analyze the security
threats, technical details and response to incidents.
7.
Ensure written procedures, conduct-standards and
policies are implemented (Cascardo, 2016).
These manage the selection and execution of essential security
measures so as to protect the data and manage the conduct of the
personnel.
Privacy Breach Consequences
3
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Covered Entity
Legal Penalty(ies)*
Additional Consequences
Individual Leader
Within Health Care
Organization
Fine of up to $ 250, 000 for violations with
intentions to use data for malevolent reasons.
Fines of up to $ 100,000 for deception.
Fines of up to $50, 000 for knowingly disclosing
individually identifiable health information
(What are the Penalties for HIPAA Violations?
2015).
Prison sentences as high as ten years.
Up to 5 years imprisonment for deception.
Imprisonment up- to 1 year for knowingly disclosing
identifiable information
Other Internal
Health Care
Organization
Stakeholders
Can be charged guilty as a co-conspirator or an
accomplice.
Health Care
Organization
Fine of $100 to $ 50,000 for each instance of
privacy rule violation depending on whether the
covered entity was unaware, aware, or willfully
neglected the HIPAA rules (What are the
Penalties for HIPAA Violations? 2015).
Removal from the Medicare System
Evidence-Based Recommendations
Numbe
r
Evidence-Based Recommendation
Additional Insights/Salient Points
Source(s)*
1.
Implement HIPAA security rules safeguard
through conducting a risk analysis.
This is supposed to be complied by the covered
entities and the business associates. Assessment
of the organization’s technical and physical PHI
safeguard should be considered.
McDavid, J. (2013).
HIPAA
risk is contagious: Practical
tips to prevent breach
.
The
Journal of Medical Practice
4
Numbe
r
Evidence-Based Recommendation
Additional Insights/Salient Points
Source(s)*
Management, 29
(1), 53–55.
2.
Standardization of PHI policies and
centralization of the processes of the release
of information (ROI) to reduce risk of a
breach.
In order to enhance the level of breach protection,
one can engage vendors with advanced
technology, highly trained and with
knowledgeable staff and also offer best practices
that are HIPAA compliant.
McDavid, J. (2013).
HIPAA
risk is contagious: Practical
tips to prevent breach
.
The
Journal of Medical Practice
Management, 29
(1), 53–55.
3.
Continuous education, training and auditing
of staff due to the evolving of technologies
that manage PHI.
It is important to ensure that the staff understands
the technology and that they follow the HIPAA
compliant procedures.
Can be done through mock breaches to stimulate
steps of response.
McDavid, J. (2013).
HIPAA
risk is contagious: Practical
tips to prevent breach
.
The
Journal of Medical Practice
Management, 29
(1), 53–55.
4.
Avoid access barriers for patients. Patients
can use specific forms to access their own
PHI ensuring that the form doesn’t create an
obstacle.
HIPAA compliant authorizations are only
required when PHI is requested by a third party.
The patients’ personal representatives have the
same rights as the patient to the PHI if the can
provide documentation to prove their authority to
act on behalf of the patient.
McDavid, J. (2013).
HIPAA
risk is contagious: Practical
tips to prevent breach
.
The
Journal of Medical Practice
Management, 29
(1), 53–55.
5
Numbe
r
Evidence-Based Recommendation
Additional Insights/Salient Points
Source(s)*
5.
Assessment of business associates to ensure
that they also comply with the applicate
federal and state privacy and security laws.
This is done through periodic vendor
assessments to ensure that the business
associates comply with the business associate’s
agreements and HIPAA.
McDavid, J. (2013).
HIPAA risk
is contagious: Practical tips to
prevent breach
.
The Journal of
Medical Practice Management,
29
(1), 53–55.
Ethical Decision-Making Framework for Health Care Leaders
Numbe
r
Ethical Decision-Making Step*
Apply the Ethical Decision-Making Step to the Privacy
Breach/HIPAA Violation
1.
The healthcare executive’s responsibility to the
healthcare management profession (Nelson,
2015).
This enables the healthcare executive to conduct all the activities
with honesty, integrity, and compliance with the laws such as that of
privacy rules. This decision is used to further the interest of the
profession and not personal gain. It involves the decision to disclose
when appropriate.
2.
Healthcare executives’ responsibilities to patients
or others served (Nelson, 2015).
Through this decision, it is possible to educate the patients on their
rights and responsibilities, they should demonstrate zero tolerance to
any activity that compromises the privacy of the patient and should
also ensure that there are essential procedures to protect
confidentiality and privacy of patients.
3.
The healthcare executives’ responsibilities to the
organization (Nelson, 2015).
Through this responsibility they are able to minimize mistakes such
as a breach in the HIPAA laws and when they occur, they ensure
they are disclosed and managed effectively. It also ensures all forms
of organizational communication are truthful, maintain and
6
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Numbe
r
Ethical Decision-Making Step*
Apply the Ethical Decision-Making Step to the Privacy
Breach/HIPAA Violation
monitoring of compliance is made possible
4.
The healthcare executives’ responsibilities to the
employees (Nelson, 2015).
By creating a safe and healthy working environment, it is possible
for the employees to freely express ethical concerns and any HIPAA
violations, the mechanisms of discussion and how to address the
issues.
5.
The healthcare executives’ responsibility to the
society and community (Nelson, 2015).
Through identification of the health care needs of the society, it is
possible to encourage the public in dialogues about healthcare issues
and policies such as privacy breach and come up with solutions. It
also enables the provision of each patient with accurate information
to help them make enlightened decisions.
6.
The healthcare executives’ responsibility to report
violations of the code (Nelson, 2015).
It is their duty to communicate facts to the ethics committee if they
have reason to believe that a member has violated the HIPAA rules.
Conclusion
The HIPAA is important in the safeguarding and to ensure the privacy of individuals medical data. In order to ensure HIPAA is
adhered to, transparency is required and this requires auditing. Compliance ensures that not anyone can access the information but
only those authorized, therefore enhancing patient safety. It also ensures that PHI is not used for personal and financial gain without
their consent. Access to the information is usually carefully monitored. The information is encrypted during storage and transport to
only authorized locations. Stringent guidelines should also be used for the systems that store the protected data.
References
7
Cascardo, D. (2016).
Compliance challenges facing healthcare providers in 2016
.
Journal of Medical Practice Management, 31
(5),
276–9.
Department of Health and Human Services Centers for Medicare and Medicaid Services (n.d.).
HIPAA basics for providers: Privacy,
security, and breach notification rules.
Retrieved from
https://www.cms.gov/Outreach-and-Education/Medicar...
McDavid, J. (2013).
HIPAA risk is contagious: Practical tips to prevent breach
.
The Journal of Medical Practice Management, 29
(1),
53–55
Nelson, W. (2015).
Making ethical decisions
.
Healthcare Executive
, 46–48. Retrieved
from
https://ache.org/abt_ache/EthicsToolkit/JA15_ethic...
HIPAA Guide, All About HIPAA Compliance - eVisit. (2016). Retrieved from https://evisit.com/resources/hipaa-guide/
Summary of the HIPAA Privacy Rule. (2013, July 26). Retrieved from
https://www.hhs.gov/hipaa/for-professionals/privacy/laws-
regulations/index.html
What are the Penalties for HIPAA Violations? (2015, June 24). Retrieved from https://www.hipaajournal.com/what-are-the-
penalties-for-hipaa-violations-7096/
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