Healthcare information has been under HIPAA controls for more than fifteen years now, and healthcare organizations are finally beginning to reach good compliance levels, but other regulations also impact health information privacy and security compliance. In addition to HIPAA, the rules for protecting information related to Substance Use Disorders have been in place since the 1970s, FERPA protects student information, including health and treatment information, various state laws call for protection of information, and now the European Union’s General Data Protection Regulation comes into play for the information of EU residents.
This session is designed to provide intensive, one and a half-day training in healthcare information privacy and security regulatory compliance, touching on the key regulations needing attention today.
The session will cover:
- Principles of Information Privacy and Security
- Privacy, Security, and Breach Notification under HIPAA
- Interactions with the SAMHSA 42 CFR Part 2 regulations on information relating to substance use disorders
- Interactions with the FERPA student information protections for information held by schools
- Determining the scope of your GDPR exposure and issues to address
- HIPAA as a foundation for GDPR compliance
- Challenges with issues today that didn’t even exist a few years ago, such as insecure communications, Ransomware, and social media
This seminar will also explain audits and enforcement, as well as how to respond to privacy and security breaches and how to prevent them. Numerous references and sample documents will be provided.
Learning Objectives:
This Seminar is designed for the healthcare compliance expert and newbie alike who wish to stay up with changes to HIPAA and related regulations in personal information privacy and security, such as GDPR, 52 CFR Part 2, and FERPA, as well as understand the regulatory issues most frequently encountered in day-to-day operation of health care entities. Objectives include learning related to a variety of topics, including:
- Learning about patient rights, such as access and amendment of information, and how such rights are protected and enforced under HIPAA and other rules
- How uses and disclosures may take place under HIPAA in a wide variety of circumstances, including such hot topics as sharing information with the family and friends of a patient, and how those disclosures would be limited by Part 2 rules.
- When FERPA takes over health records in schools, and when HIPAA controls them
- Changes to Substance Use Disorder records confidentiality under 42 CFR Part 2
- The EU General Data Protection Regulation (GDPR) background and scope
- Ensuring individuals have adequate access of their information under the various rules.
- Understanding the limits on Disclosures under the various rules.
- The place of Information Security and incident management using the HIPAA Security and Breach Notification Rules
- Processes to be used in managing security, mitigating risks, and handling incidents
- Proper methods of documentation and training to ensure compliance and help avoid penalties, including the use of internal audits and drills to improve compliance continuously and be prepared for incidents and enforcement investigations
Who will benefit:
This seminar will provide valuable assistance to all personnel in medical offices, practice groups, hospitals, academic medical centers, insurers, business associates (shredding, data storage, systems vendors, billing services, etc.). The following personnel will find this session valuable:
- Compliance director
- CEO
- COO
- CFO
- Privacy Officer
- Security Officer
- Information Systems Manager
- HIPAA Officer
- Chief Information Officer
- Health Information Manager
- Healthcare Counsel/lawyer
- Office Manager
- Contracts Manager
- 08.30 AM - 09.00 AM: Registration
- 09.00 AM: Session Start
- Overview of Privacy, Security, and Breach Notification Regulations
- Approaches to Privacy and Security Regulations
- Precedence in Competing Regulations
- HIPAA, FERPA, and 42 CFR Part 2 Interactions
- The GDPR Approach – Similarities and Differences
- New State Laws Like GDPR, e.g. California
- Healthcare Regulations and Patient Rights
- Types of Entities, Entity Relationships, and Business Associates
- The HIPAA Designated Record Set, Access, and Amendment
- Patient Rights under 42 CFR Part 2
- Student and Family Rights under FERPA
- Individual Rights under GDPR
- Healthcare Regulations and Uses and Disclosures of Protected Information
- General Use and Disclosure Limitations for HIPAA, Part 2, GDPR, and FERPA
- Disclosures to family and friends
- Disclosures to providers, care coordinators, etc.
- Disclosures to attorneys, the Attorney General’s office, etc., minors and guardian issues
- Day-to-day disclosures
- Training and Documentation Requirements
- Current Hot Topics in Healthcare Privacy and Security
- Access of Information
- Enforcement and Audits
- Sorting Out Regulatory Precedence
- Implementation Issues
Day one sets the stage with an overview of the healthcare information privacy and security regulations and then continues with presentation of the specifics of the HIPAA rules and recent and related rules such as 42 CFR Part 2 regarding Substance Use Disorder information, the FERPA regulations for student information held by schools, and the European Union’s General Data Protection Regulation (GDPR), including the impacts of required changes in your practices to meet the rules.
- Security and Breach Notification Principles
- How the HIPAA Privacy, Security, and Breach Rules Work Together
- Security Safeguards and The Role of Risk Analysis
- Determining What Is a Breach and What Must Be Reported
- Incident Management and Breach Reporting
- Breaches, GDPR, and 42 CFR Part 2
- Documentation, Training, Drills and Self-Audits
- The 10-Day Regulatory Compliance Plan
- How to Organize and Use Documentation to Your Advantage
- Training Methods and Compliance Improvement
- Conducting Drills in Incident Response
- Using the HIPAA Audit Protocol for Documentation
Day two begins with a detailed examination of HIPAA Security Rule and Breach Notification requirements and how they can be used to protect information under a variety of regulations, including what you need to do to protect information and what you have to do if you don’t, and the day concludes with a session on the essential activities of documenting policies, procedures, and activities, training staff and managers in the issues and policies they need to know about, and examining compliance readiness through drills and self-audits, all as part of a 10-step plan for reviewing and maintaining regulatory compliance.
Jim Sheldon-Dean,
Principal and Director of Compliance Services, Lewis Creek Systems, LLC
Jim Sheldon-Dean is the founder and director of compliance services at Lewis Creek Systems, LLC, a Vermont-based consulting firm founded in 1982, providing information privacy and security regulatory compliance services to a wide variety of health care entities.
Mr. Sheldon-Dean serves on the HIMSS Information Systems Security Workgroup, has co-chaired the Workgroup for Electronic Data Interchange Privacy and Security Workgroup, and is a recipient of the WEDI 2011 Award of Merit. He is a frequent speaker regarding HIPAA and information privacy and security compliance issues at seminars and conferences, including speaking engagements at numerous regional and national healthcare association conferences and conventions and the annual NIST/OCR HIPAA Security Conference in Washington, D.C.
He has more than 30 years of experience in policy analysis and implementation, business process analysis, information systems and software development. His experience includes leading the development of health care related Web sites; award-winning, best-selling commercial utility software; and mission-critical, fault-tolerant communications satellite control systems. In addition, he has eight years of experience doing hands-on medical work as a Vermont certified volunteer emergency medical technician. He received his B.S. degree, summa cum laude, from the University of Vermont and his master’s degree from the Massachusetts Institute of Technology.
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