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Archive for HIPAA privacy

OCR recently sent two annual reports to Congress that summarize 2011–2012 HIPAA breach and compliance activities as required by the HITECH Act.

OCR received 236 reports about breaches affecting 500 or more individuals in 2011, according to OCR’s Annual Report to Congress on Breaches of Unsecured Protected Health Information. These breaches affected approximately 11,415,185 individuals. OCR received 222 reports about large breaches in 2012. Although the number of reportable breaches affecting 500 or more individuals in 2012 decreased only slightly, the overall number of individuals affected dropped to 3,273,735. Although OCR focused primarily on 2011–2012 breaches, it included some data as far back as 2009. In total, OCR received 710 reports affecting 22.5 million individuals from September 23, 2009, to December 31, 2012.

The top causes of 2009–2012 breach incidents include theft, loss, and unauthorized access/disclosure. For 2011 and 2012 only, the report cited six causes, including theft, loss, unauthorized access/disclosure, improper disposal, hacking/IT incident, and unknown/other. Theft was the leading cause of 49% of 2011 breaches and 52% of 2012 breaches. Unauthorized access/disclosure came in at second place for 2011 (19%) and 2012 (18%).

Healthcare providers submitted the majority of breach reports in 2011 (63%) just as they did in 2012 (68%). The majority of PHI that was exposed in 2011 breaches was on paper (27%) or laptop computers (20%). In 2012, breaches of PHI on paper and on laptop computers took the lead once again but this time with paper trailing behind at 23% and laptop computers in the top spot at 27%.

Since the end of 2013, OCR entered into resolution agreements with seven covered entities for the 458 breaches that occurred 2011–2012. These are the first OCR settlements brought about by investigations into reported breaches.

OCR’s Annual Report to Congress on HIPAA Privacy, Security, and Breach Notification Rule Compliance provides enforcement data through 2012 with particular focus on 2011–2012. Since the 2003 HIPAA Privacy Rule compliance date, OCR received 70,259 complaints for alleged HIPAA violations and had resolved 91% of these complaints as of December 31, 2012. OCR issued corrective action for 66% of the 27,466 HIPAA complaints investigated since 2003. The number of new complaints rose to 9,022 in 2011 with 8,363 complaints resolved. This number peaked again in 2012 when OCR received 10,454 complaints and resolved 9,408.

The majority of issues investigated since the Privacy Rule compliance date were due to the following:

  • Impermissible uses and disclosures of PHI
  • Lack of safeguards of PHI
  • Denial of individuals’ access to their PHI
  • Uses or disclosures of more than the minimum necessary PHI
  • Lack of administrative safeguards of ePHI

The hits just keep on coming. HHS announced June 23 that OCR entered into resolution agreement and $800,000 settlement with Parkview Health System, Inc., in Fort Wayne, Indiana, for alleged HIPAA Privacy Rule violations.

Parkview obtained the medical records of 5,000–8,000 patients while helping Dr. Christine Hamilton transition her patients to new providers upon her retirement. It was believed that the health system was interested in purchasing a portion of Dr. Hamilton’s practice. Parkview failed to safeguard the PHI of these patients when its employees left 71 cardboard boxes of these medical records outside the physician’s home while she was not there. The home is within 20 feet of a public road and is near a shopping center, according to the press release.

The resolution agreement provides that Dr. Hamilton filed the complaint against Parkview. The investigation revealed that when Parkview employees left the medical records at Dr. Hamilton’s home, they were aware that she was not there and had previously refused the delivery of the records.

Parkview’s corrective action plan states that it will do the following:

  • Develop, maintain, and revise written HIPAA Privacy Rule policies and procedures for its workforce with HHS approval
  • Distribute HHS-approved policies and procedures to members of its workforce
  • Ensure that new, approved policies and procedures provide for administrative, technical, and physician safeguards to protect PHI
  • Notify HHS in writing within 30 days of a violation of the new, approved policies and procedures
  • Provide general safeguards training for its workforce members who have access to PHI
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Myth: Security is an IT function

Security involves safeguarding electronic information in various ways and by various means, including policies, processes, education, designation of security officers and managers, dedicating staff and monetary resources to providing technical tools and physical safeguards to protect systems. The Security Rule includes only two standards related to technical security—access controls and audit controls. Most Security Rule standards address administrative safeguards. The rule also includes several physical safeguard and documentation requirements.

IT professionals generally do not receive information security training. Information security is a distinct profession with specific bodies of knowledge and content that address all aspects of protecting an organization’s information assets. Many information security officers (ISO) do not report to IT. A conflict of interest may exist if an ISO reports to a chief information officer or other individual in an IT department.

Security and IT budgets should be separate. This requires an ISO to develop a security budget, justify proposed expenditures, and develop and communicate metrics to demonstrate the program’s success and activities.

Editor’s note: This article is adapted from theThe Complete Guide to Healthcare Privacy and Information Security Governance by Phyllis A. Patrick, MBA, FACHE, CHC. Click here to learn more about the book, published by HCPro, a division of BLR.

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Submit your HIPAA questions to Editor Jaclyn Fitzgerald at jfitzgerald@hcpro.com and we will work with our experts to provide the information you need.

Q: My organization is revising its HIPAA policies with the goal of consolidating current policies and making them more user-friendly overall without compromising or eliminating essential information. Is there a checklist or list of recommended policies required for an organization to be HIPAA compliant?

A: There is no specific list. However, you should ensure that your policies address all of the privacy, security, and breach notification requirements in the HIPAA rules. Various resources provide policy templates that organizations can use as a reference when simplifying policies. Ensure that templates are from a reliable vendor. Some associations have template resources that organizations can access and customize.

There is no set number of policies that organizations must implement. You can combine requirements in one policy. For example, all use and disclosure requirements (e.g., for treatment, payment, healthcare operations, required by law) can be combined in one policy.

When purchasing templates, customize them to meet the needs of your organization. Consider other applicable laws, such as state privacy laws and federal alcohol and chemical dependency laws. Policies must be current, accurate, and enforceable. Some templates may not apply to your organization, so it is wise not to use them.

Editor’s note: Chris Apgar, CISSP, president of Apgar & Associates, LLC, in Portland, Oregon, answered this question for HCPro’s Briefings on HIPAA. This information does not constitute legal advice. Consult legal counsel for answers to specific privacy and security questions.

Join us for a 90-minute webcast about HIPAA auditing at 1 p.m. (Eastern) Tuesday, July 29.

With HIPAA audits slated to resume and OCR monetary settlements steadily increasing, the threat of ending up on OCR’s “wall of shame” is greater than ever. OCR recently hit two covered entities with the largest HIPAA settlement to date: a combined $4.8 million penalty for alleged violations during a joint arrangement.

The first step to ensuring HIPAA compliance is developing an effective risk analysis and management process that identifies gaps, thereby keeping your organization off the government’s radar. Learn strategies for conducting an internal audit of your organization—before the government audits you.

During this program, HIPAA compliance experts Margret Amatayakul, MBA, RHIA, CHPS, CPHIT, CPEHR, CPHIE, FHIMSS, and Kathy Perkins-Smerdel, BS, CHC, will explain how to develop a thorough risk analysis process and implement an internal auditing program, offer tips on how to prepare for an audit, and identify flaws in privacy and information security programs.

At the conclusion of this program, participants will be able to do the following:

  • Develop an effective, well-documented risk analysis process
  • Prepare for OCR/CMS audits
  • Identify privacy and information security program deficiencies

For more information or to place an order, call 800/650-6787 and mention Source Code EZINEAD or visit the HCPro Healthcare Marketplace.