Understanding HIPAA Incidental Disclosures: Examples and Best Practices
HIPAA (Health Insurance Portability and Accountability Act) regulations are crucial for safeguarding sensitive patient information. However, despite meticulous efforts, incidental disclosures can occur. Healthcare professionals and covered entities must grasp what constitutes an incidental disclosure and how to mitigate risks effectively. A patient care covered entity must implement reasonable safeguards to protect PHI.
In this article, we’ll delve into the concept of incidental disclosures under HIPAA, provide examples, and offer best practices to minimize their occurrence.
1. What is an Incidental Disclosure?
A HIPAA incidental disclosure, as per HIPAA guidelines, refers to the unintentional exposure of protected health information (PHI) during the course of a permitted use or disclosure. These disclosures are typically secondary to an otherwise permissible or required use or action and occur despite reasonable safeguards in place.
2. Examples of HIPAA Incidental Disclosures:
1. Overheard Conversations: A healthcare provider discusses a patient’s diagnosis or treatment plan with a colleague in a crowded hallway or waiting room, inadvertently allowing nearby patients or visitors to overhear sensitive information.
2. Shared Workstations: Employees working in a healthcare facility share workstations or computer screens, and PHI belonging to one patient is inadvertently viewed by another employee or visitor.
3. Faxing Errors: A staff member mistakenly faxes medical records or prescriptions to the wrong recipient, resulting in the unintended exposure of PHI.
4. Email Mishaps: An employee sends an email containing PHI to the wrong recipient due to auto-fill errors or selecting the incorrect email address from the contact list.
5. Paper Records Left Unattended: Patient files or documents containing PHI are left unattended in public areas of many health care providers, such as waiting rooms or consultation rooms, allowing unauthorized individuals to view the information.
6. Electronic Device Theft: Theft or loss of electronic devices such as laptops or smartphones containing unencrypted PHI, potentially leading to unauthorized access to a patient’s medical chart information, or other sensitive information.
3. Best Practices to Prevent Incidental Disclosures: Implementing Reasonable Safeguards
1. Employee Security Awareness Training: Provide comprehensive HIPAA training to all staff members, emphasizing the importance of confidentiality, the potential consequences of incidental disclosures, and the requirements for covered entity’s safeguards.
2. Privacy Screens and Physical Barriers: Install privacy screens on computer monitors and implement physical barriers in work areas to prevent unauthorized viewing of PHI. Ensure reasonable physical safeguards are in place to protect individuals’ health information.
3. Secure Communication Channels: Use encrypted email platforms and secure messaging apps to transmit PHI electronically, minimizing the risk of interception or unauthorized access. Focus on implementing reasonable safeguards to protect against unauthorized uses and disclosures.
4. Clear Communication Policies: Establish clear protocols for discussing patient information in public areas, emphasizing the need for discretion and patient confidentiality at all times.
5. Access Controls: Implement access controls and user authentication measures to restrict access to PHI only to authorized personnel. Ensure reasonable minimum necessary policies are in place to limit access based on job responsibilities.
6. Regular Audits and Risk Assessments: Conduct regular audits and risk assessments to identify potential vulnerabilities in data handling practices and address them promptly.
5. The Cost of HIPAA Violation: Protecting Health Information
Your clients trust you with their private medical information, but security breaches at health care providers are increasing. In 2023, over 109 million healthcare records were breached, as compared to 2022’s 55 million records.
Implementing reasonable safeguards to protect against unauthorized uses of patients medical records and disclosures can impose a significant financial and administrative burden on covered entities. If you have a breach affecting 500 or more individuals, you’ll face a HIPAA investigation and end up on the US Department of Health & Human Services’ Office for Civil Rights (OCR) “Wall of Shame.” This could lead to fines, loss of trust, and a corrective action plan.
Even small practices can end up on the Wall of Shame. For example, if you’ve been keeping records for six years and adding 8 new clients per month, you could impact over 500 individuals in case of a breach.
Example of past HIPAA violation fines:
LA Care Health Plan: $1,300,000
Banner Health: $1,250,000
Lafourche Medical Group: $480,000
MedEvolve: $350,000
Yakima Valley Memorial Hospital: $240,000
Conclusion
Incidental disclosures of PHI pose significant risks to patient privacy and can lead to legal and reputational consequences for healthcare providers and organizations. By understanding what constitutes an incidental disclosure, recognizing common examples, and implementing robust preventive measures, healthcare professionals can uphold HIPAA compliance and maintain the confidentiality of patient information effectively. The HIPAA Privacy Rule permits incidental disclosures of protected health information as long as reasonable safeguards and minimum necessary policies and procedures are implemented to protect an individual’s privacy.
Contact us today and learn how your medical practice can reduce the risks of incidental disclosure and meet HIPAA compliance.
Frequently Asked Questions
At eSudo, we help your law firm, accounting practices and small business feel like a big business when it comes to technology. For over 23+ years, we give you all the tools and support you need without the cost of hiring extra staff. That means if things go wrong, you don’t have to worry about layoffs or added expenses.
Our IT services give you the power of a large business at a fraction of the cost, helping you stay competitive in today’s digital world. With us, your business can compete with the big players and make more money while staying secure and efficient.
We specialize in working with professional service organizations like law firms, accounting firms (CPAs), and wealth management. However, eSudo have helped other business such as non-profit organizations, manufacturing and other small businesses after we have reviewed their needs and determined if they are good fit for our services.
eSudo is not a traditional computer support company; we focus on security first, and computer support happens to be part of the security services. In the dynamic landscape of network security, a proactive approach is key to safeguarding your business. It’s not a one-time event but an ongoing commitment to keep your systems resilient against evolving threats. With the rise of a mobile workforce and the omnipresence of phishing attempts or social engineering or AI, educating your employees, continuous monitoring and proactive support are vital to prevent data breaches.
If your business is looking for break-fix support or hourly IT services, we may not be for you because we cannot fully manage your risks and more importantly, it creates a trust issue in our relationship. Under a “break-fix” model, there is a fundamental conflict of interest between your business and eSudo.
“Over 97% of American businesses in 2023, operating in a digitally-driven landscape, heavily rely on the Internet for essential functions such as productivity, performance optimization, streamlined communication, bolstered sales, and various other facets of their daily operations. This heightened dependence on digital infrastructure, however, comes with a notable caveat: more than 87% of small businesses are entrusted with customer data that could be potentially compromised in the event of a cyberattack.”
We keep your IT Systems running and data secure with our proven IT Strategy, Managed Security, and Proactive Support & End User Management. Our Strategy focuses on identifying, prioritizing, and recommending the right technology for your organization. Our Managed Security includes data backup, device encryption, zero-trust access management, and policies & procedures. Our Support includes a live phone help desk, 24/7 monitoring, on-site support as needed, employee onboarding, and asset procurement.
Proven track record: We have been building our loyal customer base since 2001 in an industry where IT consulting firms come and go. Our customers, vendors, and employees stay with us because we build and value long term relationships with them. With operations all over the San Francisco Bay Area, eSudo provides reliable IT support to Northern CA-based businesses and beyond. We’re big enough to offer the facilities, services, and expertise you expect and small enough to provide the support and attention you deserve.
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This is a very difficult question to answer because not all environments are the same, we will do our best to explain some general pricing guidelines.
For a business with 10 to 50 employees, IT support is a crucial investment to ensure smooth operations and data security. This support includes system maintenance, cybersecurity measures, help desk services, data backup, and software updates. As an IT manager and business owner, allocating a reasonable budget for IT support is essential to prevent downtime, protect against cyber threats, and ensure the firm’s efficiency and success in the digital era. Neglecting IT support can lead to potential vulnerabilities and higher costs in the long run. Thus, viewing IT support as a necessary investment is vital for sustaining your firm’s operations effectively and securely.
A typical price for IT Support and Cybersecurity ranges from $185 to $300 per user per month. Actual cost will be determined after we meet and perform an assessment of your environment.