The HITECH-HIPAA Updates: New Changes to the Regulations, New Enforcement, and Audits
Jim Sheldon-Dean, Principal and Director of Compliance Services, Lewis Creek Systems, LLC
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In July 2012, it was announced that the Minnesota Attorney General had reached a settlement agreement with Accretive, a company that functioned as a business associate for healthcare providers, for violating HIPAA rules when handling patient data.
The case was significant because it was one of the first to be resolved under HIPAA rules for Privacy and Security of Protected Health Information, as applied to Business Associates according to the HITECH Act. These changes and others, relating primarily to the HITECH Act, are expected to be finalized soon in rules to be enforced by the US Department of Health and Human Services Office for Civil Rights.
Besides introducing random audits of providers, the new amendments also make changes to rules pertaining to new patient rights and new restrictions on uses and disclosures by entities.
This seminar will explain the new rules as well as new requirements related to electronic health records that will require changes to policies, procedures, and even notices of privacy practices. Attendees will learn how new limitations on marketing and fund-raising may change how entities can reach out to individuals and the new requirements for disclosers of health information to apply "minimum necessary" standards. The seminar will detail the best practices needed to ensure that a healthcare entity or business associate is in compliance with the act's evolving requirements.
Key goals of the conference will include:
- Learn how the changes to HIPAA came to pass
- Find out the details of the changes to HIPAA, including new definitions
- Learn how the new regulations change the way individuals have access to their records, and how much they can find out about who has accessed their records.
- Find out about how Individuals can now request certain restrictions on disclosures that you must honor.
- Learn about the new requirements for disclosers of health information to apply “minimum necessary” standards.
- Understand the new requirements for Business Associates to comply with HIPAA privacy protections and security safeguards and how BAs are subject to enforcement and penalties directly by HHS.
- Learn how Health Information Exchanges, Regional Health Information Exchanges, and e-Prescribing gateways are now considered to be Business Associates
- Find out about how new limitations on marketing and fund-raising may change how entities can reach out to individuals.
- Learn all about how new audit and penalty requirements increase the need to make sure you are in compliance before HHS OCR knocks on the door.
Who will Benefit:
- Information Security Officers
- Risk Managers
- Compliance Officers
- Privacy Officers
- Health Information Managers
- Information Technology Managers
- Medical Office Managers
- Chief Financial Officers
- Systems Managers
- Legal Counsel
- Operations Directors
- Medical Offices, Practice Groups, Hospitals, Academic Medical Centers, Insurers, Business Associates (Shredding, Data Storage, Systems Vendors, Billing Services, etc.)
- HIPAA History and Changes
- Structure of the HIPAA Regulations
- Privacy Rule
- Individual Rights
- Restrictions on Uses and Disclosures
- Security Rule
- Breach Notification Rule
- Enforcement Rule
- Origin of Changes to HIPAA
- Overview of HIPAA Amendments
- Expansion of Application
- Individual Rights
- Restrictions on Uses and Disclosures
- Breach Notification
- Scope of Changes
- History of Implementation
- Status of Changes
- HIPAA Business Associates
- Who Is and Is Not a Business Associate?
- The Significance of the BA Designation
- How Business Associates Have Changed Under HIPAA
- Expansion of Regulations To Business Associates
- New Kinds of Business Associates
- Appropriate HIPAA Policies for a Business Associate
- HIPAA Business Associate Agreements
- BAs and Security Compliance
- Risk Analysis and Business Associates
- Changes to Individual Rights Under HIPAA
- New Rights Concerning EHRs
- Copies of Electronic Records
- Accounting of Disclosures
- Necessity for New and Updated Policies
- New Rights on Restriction of Disclosures
- Requests Must Be Honored
- Requires New Policies, Processes, EHR Support
- New Rights Concerning Sale of PHI
- Changes to CLIA, HIPAA, and Laboratory Information
- Rewriting the Notice of Privacy Practices
- New Restrictions on Uses and Disclosures
- Changes to Minimum Necessary
- New Marketing and Fundraising Limitations
- Marketing Definitions Revised, Complicated
- Necessity to Honor Opt-Outs
- New Controls on Sale of PHI
- New Responsibilities for EHRs
- Must Help Manage Individual Requests, Rights
- Must Provide Access for Individuals
- Must Provide Access Reports, Accountings
- What to Ask Your EHR Vendor About HIPAA
- HIPAA Enforcement
- Changes to the Enforcement Rule
- New Tiered Penalty Structure
- Willful Neglect of Compliance
- New Higher Penalties
- Enforcement Actions
- Investigations and Settlements
- What Happens When You Ignore HHS-OCR
- Preparing for HIPAA Audits and Breach Notification
- Review of Questions Asked in Prior Audits
- Expansion of HIPAA Audits Under HITECH
- Exploration of the HIPAA Audit Protocol
- Scope of the Audit Protocol
- Using the HIPAA Audit Protocol as a Tool for Compliance Management and Documentation
- Policies, Procedures, and the NIST HIPAA Security Rule Toolkit
- HIPAA Breach Notification
- Who, What, When, and How
- Avoiding Breaches
- Learning from Breaches
- Using Audit Drills to Be Ready for Audits and Breaches
- Planning Your Compliance Effort
- Consider Compliance As A Series of Projects
- Selecting Your Compliance Team
- The Importance of Top-Level Support
- Selecting Your Compliance Management Tools
- The HIPAA Audit Protocol
- The NIST HIPAA Security Rule Toolkit
- Providing and Documenting Training
- Updating and Maintaining Your Compliance Plans
Meet Your Instructor
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 variety of health care providers, businesses, universities, small and large hospitals, urban and rural mental health and social service agencies, health insurance plans, and health care business associates. He serves on the HIMSS Information Systems Security Workgroup, co-chairs the Workgroup for Electronic Data Interchange Privacy and Security Workgroup, and co-chairs the WEDI HIPAA Updates and Privacy and Security Meaningful Use sub-workgroups. He is a frequent speaker regarding HIPAA and information privacy and security compliance issues at seminars and conferences, including speaking engagements at AHIMA national and regional conventions and WEDI national conferences, and before the New York Metropolitan Chapter of the Healthcare Financial Management Association, Health Information Management Associations of New York City, New York State, Virginia, and Vermont, the Connecticut Hospital Association, and the Hospital and Health System Association of Pennsylvania. Sheldon-Dean has nearly 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. Sheldon-Dean 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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Philadelphia Museum of Art
The Philadelphia Museum of Art sits majestically on a rise at the end of the Benjamin Franklin Parkway. The vast collections of this temple of art make it the third-largest art museum in the country, and an absolute must-see on the city's cultural circuit.
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Valley Forge National Historical Park
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The Liberty Bell Center
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National Constitution Center
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The Franklin Institute
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The Barnes Foundation
The Barnes Foundation was created in 1922, a school originating with Barnes’ educational experimentation in his Argyrol (pharmaceutical) factory. Barnes and The Foundation’s first director of education, John Dewey, were interested in fostering cognitive development through new approaches to education, and in heightening critical-thinking and problem-solving skills through the study of art. Barnes, like Dewey, was actively engaged in development of an intellectual framework and educational philosophies and practices with many of the best artists and thinkers of his day.
The Rocky Statue
One of Philadelphia’s most famous pieces of public art is a bigger-than-life boxer… literally. Originally created for Rocky III, the sculpture is now a real-life monument to a celluloid hero. The fictional Rocky Balboa of Sylvester Stallone’s Rocky movies was immortalized in bronze in 1980. After filming for the movie completed, Stallone donated the statue to the City of Philadelphia.
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