The provision of HIPAA training is a requirement for all organizations subject to the Health Insurance Portability and Accountability Act (HIPAA); but, although this Act has been in force for more than twenty years, there are still many organizations that fail to provide effective HIPAA training – leading to avoidable violations of HIPAA and fines for compliance failures.
One of the reasons why organizations fail to provide effective HIPAA training is that the Privacy Rule stipulates Covered Entities “must train all members of the workforce on the policies and procedures with respect to Protected Health Information required by this subpart [the Privacy Rule] and Subpart D of this part [the Breach Notification Rule]”.
This standard implies that Covered Entities (generally health plans, health care clearinghouses, and health care providers) only have to train members of the workforce on the policies and procedures developed by the Covered Entity “as necessary and appropriate for the members of the workforce to carry out their functions within the Covered Entity”.
There is no consideration that members of the workforce may not understand what PHI is or why PHI has to be protected. It can also be the case that by providing HIPAA training “to the letter of the law”, Covered Entities are fulfilling their compliance requirements, but failing to provide training in context – increasing the risk that training may not be effective.
There is No One-Size-Fits-All HIPAA Training Solution
Because Covered Entities have to provide HIPAA training on the policies and procedures they have developed to protect the privacy of individually identifiable health information and ensure the confidentiality, integrity, and availability of electronic PHI, there is no one-size-fits-all solution to HIPAA training. However, there are some common subjects in all HIPAA training:
- An explanation of what Protected Health Information.
- Permissible uses and disclosures of Protected Health Information.
- The Minimum Necessary Standard and incidental disclosures.
- The difference between patient consent and patient authorization.
- Patients´ HIPAA rights – including the right to limit disclosures.
- The basics of the Security Rule and the three main safeguards.
- The basics of the Breach Notification Rule and HIPAA enforcement.
Although it is essential all members of the workforce are familiar with the above, it is not practical to include the basics of HIPAA in a policy and procedure training session. This would make a single training session too long for members of the workforce to retain the information. Similarly, it is not practical to organize multiple HIPAA training sessions for each new member of the workforce.
However, without a knowledge of the basics of HIPAA, any new member of the workforce who has not undergone training in a former employment may find it difficult to comply with a Covered Entity´s policies and procedures. This can lead to avoidable violations of HIPAA and fines being issued by HHS´ Office for Civil Rights for training failures.
HIPAA Violation Fines That Were Preventable with HIPAA Training
In most cases, HHS´ Office for Civil Rights will respond to a HIPAA violation attributable to a lack of compliance training by imposing a corrective action plan. However, that is not always the case – especially when multiple violations are attributable to a lack of HIPAA training. The following is a selection of HIPAA violation fines that were preventable with HIPAA training.
In 2019, West Georgia Ambulance Inc. agreed to pay $65,000 to settle violations of HIPAA that led to the loss of an unencrypted laptop containing the PHI of 500 individuals. During its investigation, HHS´ Office for Civil Rights found the ambulance service had failed to implement a security and awareness HIPAA training program as required by the Security Rule.
The following year, the Athens Orthopedic Clinic in Pennsylvania was fined $1.5 million following a data breach that exposed the PHI of 208,557 patients. HHS investigators identified a series of failings that included the failure to conduct a risk analysis, maintain HIPAA policies and procedures, and provide HIPAA Privacy Rule training to members of the workforce.
It is not only HHS´ Office for Civil Rights that can issue HIPAA violation fines for training failures. In 2022, the New Jersey Attorney General fined Regional Cancer Care Associates $425.000 following a successful phishing attack that exposed the PHI of 105,000 individuals. Among many HIPAA violations, the organization had failed to implement a security and awareness HIPAA training program.
How to Make HIPAA Compliance Training Effective
The way to resolve any issues with the provision of HIPAA training is to ensure all new members of the workforce take a basic HIPAA training course prior to undergoing policy and procedure training. Most courses of this nature require each module to be completed before trainees move onto more advanced topics to ensure they have a fundamental understanding of HIPAA.
“Off-the-shelf” training courses that can be completed online remove the need for Covered Entities to provide live training in a classroom environment or disrupt workflows by removing new members of the workforce from the workplace. Additionally, they have the advantage of being re-usable for refresher training or if a need for further training is identified in a risk assessment.
For Covered Entities, “off-the-shelf” HIPAA training courses support their own policy and procedure training so that their HIPAA compliance training is more effective. While it won´t be necessary for all new members of the workforce, having new members of the workforce enter the workplace with a full understanding of HIPAA can help Covered Entities be more HIPAA compliant.
What You Should Know about HIPAA Compliance
The term HIPAA compliance can mean different things to different people. However, there is little doubt that complying with the Administrative Simplification provisions of the Health Insurance Portability and Accountability Act can be beneficial for all types of organizations, for the people who work for them, and for the individuals served by them.
The benefits are not necessarily isolated in each group. For example, the provision of effective HIPAA compliance training by an organization reduces the risk of PHI being impermissibly disclosed by healthcare workers. When patients believe private information shared with a healthcare worker will remain private, they tend to be more forthcoming about their symptoms.
With more information about their patients, healthcare workers can make informed diagnoses and treatment decisions. This leads to better patient outcomes and higher staff morale, which results in increased patient satisfaction scores and staff retention. HIPAA training is only one part of compliance – yet providing it effectively, can have a significant beneficial impact for all involved.
The Benefits of HIPAA Compliance for Organizations
The benefits of HIPAA compliance for organizations vary according to the nature of each organization´s business. For many Covered Entities, HIPAA compliance can mean benefitting from the efficiencies created by the standardization of identifiers, code sets, and the operating rules for transactions such as eligibility checks, claims statuses, and fund transfers.
In addition to the administrative benefits of HIPAA compliance, healthcare organizations have also benefitted from the amendments to HIPAA introduced via the HITECH Act. These enabled the Meaningful Use program – which incentivized the use of health IT technology and led to the more efficient delivery of health care and a reduction in medical errors.
Business Associates can also benefit by demonstrating compliance with HIPAA when Covered Entities conduct due diligence on their operations. Given a choice between two organizations – one who is HIPAA compliant, and one who isn´t – a Covered Entity have no option but to engage the services of the organization who will ensure PHI remains secure.
The Benefits of Compliance for Healthcare Workers
The primary benefits of HIPAA compliance for healthcare workers have previously been mentioned inasmuch as when patients believe private healthcare information will remain private, research shows patients are more willing to share information. This enables healthcare workers to make better treatment decisions, which can result in better patient outcomes.
While this could be considered as a benefit of HIPAA compliance for patients, better patient outcomes typically raise workforce morale, which – for individual healthcare workers – results in a more rewarding work experience. Indirectly, this implies that the benefits of HIPAA compliance for healthcare workers can be greater satisfaction and motivation.
Additionally, HIPAA-trained healthcare workers have knowledge they can take to any place of work. While a knowledge of compliance may not be a requirement for a better paid job, it can be a determining factor for a prospective employer when multiple candidates with similar professional skills apply for the same position.
The Benefits of Complying with HIPAA for Individuals
One of the benefits of HIPAA compliance for individuals has also been mentioned inasmuch as being more trusting that health information will remain private encourages patients to be more forthcoming about healthcare issues and this can result in better outcomes. The same could apply to plan members being more forthcoming and benefiting from more appropriate health insurance.
In addition to trusting that their health information is secure, it is important for individuals to trust that, if their health information is hacked or disclosed impermissibly, they will be informed about the incident as quickly as possible. The speed of a breach notification and the content of the notification can help individuals take steps to protect themselves from fraud, theft, and loss.
This is quite an important part of HIPAA compliance that can help regain trust after a data breach or impermissible disclosure and it is important for Covered Entities and Business Associates to be aware that training on Breach Notification Rule policies and procedures must be provided under the training standard in §164.530 of the Privacy Rule´s Administrative Requirements.
The Importance of Effective HIPAA Compliance Training
The training standards in HIPAA (in §164.530 and §164.308) can leave gaps in HIPAA knowledge and compliance. This can be due to risk assessments failing to identify avoidable risks, analyses of assessments being misinterpreted when policies and procedures are being compiled, or the failure to provide effective training on the policies and procedures in the context of HIPAA.
The benefits of effective HIPAA compliance training are clearly worth pursuing; and, if you are a member of a Covered Entity´s or Business Associate´s workforce with the responsibility for HIPAA compliance, and you could benefit from help with developing your organization´s HIPAA training curriculum, you are advised to speak with a compliance professional.