Unattended USB Drive in the IT Department: This is an incidence that is in clear violation of the Health Insurance Portability and Accountability Act (HIPAA) Security Rule, which requires that covered entities avail protective measures in an environment where the electrically protected health information (ePHI) is located. An unattended USB discloses patient-sensitive information that might be open to unauthorized access, consequently infringing and contravening a patient’s right to privacy from access or theft.
Improper Disposal of Electronic Devices: Disposing old laptops and digital printer/copy cartridges in a dumpster without proper data destruction procedures violates HIPAA’s Privacy Rule. Per HIPAA’s disposal requirements, protected health information stored on these devices must be securely erased to prevent unauthorized access.
Unauthorized Access to Electronic Health Records (EHR): Permitting high school students or other unauthorized persons to access patient information violates the Privacy Rule under HIPAA. Access to patients’ data should be provided only for those authorized for it, and such authorization can be granted only on a need-to-know basis to guarantee privacy and confidentiality.
Regulatory Stakeholders
Governmental, regulatory, accrediting bodies, state professional boards, and individual healthcare facilities are responsible for ensuring privacy and security regulations compliance. The Joint Commission and Commission on Accreditation of Rehabilitation Facilities, among other accrediting bodies, certify AHS and emphasize adherence to criteria that guarantee the confidentiality of patient information. The state professional boards police the rules governing healthcare providers’ behavior and practice requirements. Similarly, the Office is granted the power to enforce HIPAA and conduct investigations into privacy complaints. Thus, by granting stewardship responsibility, stakeholders who influence the facility’s operations, regulatory standard setters, and auditors or investigators responsible for ensuring compliance are allowed to establish protocols. Equating to failure are the damages incurred through lawsuits, prospective losses of enrolments, and the negative impact on the reputation and financial standing of AHS (Supsermpol, 2023)
Patient and Provider Rights
HIPAA guarantees patients’ privacy and confidentiality in matters regarding their health information. Medical providers should respect these rights, and hence, they must protect their patients’ information from unauthorized access. Such actions can pose a risk to patient care or result in legal action against the provider, which may come in the form of either penalties or damages caused to his reputation. There are also other obligations, such as maintaining accurate medical records and preserving the confidentiality of patient data, thus preventing its loss or exposure to fraudsters (Ayugi, 2021). Through this mechanism, certain standards of care have been set to avoid breaches, and consequently, there is a duty upon clinicians not to behave irresponsibly either through negligence or by design.
Compliance and Risk Management Factors of Medical Records
AHS is seriously exposed to risk management problems when unauthorized people access EHR. Breaches of this nature violate HIPAA regulations, compromise patient privacy, and could lead to financial penalties, legal liabilities, and reputational damage. In compliance with HIPAA laws, AHS must protect medical records and ePHI through administrative, physical, and technical safeguards measures (Klein, 2023). Risk management strategies that include implementing access controls training the staff on privacy protocols, and carrying out regular risk assessments are essential for the organization. The proactive stance on compliance will decrease violations and show an AHS commitment to protecting patient information.
Basic Plan of Action
Employee Training and Awareness: Create comprehensive HIPAA, privacy, and security training programs for staff. Stress patient data security and the repercussions of noncompliance.
Secure Disposal Procedures: Implement proper procedures for disposing of electronic devices and media containing patient data. To prevent unauthorized access, use certified disposal services or software to permanently erase data before disposal.
Access Control Measures: Restrict EHR system access to approved users. Employ unique usernames, strong passwords, and session timeouts to prevent unauthorized access.
Physical Security Measures: Increase physical security to protect IT departments and nurses’ stations. Install surveillance cameras, restrict access to authorized people, and have clear desk policies to reduce breaches.
Regular Audits and Assessments: Conduct regular audits and risk assessments to identify vulnerabilities and gaps in compliance. Address findings promptly and implement corrective actions to mitigate risks and ensure ongoing compliance.
Incident Response Plan: Develop an incident response plan to effectively respond to and mitigate privacy and security breaches. Establish procedures for reporting incidents, conducting investigations, notifying affected individuals, and implementing corrective measures to prevent recurrence.
Continuous Monitoring and Improvement: Implement regular training, audits, and policy changes to monitor privacy and security practices. Maintain patient-provider trust by promoting compliance and responsibility throughout the enterprise.
By implementing these strategies, AHS can strengthen its privacy and security practices, mitigate compliance risks, and uphold patient trust and confidentiality.
References
Ayugi, E. D. (2021). Information Security Strategies and Patient Data Privacy Among Health Facilities in Nairobi. Repository. combi.ac.ke. http://erepository.uonbi.ac.ke/handle/11295/157072
Klein, J. (2023). Information Security Officers Perceptions of How to Implement Successful Information Security Programs in Health Sciences Center Environments. Ttu-Ir.tdl.org. https://ttu-ir.tdl.org/items/248d1dfc-1a9b-48e0-acc7-c58bd1d5822e
Supsermpol, P. (2023). Predicting financial performance for listed companies in Thailand during the transition period: A class-based approach using logistic regression and random forest algorithm. Journal of Open Innovation: Technology, Market, and Complexity, 9(3), 100130. https://doi.org/10.1016/j.joitmc.2023.100130