Background:
Protection of healthcare data needs concrete policies along with integrated technology. In modern world, the patient data has become very significant for various purposes like delivery of healthcare services and enactment of laws by the government departments. Such a scenario can be addressed by HIPPA violations and breaches. For example, in the case of patient’s surgery, Villa Health Clinic did not take a written consent at that time. The law states to acquire a consent copy for insurance purposes but due to such delay the insurance provider may face some difficulties. Meanwhile, the employee at clinic provided the required information of the patient to the insurer. In such cases, having valid reasons for providing information, the supervisor may direct the information provider to report this issue of emergency concerning HIPPA violation.
Problem Summary: Privacy Breach—HIPAA Violation:
| Number | Briefly Explain the Law, Regulation, Standard, et cetera* | Briefly Explain How the Law, Regulation, Standard, et cetera Applies to the Privacy Breach/HIPAA Violation |
|---|---|---|
| Applicable Laws | HITECH (Health Information Technology for Economic & Clinical Health Act). It deals with the sharing the patient data via online means (Chen & Benusa, 2017). | The violation of law occurs when hospital provide information to anyone like insurance agency or media without the consent of patient. Healthcare organizations are bound to abide by both the HIPPA rules and the HITECH act. These ensure the confidentiality of the patient community for efficient outcomes of hospitals. |
| Applicable Specific Regulations | Mainly two regulations exist i.e., 45FR164.504 and 164.506. These regulations restrict healthcare organizations to share patient data only with the consent of the concerned patient (Moore & Frye, 2020). | The practice of sharing prohibited information without lawful way is violation of these regulations. These regulations ensure safety of patient data. The data sharing needs written consent except emergency and surgical cases which are solved with due consideration and care. |
| Disclosure | The HIPPA regulations declare that disclosing any patient’s private information without consent is illegal. Moreover, such consent must be in written form (Moore & Frye, 2020). | Patient critical information includes several objects like imaging reports, laboratory test reports, history of immunization, recoded symptoms, medication history, current medicine usage, and personal details of the patient. Sharing of all such information without written consent is violation of HIPPA privacy rules. |
| Applicable Human Resource Laws | Being a part of Villa Heath, the employees become part of data security system. So, they are bound to obey and abide by HIPPA regulations. Hence, employees of healthcare organizations are prohibited to share the patient’s information (Chen & Benusa, 2017). | The violation of this law occurs when data is transferred by the concerned employees. The organization should ensure proper education to the employees about violation laws. Such measures come out as culture of the organization. |
| Applicable Industry Accrediting Body Standards | In such a scenario, HIPPA violation rules are applied (Chen & Benusa, 2017). | The privacy rights of the patient community are snatched by breaching HIPPA regulations. The profound form occurs when employees share data without consent of the patient. |
Seven Essential Elements of an Effective Compliance Program:
| Number | Element of an Effective Compliance Program (Federal Register) * | How Does This Element Apply to the Privacy Breach/HIPAA Violation? |
|---|---|---|
| 1. | Employees of healthcare organizations should be trained and educated regarding HIPPA privacy laws (Gajwani et al., 2022). | This measure applies to Villa health as the employees who shared information had no knowledge of law. They had no understating that sharing such information is violation of law. So, their training has become mandatory. In such cases, the training should be in teams for better results. |
| 2 | In the clinical practice, supervisors and respective employees may adopt some efficient communication platforms (Gajwani et al., 2022). | At Villa Health, the sharing of information is unclear. Employees lack sufficient knowledge and clinic should provide communication line to resolve the issue at the beginning. |
| 3 | For tackling such issues, compliance committee along with compliance officers should be given tasks (Gajwani et al., 2022). | The compliance committee and the concerned officer can safe Villa Health from such issues. Because they investigate and ensure the implementation of health policies. |
| 4. | Employees may have access at any time and for that reason, various written policies, execution standards, and implementation of procedures should be adopted (Gajwani et al., 2022). | It will allow the employees to update, recall and implement the health policies and HIPPA regulations at Villa Health. |
| 5. | Quick response must be ensured regarding an offence on clinic along with taking speedy and corrective actions (Gajwani et al., 2022). | It applies to the existing case at Villa Health as the increased speed may correct the problem before damaging normal clinical operations. |
| 6. | Monitoring along with impactful internal auditing (Gajwani et al., 2022). | This auditing process allows Villa health to investigate breach and also devise some mechanism to limit such violations in future. |
| 7. | Employees are enabled to read disciplinary guidelines and respective implementation (Gajwani et al., 2022). | This will apply at Villa Health concerning the identification of breach by mutual work of legal and HR department. |
Privacy Breach Consequences:
| Covered Entity | Legal Penalties* | Additional Consequences |
|---|---|---|
| Individual Leader Within Health Care Organization | An employee will have to face Tier A penalties for concerned violation which may include a fine of $100 for the said violation (Heath et al., 2021). | The administration of Villa Health devises the mechanism to train the employees with one month probation. In addition, a warning letter must be issued to the employees concerning their conduct. |
| Other Internal Health Care Organization Stakeholders | The compliance officer would be declared as negligent official for not proposing necessary training at the clinic. Such an act may face Tier A or Tier B penalties (Heath et al., 2021). | The compliance officer may ensure effective duty performance at clinical sites. In addition, proper training must be provided to prevent such discrepancies in future. |
| Health Care Organization | The healthcare organization will face a Tier C penalty which may include $10,000 fine against all the incidents reported (Heath et al., 2021). | In the case of the healthcare organization, there should be a mechanism to pay compensation to the patients. Such compensation would be according to the mutual contract of the organization and the effected patients if negotiated. |
Evidence-Based Recommendations:
| Number | Evidence-Based Recommendation | Additional Insights/Salient Points | Sources* |
|---|---|---|---|
| 1. | The gap analysis in HIPPA laws should be conducted. | HIPPA rules undergo several changes with the passage of time. So, remaining updated by the employees and organization is mandatory. This analysis may be helpful in determining current and past position along with highlighting the important options for the organization. The analysis will be helpful for profound development. | Guidance for Psychologists on HIPAA Breach Notification Rule. PsycEXTRA Dataset. |
| 2. | Employees may enroll fresher courses for protection of privacy and information of the patient. | The technique assumes that all the employees are not well aware of the privacy and protection rules. So, fresher courses ensure that such mishap would not harm any patient in future. | Guidance for Psychologists on HIPAA Breach Notification Rule. PsycEXTRA Dataset. |
| 3. | For investigating any breach, the compliance committee has wide scope and authority. | Effective analysis allows the committee to find the root cause of problem and probe its solution. After investigation, the committee may recommend several measures including training of employees, imposing fines and punishments. | Guidance for Psychologists on HIPAA Breach Notification Rule. PsycEXTRA Dataset. |
| 4. | OCR (office of civil rights) and the clinic should work in collaboration. | Both patients and healthcare officials understand their rights by working with OCR regarding their privacies and information. | Guidance for Psychologists on HIPAA Breach Notification Rule. PsycEXTRA Dataset. |
| 5. | There should be a culture to execute sharing of information on constant basis. | Effective mechanisms of sharing information at the clinic help employees to consult other professional before taking any decision. | Guidance for Psychologists on HIPAA Breach Notification Rule. PsycEXTRA Dataset. |
Ethical Decision-Making Framework for Health Care Leaders:
| Number | Ethical Decision-Making Step* | Apply the Ethical Decision-Making Step to the Privacy Breach/HIPAA Violation |
|---|---|---|
| 1. | A background cross-check should be conducted on respective breach (Nelson, 2017). | Such an analysis would help the professionals to cope with diverse situation. It determines the awareness level of employees about HIPPA violations. |
| 2. | Priority to identify any ethical issue or emerged question (Nelson, 2017). | The ethical aspect leads to violation if the patient’s information is shared with insurance agency without consent. |
| 3. | Observing concerned principles based on ethics (Nelson, 2017). | An ethical principle demands no violation of HIPPA standards. For example, in surgical case, the surgical procedure would be considered as private information of patient. |
| 4. | Efficient means to respond to any situation (Nelson, 2017). | The organization and the patient have limited options in the eye of law. The law will take action against the employees’ deeds if violation occurs. |
| 5. | The efficient response on the issue should be recommended (Nelson, 2017). | Warnings, suspension, fines or other related punishments to the involved employee are helpful. Meanwhile, the employees will be provided full-fledged information about the legal matters of information privacy. |
| 6. | Focusing on ethical conflicts regarding domains of future (Nelson, 2017). | For future concerns, the most impactful way is the training of employees and concerned staff to mitigate any conflicts between the parties. |
Conclusion:
HIPPA standards primarily require the strict obedience towards safety and security of patients’ private information. Strict adherence to these guidelines reduces the disparity of legal actions against organizations as well their employees. The penalties in the form of fines are high mounted in case of HIPPA violations and organizations face its bleak impact on their financial positions. These regulations play vital role in streamline the healthcare organizations in accordance with law along with protection of patient privacy. Various legal regulations, breach elements and respective consequences may provide the practice demonstration and analysis to investigate some malfunctioning on the part of organizations and its employees. For catering such situations, necessary practical training must be ensured to all the concerned employees. Similarly, the organizations undertake to identify and act upon such needs of employees on priority basis. These urgent precautions may reduce the violation of HIPPA standards up to maximum extent. Hence, the practical analysis may play an effective role to solve the problems relating to legal aspects for smooth running of healthcare organizations.
References
Chen, J. Q., & Benusa, A. (2017). HIPAA security compliance challenges: The case for small healthcare providers. International Journal of Healthcare Management, 10(2), 135-146.
Gajwani, A., Shah, A., Patil, R., Gucer, D., & Osier, N. (2022). Training undergraduate students in HIPAA compliance. Accountability in Research, 1-12.
Heath, M., Porter, T. H., & Silvera, G. (2021). Hospital characteristics associated with HIPAA breaches. International Journal of Healthcare Management, 1-10.
Moore, W., & Frye, S. (2020). Review of HIPAA, part 2: limitations, rights, violations, and role for the imaging technologist. Journal of Nuclear Medicine Technology, 48(1), 17-23.
Nelson, W. (2017). Making Ethical Decisions. Healthcare Management Ethics. ISSN/ISBN: 0883-5381
Stuart, L. (2019). Guidance for Psychologists on HIPAA Breach Notification Rule. PsycEXTRA Dataset. 0, 1-12.
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