🎓 HIPAA Training Center

Comprehensive training on Health Insurance Portability and Accountability Act compliance

📚 Introduction to HIPAA

🎯 Learning Objectives:
  • Understand the purpose and history of HIPAA
  • Identify who must comply with HIPAA
  • Recognize the main components of HIPAA
  • Understand why HIPAA compliance is critical

What is HIPAA?

The Health Insurance Portability and Accountability Act (HIPAA) is a federal law enacted in 1996 to protect sensitive patient health information from being disclosed without the patient's consent or knowledge.

📅 History

  • 1996: HIPAA enacted
  • 2003: Privacy Rule takes effect
  • 2005: Security Rule takes effect
  • 2009: HITECH Act expands HIPAA
  • 2013: Omnibus Rule updates

🎯 Primary Goals

  • Protect patient privacy
  • Secure health information
  • Enable healthcare portability
  • Reduce healthcare fraud
  • Standardize transactions

Who Must Comply?

🏥 Covered Entities

Healthcare Providers Health Plans Healthcare Clearinghouses

Organizations that transmit health information electronically

🤝 Business Associates

Vendors Contractors Service Providers

Third parties that handle PHI on behalf of covered entities

💼 Examples

Hospitals Clinics IT Companies Billing Services

Both direct providers and support services

Three Main Rules

Rule Purpose Key Focus
🔒 Privacy Rule Protects all individually identifiable health information Patient rights, permitted uses, disclosures
🛡️ Security Rule Sets standards for securing electronic PHI (ePHI) Administrative, physical, technical safeguards
⚠️ Breach Notification Rule Requires notification after PHI breaches Timely reporting, risk assessment, documentation
⚠️ Important: At CardioAI, HIPAA compliance is not optional. Every employee must understand and follow HIPAA regulations. Violations can result in severe penalties for both the organization and individuals.

Why HIPAA Matters at CardioAI

As a healthcare AI company, we handle sensitive cardiac health data daily. Our compliance ensures:

🔒 HIPAA Privacy Rule

🎯 Learning Objectives:
  • Understand what constitutes Protected Health Information (PHI)
  • Know when PHI can be used and disclosed
  • Recognize minimum necessary standard
  • Understand Notice of Privacy Practices requirements

What is Protected Health Information (PHI)?

PHI is any individually identifiable health information held or transmitted by a covered entity or its business associate. This includes information that:

📋 18 Identifiers

  1. Names
  2. Geographic subdivisions smaller than state
  3. Dates (birth, admission, discharge, death)
  4. Telephone numbers
  5. Fax numbers
  6. Email addresses
  7. Social Security numbers
  8. Medical record numbers
  9. Health plan beneficiary numbers
  10. Account numbers
  11. Certificate/license numbers
  12. Vehicle identifiers and serial numbers
  13. Device identifiers and serial numbers
  14. Web URLs
  15. IP addresses
  16. Biometric identifiers
  17. Full-face photos
  18. Any unique identifying number, characteristic, or code

🏥 Health Information Includes

  • Medical history: Past conditions, surgeries, treatments
  • Test results: Lab work, imaging, diagnostics
  • Diagnoses: Current and past conditions
  • Treatment plans: Medications, therapies, procedures
  • Billing information: Charges, payments, insurance
  • Appointments: Dates, times, locations
  • Communications: Doctor notes, care coordination
At CardioAI: This includes all cardiac imaging data, ECG results, risk assessments, and AI-generated diagnostics.

Permitted Uses and Disclosures

✅ Without Patient Authorization

Purpose Description Example
Treatment Providing, coordinating, or managing healthcare Cardiologist reviews AI analysis to plan treatment
Payment Billing and reimbursement activities Submitting insurance claims for diagnostic services
Healthcare Operations Quality improvement, training, auditing Using de-identified data to train AI models
Required by Law Court orders, legal obligations Responding to valid court subpoena
Public Health Disease reporting, investigations Reporting cardiac disease trends to health authorities

📝 Requires Patient Authorization

⚠️ These uses ALWAYS require written patient authorization:
  • Marketing purposes
  • Sale of PHI
  • Most uses of psychotherapy notes
  • Any use not covered by TPO (Treatment, Payment, Operations)

Minimum Necessary Standard

✅ Best Practice: Only access, use, or disclose the minimum amount of PHI necessary to accomplish the intended purpose.

Examples at CardioAI:

❌ NOT Minimum Necessary

  • Viewing entire patient file when only need ECG results
  • Including full medical history in billing request
  • Sharing patient names with IT when troubleshooting
  • Copying entire chart for quality review

✅ Minimum Necessary

  • Accessing only cardiac imaging for AI analysis
  • Providing only diagnosis codes for billing
  • Using patient ID numbers (not names) for technical issues
  • Reviewing only relevant sections for quality checks

Notice of Privacy Practices

Every covered entity must provide patients with a Notice of Privacy Practices that explains:

📄 CardioAI's Notice: Available at https://hipaa-notice-practices.vercel.app/

🛡️ HIPAA Security Rule

🎯 Learning Objectives:
  • Understand the three types of safeguards
  • Recognize security best practices
  • Identify common security threats
  • Know how to respond to security incidents

Three Types of Safeguards

🏢 Administrative Safeguards

Policies, procedures, and training

  • Risk assessments
  • Employee training
  • Access management
  • Incident response plans
  • Business Associate Agreements
  • Security officer designation

🔒 Physical Safeguards

Protecting physical access

  • Facility access controls
  • Workstation security
  • Device and media controls
  • Visitor logs and badges
  • Secure disposal of records
  • Environmental protections

💻 Technical Safeguards

Technology-based protections

  • Access controls
  • Audit controls
  • Integrity controls
  • Transmission security
  • Encryption
  • Authentication

Key Security Requirements

Requirement Implementation At CardioAI
Risk Assessment Regular evaluation of security risks Annual security audits, continuous monitoring
Access Control Unique user IDs, emergency access procedures Multi-factor authentication, role-based access
Encryption Protect data in transit and at rest AES-256 encryption, TLS 1.3 for transmission
Audit Trails Log and monitor system activity Comprehensive logging, regular review
Training Security awareness for all staff Annual training (this course!) plus updates

Common Security Threats

⚠️ Top Threats to Watch For:

🎣 Phishing Attacks
  • Fake emails requesting login info
  • Malicious links or attachments
  • Impersonation of colleagues or vendors
🦠 Malware/Ransomware
  • Malicious software installations
  • Data encryption/hostage demands
  • System compromise
👤 Insider Threats
  • Unauthorized access to records
  • Data theft or misuse
  • Sharing credentials
📱 Lost/Stolen Devices
  • Unencrypted laptops
  • Stolen mobile devices
  • Unsecured USB drives

Security Best Practices

✅ DO:

  • ✓ Use strong, unique passwords (12+ characters)
  • ✓ Enable multi-factor authentication (MFA)
  • ✓ Lock your workstation when stepping away
  • ✓ Encrypt all devices containing ePHI
  • ✓ Report suspicious emails or activity immediately
  • ✓ Keep software and systems updated
  • ✓ Use VPN for remote access
  • ✓ Verify requests for PHI before sharing

❌ DON'T:

  • ✗ Share your login credentials
  • ✗ Write passwords on sticky notes
  • ✗ Access PHI on public Wi-Fi
  • ✗ Email unencrypted PHI
  • ✗ Leave PHI visible on screens in public areas
  • ✗ Use personal devices for work without authorization
  • ✗ Click links in suspicious emails
  • ✗ Discuss patients in public spaces

Incident Response

🚨 If you suspect a security incident:
  1. Stop: Don't delete or modify anything
  2. Document: Note what happened, when, and what was affected
  3. Report: Immediately notify:
  4. Preserve: Keep all evidence intact
  5. Cooperate: Work with security team on investigation

⚠️ Breach Notification Rule

🎯 Learning Objectives:
  • Understand what constitutes a breach
  • Know reporting timelines and requirements
  • Recognize your role in breach response
  • Learn how to prevent breaches

What is a Breach?

A breach is an impermissible use or disclosure of PHI that compromises the security or privacy of the information. This includes:

🔓 Unauthorized Access

  • Employee accessing records without authorization
  • Hacker gaining access to systems
  • Viewing PHI without business need
  • Sharing login credentials

📤 Unauthorized Disclosure

  • Emailing PHI to wrong person
  • Leaving PHI visible in public
  • Mailing to incorrect address
  • Discussing patients where others can hear

Breach Notification Timeline

⏱️ Critical Deadlines:
Affected Individuals Timeline Method
500 or more people Within 60 days Written notice + HHS + media
Fewer than 500 people Within 60 days Written notice + annual HHS report
Immediate notification Immediately upon discovery Internal reporting to Privacy Officer

Risk Assessment

Not every incident is a reportable breach. We must assess four factors:

1️⃣ Nature and Extent

  • Types of identifiers involved
  • Amount of PHI disclosed
  • Sensitivity of information

2️⃣ Unauthorized Person

  • Who received/accessed the PHI?
  • Their relationship to organization
  • Their ability to re-identify data

3️⃣ Was PHI Acquired?

  • Was information viewed or taken?
  • How long was exposure?
  • Evidence of actual viewing

4️⃣ Risk Mitigation

  • Actions taken to mitigate harm
  • Likelihood of re-disclosure
  • Safeguards in place

Common Breach Scenarios

❌ Real Examples of Breaches:

  1. Wrong Recipient: Email with patient ECG results sent to wrong doctor
  2. Lost Device: Unencrypted laptop with patient data stolen from car
  3. Hacking: Ransomware attack encrypting patient database
  4. Snooping: Employee accessing celebrity patient records out of curiosity
  5. Improper Disposal: Patient records thrown in regular trash instead of shredding
  6. Public Discussion: Discussing patient case details in hospital cafeteria

Your Responsibilities

✅ What YOU Must Do:
  1. Recognize potential breaches immediately
  2. Report within 24 hours to:
  3. Document everything: What, when, where, who, how
  4. Preserve evidence: Don't delete or modify files
  5. Cooperate fully with investigation
  6. Never try to "fix it" yourself without authorization

Breach Prevention

🔒 Technical Prevention

  • Always encrypt devices and emails
  • Use VPN for remote access
  • Enable auto-lock on all devices
  • Keep software updated
  • Use secure file sharing tools

👤 Human Prevention

  • Double-check email recipients
  • Never leave devices unattended
  • Lock screens when away
  • Verify identity before sharing PHI
  • Keep work private and personal separate
💡 Remember: It's always better to report a potential breach that turns out to be nothing than to fail to report an actual breach. When in doubt, report it!

👥 Patient Rights Under HIPAA

🎯 Learning Objectives:
  • Understand the seven key patient rights
  • Know how to respond to patient requests
  • Recognize timelines for each right
  • Learn proper documentation procedures

The 7 Key Patient Rights

1️⃣ Right to Access

Patients can request copies of their medical records

  • Timeline: 30 days (60 days if offsite)
  • Format: Electronic or paper, as requested
  • Fee: Reasonable cost-based fees only
  • Includes: All PHI used for treatment and payment
At CardioAI: Patients can request their cardiac imaging, ECG results, and AI analysis reports

2️⃣ Right to Amend

Patients can request corrections to their records

  • Timeline: 60 days to respond
  • Requirements: Written request with reason
  • Can deny if: Record is accurate and complete
  • If denied: Patient can submit statement of disagreement

3️⃣ Right to Accounting

Patients can get list of PHI disclosures

  • Timeline: 60 days (90 days with extension)
  • Period: Up to 6 years of disclosures
  • Excludes: Treatment, payment, operations
  • Includes: Disclosures to HHS, public health, etc.

4️⃣ Right to Restrictions

Patients can request limits on uses/disclosures

  • Not required: Most requests can be denied
  • Must honor: Requests to restrict disclosures to health plans for services paid out-of-pocket in full
  • Process: Must respond, but can decline

5️⃣ Right to Confidential Communications

Patients can request alternate contact methods

  • Examples: Different phone, address, email
  • Must accommodate: All reasonable requests
  • No explanation needed: Must honor without asking why

6️⃣ Right to Notice

Patients must receive Notice of Privacy Practices

  • When: First service delivery
  • Format: Written or electronic
  • Must post: On website and in facility
  • Get acknowledgment: Best effort to obtain signature

7️⃣ Right to Breach Notification

Patients must be notified of breaches

  • Timeline: Within 60 days
  • Method: Written notice by mail
  • Content: What happened, what we're doing, how to protect themselves

Responding to Patient Requests

✅ Standard Process:
  1. Receive request - Can be verbal or written
  2. Verify identity - Confirm patient identity before proceeding
  3. Log the request - Document in tracking system
  4. Forward to Privacy Office - [email protected]
  5. Track timeline - Ensure timely response
  6. Document response - Keep records of all actions

Common Request Scenarios

Scenario Correct Response Timeline
Patient wants copy of recent ECG Forward to Privacy Office, provide within 30 days 30 days
Patient disputes AI risk assessment result Review with clinical team, explain or amend as appropriate 60 days
Patient requests no calls at work number Update contact preferences immediately Immediate
Patient wants list of who accessed their records Generate accounting of disclosures (exclude TPO) 60 days
Patient wants to restrict info to insurance Must honor if service paid in full by patient Immediate

What You Should Never Do

❌ NEVER:
  • Ignore or dismiss a patient rights request
  • Provide PHI without verifying identity
  • Charge excessive fees for copies
  • Miss deadlines for responding
  • Refuse requests without valid reason
  • Fail to document requests and responses
  • Retaliate against patients who file complaints
⚠️ Important: Failure to honor patient rights is a HIPAA violation that can result in significant penalties. Always take patient requests seriously and process them promptly.

⚖️ HIPAA Compliance & Penalties

🎯 Learning Objectives:
  • Understand penalty structure and enforcement
  • Recognize compliance requirements
  • Know complaint and audit processes
  • Learn individual vs. organizational liability

HIPAA Penalty Tiers

Tier Violation Type Minimum Fine Maximum Fine Annual Cap
Tier 1 Unknowing violation $100 $50,000 $1.5 million
Tier 2 Reasonable cause $1,000 $50,000 $1.5 million
Tier 3 Willful neglect - corrected $10,000 $50,000 $1.5 million
Tier 4 Willful neglect - not corrected $50,000 $50,000 $1.5 million
⚠️ Criminal Penalties:
  • Tier 1: Up to $50,000 and 1 year in prison
  • Tier 2: Up to $100,000 and 5 years in prison (false pretenses)
  • Tier 3: Up to $250,000 and 10 years in prison (intent to sell/profit)

Who Enforces HIPAA?

🏛️ Office for Civil Rights (OCR)

Department of Health and Human Services

  • Investigates complaints
  • Conducts compliance audits
  • Issues civil penalties
  • Provides guidance and education

Website: www.hhs.gov/ocr

⚖️ Department of Justice (DOJ)

Criminal Prosecutions

  • Prosecutes criminal violations
  • Handles cases involving intent
  • Can impose prison sentences
  • Works with state attorneys general

Compliance Requirements

✅ What CardioAI Must Do:

📋 Documentation
  • Maintain policies and procedures
  • Keep training records
  • Document risk assessments
  • Retain business associate agreements
  • Log security incidents
🔍 Ongoing Activities
  • Annual risk assessments
  • Regular security updates
  • Periodic audits
  • Staff training (annual minimum)
  • Incident response drills

Audit Process

OCR conducts two types of audits:

1️⃣ Compliance Audits

Random selection to assess compliance

  • Desk audits (remote review)
  • On-site visits possible
  • Review of policies, procedures, documentation
  • Interviews with staff
  • Technical system reviews

2️⃣ Complaint Investigations

Triggered by patient or employee complaints

  • Can be filed by anyone
  • Must be filed within 180 days
  • OCR determines if investigation warranted
  • May result in corrective action plan
  • Potential penalties if violations found

Recent HIPAA Settlements

💰 Real Examples:
Organization Violation Settlement
Health System Hacking breach affecting 3.3M patients $16 million
Insurance Company Improper PHI disclosures to vendors $6.85 million
Medical Center Lack of risk assessment, weak security $3.2 million
Clinic Unencrypted laptop stolen from vehicle $2.5 million

Individual Liability

⚠️ YOU Can Be Held Personally Liable:
  • Criminal charges for knowingly obtaining or disclosing PHI
  • Civil lawsuits from patients for privacy violations
  • Termination of employment
  • Loss of professional licenses
  • Difficulty finding future employment in healthcare
  • Damage to professional reputation

Compliance at CardioAI

✅ Our Commitment:
  • Designated Privacy Officer and Security Officer
  • Annual comprehensive risk assessments
  • Regular third-party security audits
  • Mandatory training for all employees (this course!)
  • 24/7 incident response team
  • Encryption of all PHI (in transit and at rest)
  • Business Associate Agreements with all vendors
  • Regular policy reviews and updates
📞 Compliance Questions?

Privacy Officer: [email protected]
Phone: (614) 356-7890
Available: Monday-Friday, 9 AM - 5 PM EST

✅ Knowledge Check

📝 Instructions:

Complete your information below, then test your understanding of HIPAA. You must score 80% or higher to pass. Select the best answer for each question.

👤 Employee Information

* Required fields - This information will appear on your certificate

0 of 10 Questions

CardioAI HIPAA Training

Questions or concerns? Contact our Privacy Office:
[email protected] | (614) 356-7890

View Our HIPAA Notice of Privacy Practices

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