Protected health information (PHI) is among the most sensitive data in healthcare, and safeguarding establishes patient privacy, maintains trust, and complies with the legal requirements of the Health Insurance Portability and Accountability Act (HIPAA).
Developing effective policies for handling PHI is a key step in protecting both the individuals whose information you manage and the reputation of your organization.
Understanding the scope of PHI
Before developing policies, you must first define what constitutes PHI: PHI refers to any health information that can identify an individual and is related to their physical or mental health, healthcare services, or payment for healthcare. This includes, but is not limited to:
- Personal identifiers (e.g., name, address, Social Security number)
- Health records (e.g., diagnoses, treatment plans, prescriptions)
- Payment information (e.g., insurance details, billing records)
Excluded from this definition is “individually identifiable health information that is maintained in education records covered by the Family Educational Right and Privacy Act …, and employment records containing individually identifiable health information that are held by a covered entity in its role as an employer,” says the National Institutes of Health (NIH).
See also: FAQs: Protected health information (PHI)
Policies for handling PHI
Access control
Data encryption
- Encrypt PHI during storage and transmission to protect it from unauthorized access or interception.
- Use secure communication channels (e.g., HTTPS, secure email) when sending PHI electronically.
Related: HIPAA Compliant Email: The Definitive Guide
Data minimization
- Only collect, use, and store PHI that is necessary for the task at hand.
- Avoid sharing unnecessary or excessive PHI, particularly in communications or external reports.
Training and awareness
- Provide ongoing training for all employees on the importance of PHI privacy and security.
- Educate staff about the proper handling of PHI, including its storage, transmission, and disposal.
Go deeper: Developing a HIPAA compliant training policy
Confidentiality agreements
- Require employees, contractors, and any third-party vendors with access to PHI to sign confidentiality agreements.
- Ensure that the agreements outline the expectations and legal consequences for mishandling PHI.
Audit and monitoring
- Regularly monitor systems that store, process, or transmit PHI for signs of unauthorized access or breaches.
- Conduct periodic audits of PHI access logs to ensure compliance with privacy policies.
Incident response and breach notification
- Establish a clear procedure for reporting and handling data breaches involving PHI.
- Notify affected individuals and relevant authorities, including the Department of Health and Human Services (HHS), as required by HIPAA within 60 days of discovering a breach.
Go deeper: Navigating HIPAA’s Breach Notification Rule
Data retention and disposal
- Set policies for retaining PHI for the necessary duration according to legal or regulatory requirements.
- When PHI is no longer needed, ensure it is securely disposed of by shredding physical documents or using secure data-wiping tools for electronic records.
Physical security
- Secure physical locations containing PHI, such as filing cabinets and storage areas, with locked doors or cabinets.
- Implement security measures for devices used to access PHI, such as laptops, mobile phones, and USB drives.
Read also: What physical safeguards are required by HIPAA?
Third-party access and business associate agreements (BAAs)
- Ensure that any third-party vendors or business associates that handle PHI sign a BAA that outlines their responsibilities for safeguarding the information.
- Regularly review BAAs to ensure compliance with HIPAA requirements.
Best practices for developing policies
Developing effective policies for handling PHI is essential for ensuring patient privacy, complying with regulations, and protecting sensitive data. Key best practices include:
- Understand legal framework: Familiarize yourself with HIPAA and relevant state laws to guide policy development.
- Collaborate with stakeholders: Involve healthcare teams, IT professionals, and legal advisors to create practical and comprehensive policies.
- Adopt a risk-based approach: Assess and prioritize risks to PHI, tailoring policies to address the most significant threats.
- Provide regular training: Offer initial and ongoing training to employees, covering security measures, privacy regulations, and potential risks.
- Regularly review policies: Continuously audit and update policies to remain compliant with evolving regulations and risks.
- Document and standardize procedures: Standardize PHI handling procedures and create written guidelines to ensure consistency.
FAQs
Why is it important to have policies for handling PHI?
Developing policies for handling PHI ensures that sensitive patient data is protected, complies with HIPAA, reduces the risk of data breaches, and builds trust with patients by safeguarding their privacy.
How often should training on PHI handling be conducted?
Initial training should be provided to all new employees as part of their onboarding process. Regular refresher training should also be conducted, ideally annually, to keep employees updated on security best practices, privacy regulations, and emerging risks.
What are the consequences of not following PHI handling policies?
Failure to follow PHI handling policies can result in data breaches, legal penalties, loss of patient trust, and significant financial consequences. Under HIPAA, violations can lead to civil or criminal penalties, depending on the severity of the breach.
Tshedimoso Makhene
