The Health Insurance Portability and Accountability Act of 1996 (HIPAA) and the Health Information Technology for Economic and Clinical Health Act of 2009 (HITECH) as amended by the HIPAA Omnibus Rule in 2013 define the regulations for the private and secure management of health information. Covered entities and business associates that neglect adhering to these regulations can face rigid sanctions from a multitude of agencies, including the U.S. Department of Health and Human Services (HHS), its Office for Civil Rights (OCR), the Federal Trade Commission and state Attorneys General.

Each regulatory agency can impose fines against covered entities and business associates that fail to document, investigate and remedy HIPAA and HITECH violations. Without the proper compliance planning, covered entities and business associates can be slammed with heavy financial penalties and regulatory oversight, as happened to Cignet Health of Prince George's County in Maryland.

Learning from the Past

According to Healthcare ITNews, Cignet denied 41 patients access to their medical between September 2008 and October 2009, a right guaranteed by the HIPAA Privacy Rule. Cignet further failed to cooperate with OCR's investigation of the patients' complaints and with HHS' subpoena for the records, which was enforced by the District Court.

The court levied a $1.3 million fine against Cignet for failing to grant access to the patients' records, and an additional $3 million for willful neglect of the HIPAA Privacy regulations.

The time for proper HIPAA and HITECH compliance planning is now.

Training Modules Available

"HIPAA and HITECH, Pathway to Compliance" is a four-part do-it-yourself instructional series that guides its users in drafting a HIPAA/HITECH Compliance Plan. Each part provides regulatory information and resources necessary to build a customized plan. Documentation developed in this series can be used when faced with OCR investigations and/or audits to demonstrate compliance efforts.

In this series, Patricia Wynne, Esq., CIPP, a seasoned HIPAA/HITECH subject matter expert familiar with the day-to-day challenges of compliance, presents guidelines for drafting a Compliance Plan that are easy to understand and practical to implement - not bogged in technical jargon. Each course is one hour in length and includes case studies and questions to enhance learning, as well as resources that can be downloaded and used in the compliance planning process. Now is the time to build your HIPAA/HITECH Compliance Plan with the professional insight of Merit Career Development.

HIPAA and HITECH, Pathway to Compliance on Udemy
Click here to access Part 1: Policies & Procedures
Click here to access Part 2: Complaints & Breaches
Click here to access Part 3: Assessments & Risk Analysis
Click here to access Part 4: Workforce Training

HIPAA and HITECH, Pathway to Compliance on Arbington
Click here to access Part 1: Policies & Procedures
Click here to access Part 2: Complaints & Breaches
Click here to access Part 3: Assessments & Risk Analysis
Click here to access Part 4: Workforce Training

Listening includes a lot more than just hearing words. Frequently, we need to interpret or infer a deeper or underlying message beyond the spoken word. We deploy many of our senses to detect non-verbal cues and assimilate our life experiences with the verbal message when we actively listen.

Usually, the objective of a conversation is to expand the listener’s knowledge, perspective or sensitivity to a topic that impacts behavior or beliefs. In the workplace, managing projects can implode due to poor communications. These can result in missing a critical deadline, budget overages, decreased sales, and in some cases, costly lawsuits.

The most effective communication takes place when both parties are actively listening. So what is “active listening” and how do we do this?

Your active listening is apparent to the other party through your audible or visible signals. This can include something as subtle as raising our eyebrows, leaning towards the speaker, or using certain gestures (like a thumbs up, high five, etc.) Tilting our heads when we listen, on the same angle as the speaker, generally reflects a subconscious agreement Uttering sounds like “uh huh” or “hmm” also tell the speaker that you’re paying attention. In America, making eye contact is considered a must in showing that you are listening, although this does vary in some cultures.

Of course asking good questions is one of the best ways to demonstrate that you are listening.
If you don’t have any questions (perhaps, because the message is crystal clear to you) then paraphrase the speaker’s message. You can preface your restated summary by saying something like: “Ok, now, if I understand what you’re telling me, you’d like to … (paraphrased summary of speaker’s objective).”

It is important to be authentic, too! In your effort to make it evident that you genuinely hear the speaker’s message, do not diminish your own persona or credibility. Be sure to phrase your introduction to your rephrased statement in a style that is consistent with the way you speak.

Why not find out if you’re as good a listener as you think you are? If you haven’t taken this insightful (and free) listening assessment yet, you can right now – or later when you have about 45 minutes and no distractions. When you’re ready, take the Active Listening Assessment here. Upon completion, you will receive an explanatory report along with tips and techniques that you can use to become a better active listener and communicator.

If you or your staff would benefit from mastering effective communications, improving active listening and learning “meaning-centered communication”, we can help. Please contact Jim Wynne at jwynne@meritcd.com or call him at 610-225-0449.


NOTE: PMPs^®: This assessment qualifies for one PDU^® and you will receive a certificate.

---

PMP and PDU are registered trademarks of the Project Management Institute, Inc.

During my research on how to make better decisions I came across the pre-mortem in the writings of Nobel Prize winner Daniel Kahneman. He notes in his book, Thinking, Fast and Slow (2011), that the pre-mortem technique is valuable in the decision-making process because it has two main advantages.

First, it overcomes “groupthink” that affects many teams once a decision appears to be made. When groupthink is in effect, the wisdom of a plan or decision is gradually suppressed and eventually come to be treated as evidence of disloyalty. The collective suppression of doubt contributes to the group’s overconfidence, which is often a tragic flaw.

Second, it unleashes the imagination of knowledgeable individuals in a much needed direction—the opposite direction of the decision. The principal advantage of the pre-mortem technique is that it legitimizes doubts and encourages everyone, even supporters of the decision, to search for possible threats not considered in the decision-making process. I immediately recognized it as an excellent technique for decision-making, risk management and general leadership.

Because this has proven to be of great value, I would like to share this excellent technique with you. The pre-mortem is easy to implement once the team reaches a decision or finalizes a course of action. Here’s what you need to do:

Step back and state the following: “Imagine that we are one year into the future. We implemented (the decision and plan) exactly as decided here today. The outcome was a total complete disaster. Take 5 to 10 minutes to write a brief history of that disaster.” If someone asks: “What do you mean by a total disaster?” Reply: “In any and every way imaginable it was a total failure.”

Then, explore all the possible reasons that the decision or plan failed. By taking this opposite approach to brainstorming the ideas, your team will likely realize that there are more points that need to be thought through before the plan is implemented.

Merit Career Development incorporates this technique into our leadership, strategic decision-making, risk management and project management classes and it is very well received. In one recent class the participants clutched the flip charts from the group discussion. I saw this and asked what were they going to do with them? I was told that they were going to present the findings to upper management; they had never participated in such a rewarding experience.

Merit can help guide your team through various tools and techniques to optimize your team’s knowledge, skills and ability with techniques and tools such as pre-mortem and many others. Please contact Jim Wynne at jwynne@meritcd.com or call him at 610-225-0449 to schedule training to learn this and other valuable decision-making techniques.

The Results are In!

On behalf of all of us at Merit Career Development, we’d like to thank everyone who participated in our 2^nd annual 3-Question Training Planning Survey last month. As promised, we are reporting on the results – which have, interestingly, shifted even from a year ago.

Hot Topics

Although project management professionals represented more than 60% of our invitation mailing, the topics in greatest demand for 2016 are Leadership, Team-Building, Communications, and Critical Thinking and Decision-Making. These ranged from 38% to 29%, while the overall category of Project Management (PM) dropped to 13% this year (from 45% last year.) In the PM arena, both years, “Identifying and Managing Project Risks” were in the top third ranking at 29%. See the Q1 chart above for details.

Delivery Methods

The preferred delivery methods have changed, as well. For the past few years, there was a growing interest in
web-based learning and self-paced, DIY courses. This year, on-site, full day courses have re-gained their
popularity, with 54.4% of respondents choosing this as their preferred delivery method. In 2014 on-site, full day courses were only requested by 34.2% of respondents. For more details, see the Q2 chart.

Choosing the Course and the Provider

The basis for choosing a course and provider were measured differently last year, but in both instances, the primary driver is the course topic and/or area that most needs development, followed by convenience of timing, and location. The program cost was lower in priority. See Q3 chart on the left for details.


If you are seeking to reduce your organization’s gaps in skills, improve cooperation and productivity through better communications and decision-making knowledge, or provide some morale-improving, team-building workshops, let’s talk. With a wide variety of courses, delivery techniques and a highly skilled training team, we will help you achieve your training goals for 2016 and beyond.

Contact Jim Wynne at 610-225-0449 or at jwynne@meritcd.com.

The start of a new year brings with it many changes, professionally as well as personally. Many of us choose to start the New Year by making goals and resolutions, whether resolving to stick to a budget, or picking up a new hobby. Mine? I’m in the majority of the population: lose weight. To help me achieve my resolution I’ve started an exercise program called CrossFit training.

What is CrossFit training? The CrossFit training program, as explained by its founder Greg Glassman, is a system of performing functional movements that are constantly varied at high intensity. CrossFit is a strength and conditioning program that optimizes physical competence in each of ten recognized fitness domains: Cardiovascular and Respiratory Endurance, Stamina, Strength, Flexibility, Power, Speed, Coordination, Agility, Balance, and Accuracy.

The CrossFit program was developed to enhance an individual’s competency at all physical tasks. Athletes are trained to perform at multiple, diverse, and randomized physical challenges. This type of fitness is demanded of military and police personnel, firefighters, and many sports requiring overall physical prowess.

CrossFit training benefits the body by training your individual muscles over time to work together to provide an overall greater level of personal fitness than can be achieved by only conditioning one set of muscles at a time. This got me thinking: are there other areas in my life where I can use this approach? How can I “crossfit” my skills to become better at my job? How can I crossfit new learning opportunities to become a more valuable employee?

How can CrossFit training the body carry over to crossfit training your mind? If we consider our skills, hobbies, and responsibilities in our careers as muscles, we can make the analogy that those skills are muscles needing exercise. Some muscles are used more than others; some are barely used at all. All too often in our jobs, there is a set way of doing things that is like performing a repetitive workout. However, the brain is a muscle that like all muscles must be exercised to be kept in peak condition.

Modern cognitive psychology has demonstrated that the brain is not a static entity. Rather, the brain is continually and constantly developing and pruning pathways across skillsets, linking new knowledge to existing knowledge, or destroying old pathways which aren’t utilized to make room for new synaptic links. You can take advantage of this process by crossfit training your brain with a new skill or area of knowledge, which is seemingly unrelated to your existing career or job responsibilities.

How can crossfit training your mind benefit you in your workplace? Cross-functional training has many benefits for organizations as well as employees. At an organizational level, cross training skillsets help safeguard the organization against widening skills gaps. Organizations that cross-train employees across a range of functions put themselves in a good position to prevent sudden shortfalls and manage surges in specific areas when there is a spike in demand. On an individual level, cross training enables employees to explore and assess alternative interests and abilities. It also enables managers to identify and nurture employees who show exceptional talent in a particular function. Cross-training yourself to learn new skills, can increase your employability and enable you to stay relevant.

A few examples …learning the components of Strategic Leadership as a Project Manager (PM) can help reduce the probability of failure by sharpening leadership skills that enable the PM to better understand, motivate and build consensus with other members of a project team. Or, learning to identify the role emotions and subconscious biases play in the decision making process can enable an individual to make more effective decisions. Learning Risk Management skills can enable a Human Resources manager to better anticipate potential problems and know how to create effective solutions before a problem arises.

In 2016, give consideration to learning things outside the scope of your role or responsibilities. Even if learning new skills may not seem directly related to your current work position, you will be increasing your value. Soon, you’ll wonder how you ever got along without these new skills.

If you are seeking to reduce your organization’s gaps in skills, improve cooperation and productivity through better communications and decision-making knowledge, or provide some morale-improving, team-building workshops, let’s talk. With a wide variety of courses, delivery techniques and a highly skilled training team, we will help you achieve your training goals for 2016 and beyond.

Contact Jim Wynne at 610-225-0449 or at jwynne@meritcd.com.

Despite nearly a decade of studies and warnings, Medicare cards continue to display participants’ SSNs prominently on the face of the card as their Health Insurance Claim Number (HICN) or patient identification number. This number is also displayed on all claim forms mailed to participants’ homes.

As the studies and warnings clearly point out, this practice leaves participants vulnerable to identity theft when Medicare cards are stolen or claim forms are mailed to the wrong address. This is a common occurrence. It also leaves the Medicare program itself more vulnerable to fraud when identity thieves use stolen Medicare cards to obtain personal medical care and/or to submit fraudulent claims. Using SSNs as a patient identifier is just a bad idea, particularly in light of the fact that other state and federal laws specifically prohibit the use of SSNs in this way.

Both the (CMS) and the U.S. Government Accountability Office (GAO) have studied this issue in some depth. Yet, despite across-the-board agreement that the practice needs to change, no relevant government agency, nor Congress, has taken the necessary action to require the change.

A key reason for this inaction, beyond the studies, is the cost. A 2012 GAO Report examined two options to address the issue:

1. Continue to use SSNs but hide the first five digits.
2. Replace SSNs with a new Medicare Beneficiary Identifier

However, CMS concluded that implementing either option would involve between 40 to 48 government IT systems and would take approximately four years to complete. Early CMS estimates indicated that replacing SSNs with the new MBIs would cost up to $845 million. More recent GAO estimates bring that number down considerably to between $255 million to $317 million. Note that these estimates do not include costs hospitals and providers would incur when making changes to accommodate the new MBIs.

So, things stand pretty much where they have stood since this issue first became a key point of study and discussion years ago. The most recent GAO Report (September 2013) on the matter concluded that despite the many warnings resulting from the studies and the increasing level of Medicare card theft, CMS still had not given the green light to any project that would remove SSNs as the Medicare card patient identifier. CMS has also failed to follow the lead of other existing state and federal laws prohibiting the use of SSNs as patient identifiers.

But hope springs eternal. Maybe CMS will seize the opportunity to make the change during the current modernization project of CMS’s overall IT systems. As proposed in the September 2013 GAO Report, "...one of CMS’s high-level modernization goals is to establish an architecture to support ‘shared services’ - IT functions that can be used by multiple organizations and facilitate data-sharing..." This effort includes a crosswalk function that could translate existing SSNs on claims to the new MBIs and vice-versa. The transition from the SSN to the new MBI would be much more efficient by receiving information on CMS’s modernized system with the new MBI, rather than by processing the information into the modernized system with the SSN and then making the transition.

Is it an impossible dream that the common-sense state and federal regulations already prohibiting SSNs from being used as patient identifiers will also apply to Medicare? It remains to be seen.

With all the talk about HIPAA over the past decade, most people in the U.S. now expect their confidential health care information and records (collectively “PHI”) to be just that…confidential. We expect our providers to assure its privacy and security. But this is not always the case. Read about this incident.

In September 2008, Parkview Hospital in Ohio took custody of approximately 5,000 to 8,000 patient records pertaining to a retiring physician’s medical practice. Parkview was considering purchasing some of the physician’s practice and was assisting the retiring physician to transition her patients to new providers. By taking custody of the PHI, Parkview assumed the responsibility for the private and secure management of the retiring physician’s PHI. However, on June 4, 2009, despite having custody of the records and with knowledge that the retiring physician was not at home at the time of the incident, Parkview employees left 71 cardboard boxes of medical records on the driveway of the physician’s home, within 20 feet of the public road and a short distance away from a heavily trafficked public shopping venue. This action exposed the PHI to unauthorized access and constituted a HIPAA breach.¹

The retiring physician reported the breach to the Department of Health and Human Services (HHS), resulting in an investigation by its Office of Civil Rights (OCR). Parkview cooperated with the OCR investigation. The outcome was an $800,000 civil money sanction and a corrective action plan requiring the revision of Parkview’s policies and procedures, staff training and regular reports to OCR on compliance with the corrective action plan. The extended regulatory oversight and related costs for auditors can be a greater sanction and intrusion into daily operations than any sanction check that has to be written.

HIPAA and HITECH mandate that healthcare providers and managing healthcare entities are responsible for the privacy and security of PHI from the time it is created until the time it is securely destroyed. This includes implementing and monitoring PHI policies and procedures as well as training and monitoring staff compliance with them. Failure to do so can subject healthcare providers or entities to sanctions and regulatory oversight through corrective action plans. HIPAA regulations have been in effect since 2003. HITECH regulations, enacted in 2009, have heightened sanctions for failing to protect PHI, including added sanctions up to $1.5M per year for willful neglect levied against covered entities that can demonstrate no reasonable efforts towards HIPAA/HITECH compliance.

It’s hard to believe that breaches such as the above incident are still taking place. But the OCR confirms that it is quite busy with similar investigations. It is starting up its random audit program again in October 2014 to get the message across that HIPAA/HITECH compliance is mandatory. The message from HHS is that sanctions will increase when non-compliance is identified such as in the case cited above and those noted on its Wall of Shame at www.hhs.gov.

¹See $800,000. HIPAA Fine- Blatant Violations Continue to Occur, www.Medlaw.com, posted June 25, 2014

Data thieves are feasting at the healthcare information and data buffet. The healthcare industry needs to act quickly to manage this problem.

Last year, the healthcare industry experienced more data breaches than any other industry. There were 269 incidents reported with more than 8.8 million healthcare records compromised, equaling 43.8% of breaches reported across relevant industries, according to the Identity Theft Resource Center (ITRC). So far in 2014, ITRC found that healthcare organizations are trending even higher representing 45.8% of breaches industrywide. And these statistics are only for breaches that have been reported.

The vulnerability of healthcare information and data is increasing. The FBI warned healthcare providers that their data security systems lag behind other industry sectors. This warning asserts that the healthcare industry is not as resilient to cyber intrusions compared to the financial and retail sectors. Therefore, the possibility of increased cyber intrusions is likely.

The results of risk analyses performed across the healthcare industry, including the results of the initial Office of Civil Rights (OCR) audit program, point to a lack of investment by healthcare in privacy and data security, a lack of attention to these issues at the executive level, and a tendency to spend only minimal resources to implement HIPAA/HITECH compliance plans. As the above statistics confirm, healthcare remains not only vulnerable but a preferred target for cyber criminals.

Why are cyber criminals focused on healthcare? Quite simply, that’s where the money is. The value of medical data is proving to be far more lucrative than other types of personal data. For example, a single person’s medical identity information can fetch hundreds of dollars compared to just a dollar or two or even less for a Social Security or credit card number, according to experts. Such medical identity information can provide access to prescriptions for drugs that can be re-sold, and can cover expensive medical treatment for the wrong party.

Healthcare data breaches are not only the work of shadowy hackers working out of foreign countries. In as many cases, the breaches are the work of healthcare providers’ own employees. Failure to invest in and implement verifiable privacy and security programs within the organization itself which include meaningful and appropriate workforce training programs is costing healthcare providers millions of dollars in sanctions and corrective action settlement agreements to combat carelessness such as loss of laptop computers and other devices with unencrypted data and unauthorized snooping into or copying patient records and data. Breach reports and complaints are patient and consumer driven and can be made directly to the Department of Health and Human Services (HHS) by disgruntled individuals. Breaches can also result from criminality by an employee acting on his or her own to steal healthcare data outright for personal gain.

Also, as electronic health records systems (EHRs) become more prevalent and sophisticated, the risk of medical identity theft continues to grow. Providers are accountable for data security efforts to remain on top of current threats, identify emerging problem areas and stay ahead of the myriad of new threats. Further, HITECH has pulled Business Associates and Business Associate sub-contractors into the HIPAA/HITECH regulatory realm.

Healthcare, as an industry, has a long way to go to match their counterparts in the financial and banking sectors, which have invested heavily in data privacy and security. These industries experienced only 3.7% of data breaches and less than 1% of compromised records. Excuses are no longer being tolerated by HHS, willful neglect (failure to demonstrate any effort at HIPAA/HITECH compliance) is being sanctioned at a rate of $1.5 M per year on top of corrective action settlements, and random audits by OCR are beginning again in October of 2014. Now is the time to act.

For assistance with your HIPAA/HITECH compliance efforts, contact Jim Wynne at jwynne@meritcd.com or by phone at 610-225-0193.

May 2014

The Department of Health and Human Services (HHS) entered into settlements totaling $4.8 million with New York-Presbyterian Hospital (NYP) and Columbia University Medical Center (CU) for failing to implement appropriate administrative and technical safeguards to secure the ePHI of approximately 6,800 patients^[i]. This is HHS’ highest financial sanction issued to date as a part of breach settlement agreements, confirming its commitment to enforce HIPAA compliance.

Breach Report, Investigation and Findings

NYP and CU received a complaint from an individual who found confidential health information (ePHI) including status, vital signs, medications, and laboratory results of a deceased relative, a former NYP patient, on the Internet. The HIPAA regulations require such ePHI be maintained in secure systems and kept confidential. In accordance with HIPAA requirements, they submitted a joint report of the complaint to HHS dated September 27, 2010 resulting in an investigation by HHS’ Office of Civil Rights (OCR).

OCR’s investigation found that NYP and CU have a joint healthcare services arrangement wherein CU faculty members work as attending physicians at NYP. To support the services, NYP and CU operate a shared data network including firewalls administered by employees of both entities with shared links to NYP patient information systems.

OCR identified the breach to have occurred when a CU physician employed to develop applications for both entities attempted to de-activate a networked server containing NYP patient ePHI. Due to a lack of technical safeguards in place on the network, the de-activation attempt resulted in NYP ePHI becoming accessible to internet search engines.

OCR found that neither NYP nor CU could demonstrate that its servers were secure or contained software protections prior to the breach. OCR found an additional lack of administrative safeguards, specifically that neither entity had conducted a risk analysis to identify all systems with access to NYP’s ePHI or had a risk management plan in place to address potential hazards or threats to the security of its ePHI.

Finally, OCR found that NYP failed to implement its own technical safeguards including procedures for authorizing access to its databases and information access management processes. In addition to the financial sanctions, NYP and CU agreed to a corrective action plan requiring implementation of the administrative and technical safeguards and to monitor compliance with regular reports back to HHS.

Increased HHS Enforcement of HIPAA Compliance

This action gives notice to Covered Entities and Business Associates that HHS has heightened its enforcement efforts since the enactment of HITECH and the HIPAA Omnibus Rule.

It is imperative that a healthcare organization ensure that its workforce understands the privacy and security regulations, not just completes rote training programs, and recognizes the impact that non-compliance - from even one employee - can have on an organization.

The mandated HIPAA safeguards must be in place to identify risks and threats to ePHI and patient information systems, including insider threats from its own workforce. The safeguards must be regularly monitored through risk analysis as a part of a comprehensive risk management program.

[i] See http://www.hhs.gov/news/press/2014pres/05/20140507b.html

In this era of HIPAA enforcement, it is important to understand the fundamental role of the privacy regulations. Privacy outlines the big picture for compliance. Failing to understand and implement privacy's administrative, technical and physcial safeguards can be a costly miscalculation.

Privacy regulations have been in effect since 2003 and are updated regularly on the Department of Health and Human Services’ (HHS) website.

These regulations list compliance requirements for protected health information (PHI) in all formats (oral, paper or electronic). Security regulations are a subset of privacy limited to PHI in electronic format (ePHI). Privacy encompasses the big picture for compliant access, use, and disclosure of all PHI, including ePHI. Investing the staff, resources and time necessary to meaningfully implement privacy regulations is the entrée to compliance and a prudent business decision.

Prior to 2009, regulated organizations were primarily self-monitoring. The lack of outside accountability precipitated the major investment of staff and resources allocated for HIPAA compliance being directed towards building and supporting electronic health records systems. Fewer resources were dedicated to the less concrete, yet more comprehensive, role of privacy. Responsibility for patients’ and clients’ rights; uses and disclosures of PHI; role-based access issues; business associates; and other privacy issues were disbursed over many departments. This resulted in insufficient compliance, lax oversight and a high occurrence of violations.

HITECH’s enactment in 2009 refocused HIPAA enforcement on the privacy regulations.

HITECH mandates the implementation of complaint and breach report procedures, requires accountability for management of PHI, establishes higher sanctions for violations including a new category for willful neglect, and initiated a random audit program for an expanded list of regulated organizations by HHS’ Office of Civil Rights (OCR).

More federal and state regulatory agencies, including FTC and states’ attorney generals, now coordinate with HHS’ enforcement actions. Their websites regularly post results of enforcement actions as notice and guidance for regulated organizations. Most violations settle with corrective action plans (CAPs); some include fines tipping millions of dollars.

Many CAPs require hiring auditors to monitor and report to HHS on CAP compliance, particularly revising policies and procedures and workforce training programs (basic privacy administrative safeguards) over a period of years. As the following three cases from HHS’ website confirm, HHS is serious about privacy compliance.

Continue reading "HIPAA Privacy and Security, Perfect Together"