HIPAA Compliance Training

What is HIPAA Training?

HIPAA compliance training is an essential aspect of HIPAA’s Security and Privacy Rules. The HIPAA Privacy Rule (45 CFR §164.530) states that training is an Administrative Requirement and that training should be provided “as necessary and appropriate for members of the workforce to carry out their functions”. Training is an Administrative Safeguard of the HIPAA Security Rule (45 CFR §164.308), which requires that CEs and BAs “implement a security awareness and training program for all members of the workforce”.

Although training is a critical aspect of HIPAA compliance, HIPAA’s text offers little guidance on how training sessions should be conducted, who should be involved, and what information should be presented to employees. HIPAA’s text is deliberately vague, as it must be flexible enough to apply to a range of covered entities and business associates. This lack of clarity often creates difficulties for covered entries attempting to design a robust and effective training program for their employees.

This article outlines some of the essential aspects of HIPAA compliance training and offers guidance on how such training sessions should be conducted efficiently and effectively.

What should be included in a HIPAA training course?

  1. HIPAA Overview: This should include an overview of the need for HIPAA, whom the legislation applies to, whose data is protected, and how it may affect the organisation’s practices. Definitions of basic concepts such as CEs, BAs, and PHI should be presented to the employees.
  2. Description of HIPAA’s Rules: Employees should have a thorough understanding of HIPAA’s Rules. The most important rules for HIPAA compliance are:
    1. Privacy Rule – defines PHI and informs CEs and BAs of their responsibilities to protect patient data. The Minimum Necessary Rule is also part of the Privacy Rule, and stipulates that should PHI be handed over to a third party, only the minimum amount of data necessary to complete the specific task should be handed over.
    2. Security Rule – outlines the minimum physical, technical, and administrative safeguards needed to protect electronic PHI.
    3. Breach Notification Rule – outlines procedures that must be followed in the aftermath of a breach to ensure that the risk of damage to patients is minimal. Employees must be informed on how and when to notify the OCR and the media.
    4. Enforcement Rule – contains guidance on the fines and penalties that may be levied against a CE should a data breach occur. (OCR and Department of Health and Human Services can alter punishments at their discretion.)
    5. Omnibus Rule – covers a wide range of privacy-related areas, from the length of time a patient’s records can be held to the encryption requirements of PHI.
  3. Causes of Data Breaches: Employees must understand the most significant risks to the integrity of PHI and be aware of the causes of such data breaches. This part of the training session should include a discussion of cybersecurity threats such as phishing attacks and malware but also breaches caused by employee errors, such as leaving mobile devices in locations where unauthorised individuals could access them.
  4. Handling data breaches: Employees should be aware of the potential consequences of a data breach and be familiar with the role they play in the organisation’s data breach response plan.
  5. Penalties for non-compliance with HIPAA: Employees should be made aware that the fines HIPAA violations can be substantial. The size of the fine depends on the category of the breach if the CE was negligent in preparing for the breach, and how many patients were affected. In certain instances, civil penalties may be brought against an organisation for a particularly egregious breach.

How to Conduct HIPAA Compliance Training Sessions?

Practical training sessions are focused, concise, regular, and interactive. Employees may need to run multiple training sessions to suit the functions of each employee, manager, volunteer, trainee or contractor who may have contact with PHI or ePHI. Training programs are expensive and time-consuming to run, especially if multiple small-group sessions must be carried out.

However, as these training sessions mitigate the risk of a data breach occurring, organisations benefit from proper employee training in the long-term.