HIPAA Compliance Training in Healthcare

HIPAA compliance training in healthcare is the element of policy and procedure training and/or security awareness training that explains why HIPAA compliance is important. HIPAA compliance training in healthcare should cover the purpose of HIPAA, what it means to be HIPAA compliant, the risks to compliance, and the consequences of non-compliance.

Healthcare organizations that qualify as HIPAA covered entities are required to provide HIPAA training to all members of their workforces. The content of HIPAA training is governed by §164.530 of the HIPAA Privacy Rule (policy and procedure training and material change training) and §164.308 of the HIPAA Security Rule (security awareness training).

Additional HIPAA training might be provided in response to a privacy complaint or a data breach, or due to the result of a risk assessment. HIPAA training can also be imposed as a workforce sanction for minor violations of HIPAA, or as an organizational sanction by HHS’ Office for Civil Rights in lieu of a civil monetary penalty following a compliance investigation.

What is HIPAA Compliance Training in Healthcare?

HIPAA compliance training in healthcare is the “why” of HIPAA training. For example, this is why we have this policy, this is why we are adopting a new procedure, and this is why security mechanisms are configured the way they are. By explaining the “why” of HIPAA training,  workforce members can more easily relate to the content of the training.

Sources suggest that when workforce members relate to the content of HIPAA training, they are more likely to engage with the content, retain the information, and apply the training in day-to-day scenarios. When workforce members apply training in day-to-day scenarios, it reduces the likelihood of additional training due to a complaint, data breach, or sanction.

The Wrong Way to Explain the “Why” of HIPAA Training

The wrong way to explain the “why” of HIPAA training is to claim that compliance with HIPAA is necessary because non-compliance can result in fines, loss of license, and imprisonment. While non-compliance can result in fines, loss of license, and imprisonment, it is rarely the case these consequences occur because HHS’ Office for Civil Rights does not have the resources to investigate every complaint or data breach and take enforcement action for violations of HIPAA.

For example, in 2022 – the most recent year data is available – HHS’ Office for Civil Rights received 30,435 justified privacy complaints and 64,592 breach notifications. Only 21 compliance investigations resulted in a civil monetary penalty or financial settlement. A further 653 investigations resulted in a corrective action plan, and around 100 cases were referred for criminal investigation. In total, the “HIPAA enforcement rate” was less than 1%.

The Right Way to Promote HIPAA Compliance Training in Healthcare

With more than 99% of complaints and data breaches not being investigated, there would appear to be little incentive to be HIPAA compliant. However, compliance failures can lead to a wide range of consequences beyond fines, loss of license, and imprisonment. Organizations should introduce consequences that will resonate with workforce members into HIPAA compliance training in healthcare in order to curate a compliant workforce.

One way to do this is to focus on the benefits of HIPAA compliance to members of the workforce rather than to the organization. As examples, “compliance takeaways” have been added to the four topics listed below that should always be included in HIPAA compliance training in healthcare. Organizations are invited to adopt the takeaways and adapt them to align with the way the topics are included in their HIPAA training.

The Purpose of HIPAA

The primary purpose of HIPAA was to reform the health insurance industry. Due to the costs of the reforms, Congress added a second Title to HIPAA which had the primary objectives of neutralizing the costs by reducing fraud, simplifying the administration of healthcare transactions, and giving individuals more control over their healthcare data.

By reducing fraud and simplifying the administration of healthcare transactions, insurance premiums were kept in check and there was more money available for programs such as Medicare and Medicaid. Giving individuals more control over their healthcare data would enable individuals to flag anomalies in the records to help reduce medical identity theft.

Compliance takeaway: HIPAA compliance reduces the cost of health insurance premiums and helps improve the delivery of healthcare by reducing fraud, waste, and abuse. Giving individuals more control over their healthcare data helps police HIPAA compliance. For this reason, patients are encouraged to exercise their HIPAA rights and flag anomalies.

What it Means to be HIPAA Compliant

For healthcare organizations, what it means to be HIPAA compliant is implementing a framework that supports HIPAA compliance. The framework will include “behind-the-scenes” measures (i.e., Business Associate Agreements, Notices of Privacy Practices, physical safeguards, etc.) and the development of workforce policies and procedures.

For members of healthcare workforces, what it means to be HIPAA compliant is complying with policies and procedures implemented by the organization to safeguard the privacy of healthcare data and taking care to ensure the confidentiality, integrity, and availability of Protected Health Information in all formats (oral, paper, electronic, etc.).

Compliance takeaway: The takeaway is that the framework has been set up for workforces to be HIPAA compliant, but it is only a framework. Workforce members have a responsibility to work as a team to ensure the framework remains intact by supporting colleagues to be HIPAA compliant and by reporting compliance issues when they occur.

The Risks to Compliance and Healthcare Data

The risks to compliance and healthcare data most often have a human element. According to HHS’ Office for Civil Rights “Enforcement Highlights” Webpage, the majority of complaints received by the agency are attributable to impermissible disclosures of Protected Health Information – most often inadvertent or accidental disclosures.

With regards to data breaches, Verizon’s Data Breach Investigations Report (DBIR) attributes 70% of healthcare data breaches to “miscellaneous errors” (i.e., sending emails to the wrong recipient, with a further 13% of healthcare data breaches to software misconfigurations and the actions of malicious insiders – figures that can be confirmed via HHS’ Breach Report Archive.

Compliance takeaway: Media reports imply that cybercriminals are wholly responsible for healthcare data breaches. This is not the case. Although cybercriminals may be responsible for sending phishing emails and exploiting software vulnerabilities, there is nearly always a human element in compliance failures and healthcare data breaches. Be careful!

The (real) Consequences of Non-Compliance

The primary consequence of non-compliance is that millions of Americans are at risk of becoming victims of medical identity theft through the misuse of their Protected Health Information. The misuse of Protected Health Information enables ineligible individuals to obtain healthcare, prescription drugs, and medical devices at no cost to themselves.

The provision of healthcare to ineligible individuals cost healthcare organizations, health plans, and the victims themselves millions of dollars each year. However, beyond the financial consequences, the health records of medical identity theft victims are corrupted when different people are examined, diagnosed, and treated using their health information.

According to a survey of medical identity theft victims,15% of respondents had experienced the misdiagnosis of an illness due to somebody else misusing their identity to obtain health care, while 13% of respondents had received the wrong treatment for an illness due to somebody else’s health condition corrupting their medical record.

There are also consequences of non-compliance that impact patients not affected by a data breach. A survey conducted in 2019 found that the quality of care deteriorates for all patients when hospitals adopt remediation measures following a privacy complaint or data breach. In this case, 30-day mortality rates increased during the three years following a data breach.

A loss of patient trust in healthcare providers limits the amount of information patients are willing to provide – making it harder for healthcare providers to make accurate diagnoses and prescribe effective courses of treatment. A lack of trust can also result in patients failing to adhere to medication and  treatment plans – further impacting patient outcomes.

Compliance takeaway: Benefits of HIPAA compliance to individual members of the workforce exist if any partner, friend, or family member is registered as a patient at the healthcare organization. Ensuring care is taken to ensure the confidentiality, integrity, and availability of Protected Health Information will reduce the likelihood of a partner, friend, or family member becoming a victim of medical identity theft, experiencing a deterioration in the quality of care, or losing trust in their healthcare provider.

Integrating Compliance Training into HIPAA Training

For most healthcare organizations, integrating compliance training into HIPAA policy and procedure training or security awareness training should be straightforward. Simply adding “this is why we ask you to do [x]” to existing training – and removing any threats of fines, loss of license, and imprisonment – should help make HIPAA compliance training in healthcare more relatable.

Alternatively, healthcare organizations with complex training programs can take advantage of online HIPAA awareness training that includes topics such as the purpose of HIPAA, what it means to be HIPAA compliant, the risks to compliance, and the consequences of non-compliance without connecting the topics to workplace policies and procedures. The HIPAA Journal has the best quality HIPAA training.

This type of training can be taken remotely by individual members of the workforce or as a group in a classroom environment. It can be used as an introduction to HIPAA for new members of the workforce with no previous knowledge of HIPAA, or as HIPAA refresher training for the whole workforce  – which many compliance experts advocate should be provided at least annually.

Organizations interested in subscribing to online HIPAA awareness training to support HIPAA compliance training in healthcare are advised to request samples of training content from vendors to ensure it aligns with their own HIPAA policies and procedures. It is also advisable to ensure the training is accredited by a recognized training assessor – for example, by AHIMA.