HIPAA Awareness Training
HIPAA awareness training is training designed to increase awareness of HIPAA which can be used by organizations to support privacy and policy training and security awareness training, or taken voluntarily by individuals to mitigate the risk of sanctions and/or improve their employment prospects.
Each year, covered entities and business associates invest billions of dollars into HIPAA training. Yet, each year, HHS’ Office for Civil Rights receives around 3,000 justified HIPAA privacy complaints and more than 60,000 notifications of HIPAA data breaches. Details of HIPAA data breaches affecting more than 500 individuals are published on HHS’ Breach Portal.
By reviewing the most recent HHS Report to Congress and web descriptions in the Archive section of HHS’ Breach Portal, it is possible to determine that many privacy complaints and data breaches are avoidable. A significant number are attributable to a lack of HIPAA knowledge or carelessness by members of covered entities’ and business associates’ workforces.
Ironically, the most common remedy when complaints and data breaches are investigated by HHS’ Office for Civil Rights is enforced changes to privacy practices and corrective action plans – both of which require workforce retraining. This implies the billions of dollars being invested into HIPAA training is not being invested efficiently. So, how can this be improved?
A Quick Look at the HIPAA Training Requirements
One of the ways to identify inefficiencies in HIPAA training is to review the HIPAA training requirements and how covered entities and business associates might be complying with them. For example, the HIPAA Privacy Rule training standard (§164.530) states covered entities (and business associates “where provided” by §160.102) must:
“Train all members of its workforce on the policies and procedures with respect to Protected Health Information required by this subpart [the HIPAA Privacy Rule] and subpart D of this part [the HIPAA Breach Notification Rule], as necessary and appropriate for the members of the workforce to carry out their functions within the covered entity.”
This standard can be interpreted to imply that only members of the workforce who would normally use or disclose Protected Health Information (PHI) when they carry out their functions within the covered entity need to undergo training on policies and procedures. This interpretation potentially excludes other workforce members from HIPAA Privacy Rule training.
In addition to potentially excluding some members of the workforce from HIPAA Privacy Rule training, the standard also assumes members of the workforce who do receive policy and procedure training are already familiar with topics such as what is considered PHI under HIPAA, patients’ rights to request privacy protections, and identity verification requirements.
The failure to be already familiar with topics such as these can lead to misinterpretations of policy and procedure training. If misinterpretations remain uncorrected, they can result in unnecessary precautions being taken with non-health information, privacy violations, and unauthorized disclosures – all of which can result in a privacy complaint or data breach.
How to Improve Workforce HIPAA Knowledge
It is important that members of the workforce who would not normally interact with PHI are aware of topics such as impermissible uses and disclosures because there may be occasions when they see a celebrity patient or hear gossip about a celebrity patient and share their news with friends or members of their family, or with a wider audience via social media.
The risk of HIPAA Privacy Rule violations such as these can be mitigated by providing all members of the workforce with HIPAA awareness training regardless of their functions. HIPAA awareness training covers topics such as the purpose of HIPAA, what is PHI, and why it must be protected in order to prevent medical identity theft and healthcare insurance fraud.
As well as providing a basic knowledge of the HIPAA Rules for all members of the workforce, HIPAA awareness training helps put policy and procedure training into context. This – and a better understanding of the terminologies used in policy and procedure training – can eliminate the potential for misinterpretations and the consequences of avoidable HIPAA violations.
Providing HIPAA awareness training to members of the workforce who are apparently already familiar with the HIPAA Privacy Rule also has the advantage of assessing their HIPAA knowledge to identify any bad habits that may have developed. This can further mitigate the risk of privacy complaints and data breaches and help support improved HIPAA compliance.
With regards to addressing privacy violations and data breaches attributable to carelessness, an explanation of the consequences of medical identity theft can help focus minds when interacting with PHI. It is also worth explaining how patients’ privacy concerns can undermine physician-patient relationships, potentially resulting in adverse patient outcomes.
HIPAA Awareness Training for Security Rule Compliance
HIPAA awareness training should also be designed to help covered entities and business associates comply with the HIPAA Security Rule training standard. This standard states covered entities and business associates “must, in accordance with §164.306, implement a security awareness and training program for all members of its workforce (including management).”
The reference to §164.306 – the HIPAA Security Rule General Rules – is important because, among other standards, it requires covered entities and business associates to “Protect against any reasonably anticipated uses or disclosures of such information [electronic PHI] that are not permitted or required under subpart E of this part [the HIPAA Privacy Rule]”.
This means generic security awareness training is not adequate to meet the requirements of the HIPAA Security Rule training standard. Security awareness training must include an explanation of why PHI is highly sought by cybercriminals, the methods cybercriminals use to access networks, and the measures implemented to prevent unauthorized access. The HIPAA Journal is the only HIPAA training vendor that has cybersecurity training that focusses on PHI.
Providing HIPAA awareness training on the measures implemented to prevent unauthorized access gives covered organizations the opportunity to explain why software and apps are configured in a specific way, and that any attempt to circumnavigate the measures or use unsanctioned apps is a violation of the organization’s security policies and procedures.
HIPAA awareness training for Security Rule compliance is a “catch all” for members of the workforce who would not ordinarily have access to PHI and therefore receive no training on the HIPAA Privacy Rule. It can help prevent common violations such as snooping on medical records, unauthorized alterations to medical records, and the improper disposal of PHI.
How to Deliver Workforce HIPAA Awareness Training
Unlike policy and procedure training or security awareness training – which should be unique to each covered entity and business associate – HIPAA awareness training can be a one-size-fits-all solution for improving workforce HIPAA knowledge, preventing avoidable HIPAA violations, and reducing the frequency of data breaches attributable to carelessness.
Typically, HIPAA awareness training is delivered as an on-line course divided into “knowledge modules”. Members of the workforce can take each module as time allows; and, at the end of the course, they can test their retention of the knowledge and HIPAA awareness via a final test. If they pass the final test, they are awarded a certificate of completion.
For covered entities and business associates there are two advantages of providing online HIPAA awareness training beyond the reduction of avoidable HIPAA violations. The first is that the test results will identify areas in which a lack of awareness could be problematic. This information can then be included in a risk assessment to see if further training is necessary.
The second advantage is that a copy of the certificate awarded for passing the final test can be used to demonstrate a good faith effort by the covered entity or business associate to comply with HIPAA. To continue demonstrating a good faith effort, the HIPAA awareness training can be repeated annually with a new certificate awarded to members of the workforce each time.
Note: For certificates of HIPAA awareness to be of benefit in a subsequent compliance investigation, the HIPAA awareness training should be acquired from a reputable source which is accredited by a recognized training assessor – i.e., the American Health Information Management Association (AHIMA). Not all off-the-shelf training meets this standard.
Why Take HIPAA Awareness Training Voluntarily?
If you are a member of a covered entity’s or business associate’s workforce, and your employer does not provide HIPAA awareness training by default, there is a good reason why you should take HIPAA awareness training voluntarily – the avoidance of sanctions and the chance that an “unjustified” verbal or written warning remains on your personnel record indefinitely.
Covered entities and business associates must impose sanctions against members of the workforce who violate any policy or procedure implemented to comply with the HIPAA Privacy and Security Rules, or who violate “the requirements of this subpart [the HIPAA Privacy Rule] or subpart D of this part [the HIPAA Breach Notification Rule]” (§164.530(e)).
This means that any member of the workforce can be sanctioned for any violation of the HIPAA Privacy Rule even if they have not received training on the violated standard. While, in such cases, the imposition of sanctions may appear “unjustified”, if a covered entity or business associate fails to impose sanctions, they are in violation of HIPAA themselves.
To avoid the risk of this happening, members of a covered entity’s or business associate’s workforce can voluntarily subscribe to an online HIPAA awareness training course. As with the courses available to covered entities and business associates, modules can be taken as time allows and you will be awarded a certificate if you pass the final test.
Jobseekers can also benefit from passing an online HIPAA awareness training course. An increasing number of employers are advertising vacancies for which one of the requirements for candidates is HIPAA certification. As with the courses available to covered entities, it may be important that the course is accredited by a recognized training assessor.
HIPAA Awareness Training Course Content
Despite significant investments in HIPAA training, HHS’ Office for Civil Rights receives tens of thousands of privacy complaints and breach notifications each year.
Many privacy complaints and data breaches are attributable to lack of HIPAA knowledge, the failure to understand HIPAA policies and procedures, or carelessness.
As the most common remedy enforced by HHS’ Office for Civil Rights involves workforce retraining, organizations need to look beyond the basic HIPAA training requirements.
HIPAA awareness training is a simple yet cost-effective way to improve workforce HIPAA, prevent avoidable HIPAA violations, and support HIPAA compliance.
HIPAA awareness training can also help support Security Rule compliance, put generic security awareness training into context, and help prevent common violations.
Individuals can also subscribe to an online HIPAA awareness training course in order to improve their knowledge, mitigate the risk of sanctions, and/or improve their employment prospects.
HIPAA Compliance Officer Role
Introduces the role of the HIPAA Compliance Officer as the key contact for privacy and security issues. This module helps employees understand how the officer supports the organization in maintaining HIPAA compliance and how to report concerns.
HIPAA Regulatory Rules
Provides a foundational overview of HIPAA’s three main components: the Privacy Rule, the Security Rule, and the Breach Notification Rule. Emphasizes how these rules apply to everyday handling of patient information in any setting.
Why HIPAA Compliance is Important
Explains the purpose of HIPAA, which is to protect patient privacy, prevent misuse of health data, and promote trust in healthcare systems. Reinforces that compliance is a shared responsibility across all roles.
Consequences of HIPAA Violations and Breaches
Outlines the real-world consequences of HIPAA violations, including financial penalties, disciplinary action, and loss of patient trust. Helps raise awareness of how even small mistakes can have serious impacts.
Preventing HIPAA Violations
Covers practical ways to avoid HIPAA violations, such as logging off computers, handling files securely, avoiding casual conversations about patient details, and using approved communication methods.
PHI Disclosure Guidelines
Clarifies when it’s appropriate to share protected health information (PHI) and the importance of following the “minimum necessary” rule. Employees learn to recognize when authorization is required and how to handle disclosures correctly.
HIPAA Rights for Patients
Reviews patients’ rights under HIPAA, including the right to access their records, request corrections, and receive information about how their data is used. Staff learn how to respond to these rights respectfully and appropriately.
HIPAA and Social Media
Raises awareness of the risks of discussing work or patient-related content on social media. Reinforces that any identifiable or suggestive reference to patient care online can result in a violation—even if names aren’t used.
Threats to Patient Data
Introduces common threats like phishing emails, unattended records, and weak passwords. Encourages staff to stay alert and proactive in protecting patient information from both internal and external risks.
Protecting Electronic PHI
Explains the basics of keeping electronic protected health information (ePHI) secure, such as using strong passwords, encrypted systems, secure networks, and approved devices for accessing records.
HIPAA in Emergency Situations
Explains how HIPAA rules still apply during emergencies, with some exceptions. Staff learn when limited disclosures are allowed and how to respond quickly while maintaining patient confidentiality.
Recent HIPAA Updates
Keeps staff informed about important updates to HIPAA policies, including changes to patient access rules, telehealth privacy standards, and any new regulatory guidance that may affect day-to-day operations.
