HIPAA Training for Medical Offices
The content of HIPAA training for medical offices varies depending on the functions of the medical office, workforce members’ access to Protected Health Information, and the nature of risks identified in a risk assessment. It can also vary depending on whether the medical office is part of an Organized Health Care Arrangement or operates as a business associate.
There are multiple definitions of a medical office. Under some definitions, a medical office may not qualify as a HIPAA covered entity if – for example – a sole medical practitioner does not conduct or subcontract electronic healthcare transactions for which the Department of Health and Human Services (HHS) has adopted standards in Part 162 of the HIPAA Administrative Simplification Regulations.
In other definitions, a medical office may be sole practitioner’s surgery or a walk-in clinic staffed by multiple practitioners that does qualify as a HIPAA covered entity, or an administrative department within an Organized Health Care Arrangement. It may also be the case that the sole medical practitioner who does not qualify as a HIPAA covered entity provides services on behalf of a covered entity as a business associate.
The HIPAA Training Requirements for Medical Offices
Because of the many different types of medical office, there is no one-size-fits-all HIPAA training for medical offices – when HIPAA applies. Naturally a medical office that qualifies as a HIPAA covered entity will have to comply with the HIPAA training requirements under §164.530 of the HIPAA Privacy Rule and §164.308 of the HIPAA Security Rule. These standards may also apply to a medical office within an Organized Health Care Arrangement.
However, if a medical office only provides non-public facing administrative services for the larger organization or operates as a business associate to a covered entity, workforce members only need to be trained on HIPAA Privacy Rule standards which apply to the service being provided. The nature of the services being provided may also influence the content of security awareness training and other medical office compliance training.
An exception may apply when a medical office is part of an Organized Health Care Arrangement if all components of the Arrangement share the same HIPAA Notice of Privacy Practices. In such circumstances, members of the workforce must receive HIPAA training for medical offices on any patients’ rights that are included in the Notice to ensure they are familiar with the procedures for responding to patients exercising their rights.
The Content of HIPAA Training for Medical Offices
Notwithstanding the requirements discussed above, the content of HIPAA training for medical offices should reflect the policies and procedures developed by the covered entity or business associate to comply with the applicable standards of the HIPAA Privacy Rule and HIPAA Breach Notification Rule. Security awareness training should also be tailored to align with the policies and procedures in accordance with §164.306.
With regards to security awareness training, all members of a medical office’s workforce must participate in the training program regardless of their access to Protected Health Information. As the training program has to be aligned with HIPAA policies and procedures, it will likely be necessary to provide HIPAA awareness training to members of the workforce with no access to Protected Health Information so the training is understood.
As determining the content of HIPAA training for medical offices can be resource-intensive for smaller medical offices, it can be beneficial to subscribe all members of the workforce to an online HIPAA awareness course that provides foundation information about HIPAA compliance. In many circumstances, courses such as these are a valuable support to policy and procedure training and security awareness training programs.
Other Medical Office Compliance Training
The provision of regular HIPAA training for medical offices can support other medical office compliance training. For example, covered entities and Organized Health Care Arrangements that have to comply with CMS’ emergency planning requirements will find it simpler to explain how to safeguard Protected Health Information during emergencies and what disclosures to emergency personnel are permissible in such circumstances.
Public facing medical offices required to provide OSHA bloodborne pathogen training can also integrate HIPAA training for medical offices into annual OSHA training to remind members of the workforce about the minimum necessary standard and the process for reporting incidental disclosures of Protected Health Information. Medical offices who require more information about integrating HIPAA training into other medical office compliance training should seek professional healthcare compliance advice.
