HIPAA Training for Mental Health Professionals
HIPAA training for mental health professionals can differ from HIPAA training for other types of healthcare professionals depending on the HIPAA status of the mental health professional, the nature of information created, received, maintained, or transmitted, and – when regulations do not impose training requirements – the expected “standard of care” for the privacy and security of patient data.
The “HIPAA status” of a mental health professional – or the organization they work for – most often determines what HIPAA training requirements apply. For example, those who work for a healthcare organization that qualifies as a HIPAA covered entity must receive HIPAA training for mental health professionals on the policies and procedures implemented by the covered entity to comply with the HIPAA Privacy Rule. They must also take HIPAA security awareness training.
However, small mental health practices – or mental health professionals, therapists, and life coaches who work as private practitioners – can be HIPAA covered entities, hybrid entities, business associates, qualified service providers, or none of the above if they do not conduct electronic transactions for which the Department of Health and Human Services (HHS) has adopted standards or they provide services that do not fall within the definition of a health service in 42 USC 1395x(s).
Even when no HIPAA training requirements apply, compliance with HIPAA and HIPAA training for mental health professionals can be the expected “standard of care” for the privacy and security of patient data by state licensing boards, state regulators, and professional bodies. There is also an ethical obligation to prevent patients from coming to harm – in this case, by preventing health information from being exposed to those who may misuse it to commit medical identity theft.
The HIPAA Training Standards and Who They Apply To
There are two HIPAA training standards in the HIPAA Administrative Simplification Regulations. The first – §164.530(b) of the HIPAA Privacy Rule – states covered entities must train all members of the workforce on policies and procedures with respect to Protected Health Information (PHI) required by the HIPAA Privacy Rule and the HIPAA Breach Notification Rule as necessary and appropriate for the members of the workforce to carry out their functions.
Privacy Rule HIPAA training for mental health professionals may also be necessary for hybrid entities and mental health professionals that provide a service for or on behalf of a covered entity as a business associate “as provided” by §160.102 of the HIPAA General Provisions. It may also be necessary for qualified service providers to comply with the HIPAA training standards depending on the service being provided for or on behalf of a covered entity.
With regards to the second HIPAA training standard – §164.308(a)(5) of the HIPAA Security Rule – covered entities, the covered components of hybrid entities, and business associates must “in accordance with §164.306” implement a security awareness and training program for all members of the workforce. The requirement to involve all members of the workforce is to prevent cybercriminals infiltrating networks via the weakest links in human defenses.
The reference to §164.306 – the General Rules of the HIPAA Security Rule – is relevant because it requires individuals and organizations to implement security awareness and training programs with one of the objectives being to protect against any reasonably anticipated uses or disclosures of electronic PHI that are not permitted by the HIPAA Privacy Rule. It also requires individuals and organizations to ensure workforce compliance with the HIPAA Security Rule.
The Challenges of HIPAA Training for Mental Health Professionals
The challenges of HIPAA training for mental health professionals are that different rules for uses and disclosures can apply to different types of health information (i.e., Protected vs. SUD Health Information). This makes it more complicated to provide policy and procedure training per type of information – particularly since the recent changes to the HIPAA Privacy Rule also introduced attestation requirements for certain uses and disclosures of reproductive health information.
It is also the case that although most licensed mental health professionals will have received HIPAA awareness training during their professional educations, not all mental health professionals are licensed. This means there may be circumstances in which policy and procedure training is misunderstood because of a lack of basic HIPAA knowledge (i.e., what is considered PHI under HIPAA? What uses and disclosures of PHI are permitted? Etc.).
A lack of basic knowledge can also complicate the implementation of a security awareness and training program in accordance with the General Rules. If some members of the workforce have an incomplete understanding of (for example) why PHI should be protected, why it is highly sought by cybercriminals, and how cybercriminals will attempt to infiltrate networks via the weakest links, they are more likely to circumnavigate access controls to “get the job done”.
Trying to cover the basics of the HIPAA Rules in HIPAA training for mental health professionals or security awareness training can result in cognitive overload considering the other challenges of HIPAA training for mental health professionals. Therefore, it is often worth testing each workforce members’ existing HIPAA knowledge prior to providing any further training to identify gaps that may result in misunderstandings, avoidable HIPAA violations, and data breaches.
How to Test Workforce Members’ Existing HIPAA Knowledge
The most cost-effective way to test workforce members’ existing HIPAA knowledge and resolve some of the challenges of HIPAA training for mental health professionals is to take advantage of online HIPAA training courses. These tend to include all the basic HIPAA knowledge required to support policy and procedure training and security awareness training, and can also be used in lieu of annual refresher training or training imposed on workforce members as sanctions.
Most accredited online HIPAA training courses include a test on completion of the course that will reveal the level of each workforce member’s HIPAA knowledge. When scores of less than 100% are achieved, HIPAA Privacy and Security Officers can conduct a gap analysis to identity where risks exist to the privacy and security of patient data and how they can be mitigated – i.e., by changing procedures, implementing additional technical safeguards, or targeted training.
The tests can also help workforce members identify gaps in their HIPAA knowledge and take responsibility for them. This will mitigate the likelihood of an avoidable HIPAA violation attributable to a lack of knowledge or understanding that leads to one or more of their patients becoming victims of medical identity theft. It should also help improve the patient/mental health professional relationship to facilitate more accurate diagnoses and treatment plans.
Individuals and organizations in the mental health profession who are interested in supporting HIPAA training for mental health professionals with HIPAA awareness training are advised to approach several accredited training providers to ensure the content of the course aligns with their training programs. Members of the workforce wanting to identify potential gaps in their HIPAA knowledge should reach out to their HIPAA Privacy and/or Security Officers.
