The Health Insurance Portability and Accountability Act, better known as HIPAA, is one of the most important pieces of legislation governing the healthcare industry and there are specific HIPAA training requirements for everyone in the industry. It is also quite complex, dealing with many different aspects of the sector with a number of variations and exceptions.
It should go without saying that anyone required to work with information or in an organization subject to HIPAA must have the knowledge to perform their tasks correctly without breaking the law. Just in case it wasn’t obvious enough, mandatory training is a part of two different HIPAA Rules. Below, we will examine what the Rules say; what organizations need to do to follow them; and some best practices to ensure nothing has been overlooked or forgotten.
What do the HIPAA Rules Say About Training Requirements?
The HIPAA Rules deal with many different types of organization and as such, the formal training requirements are quite loose and do not offer specifics. As mentioned above, training for staff is obligatory. Training is one of the Administrative requirements of the HIPAA Privacy Rule and an Administrative safeguard of the HIPAA Security Rule.
The HIPAA Privacy Rule says only that training should be given “as necessary and appropriate for members of the workforce to carry out their functions”. Similarly vague, the HIPAA Security Rule states that covered entities and their business associates must “implement a security awareness and training program for all members of the workforce”. Both of these Rules leave a lot of room for interpretation, and this could potentially lead to problems.
What Kind of Problems Can Occur?
Organizations may find themselves in something of a gray area as a result of these open descriptions of training requirements. Confusion can certainly arise in situations where mandatory actions are set without defining the mandatory endpoint or intermediate steps. This approach also puts a certain amount of pressure on covered entities and their business associates to ensure their training programs are solid. Should a breach occur, it is likely that health organizations could find themselves in a lot of trouble if no training had been given, or perhaps even if relevant information was not part of the training provided.
Covered entities do have a particularly important tool at their disposal when it comes to designing their training plan: the risk assessment study. Given that this is supposed to identify and categorize all potential risks to the security and privacy of the protected health information (PHI) that the organization handles, including risks of internal mishandling or mismanagement, responsibilities and tasks should be linked to the appropriate roles and the “necessary and appropriate” training plan can be defined from this basis.
Understanding the Goal of HIPAA Training
Every position in the organization will serve different functions and will require different access and permissions in relation to their use of PHI. As a result, different aspects of security awareness training will be relevant to different staff. A comprehensive range of training material and training programs may need to be developed in order to meet the needs and impart the appropriate knowledge to all internal stakeholders.
While such an approach may seem overly specific or too granular, the alternative would be a single training program to cover all aspects of all functions – something that would waste employee time as it would undoubtedly be very long; lose employees’ attention as it would not be sufficiently targeted to hold engagement; and cause further confusion as irrelevant information could easily be remembered or misremembered in place and in conjunction with the required knowledge.
Some Best Practices for HIPAA Training
While we have seen that implementing a “necessary and appropriate” training regime for HIPAA compliance can be a challenge, there are a number of steps that can ease the process and offer healthcare organizations some peace of mind with regards to their HIPAA compliance. A measure of balance and a common sense approach will be needed between providing individual training to every employee per their exact role and one single training program for all staff. We offer our advice below: every part may not be applicable to your situation but we invite you to consider those which are useful within the context of your organization:
Do: try to keep training succinct and to the point. We advise regular sessions of forty minutes or less.
Don’t: go too much into the history of HIPAA. While background information on how it came into law and evolved is nice, it is ultimately less important than role-specific information on securely managing PHI.
Do: give information on the negative effects than can occur following a HIPAA breach – not just for the company and the employees, but also for the patients whose data is disclosed.
Don’t: design a training plan that is essentially reading the HIPAA text out loud to employees. Training should be memorable, inclusive, and applicable to how staff will implement the information in their roles.
Do: have senior staff promote and participate in the program. Managers, even those who do not deal with PHI, should be seen to engage and support the initiative to show employees that it is an important priority for the organization.
Don’t: be lax when documenting training. Should auditors or inspectors arrive, it will be useful to have detailed records of training content, regularity, and attendance. Proof of a robust training program and schedule could save the organization from legal difficulties.