This article provides a solution sample about Policy Manual Introduction on Protection of Patient Data at United General Hospital.
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To prepare for your Final Assessment, review the United General Hospital case study. Consider how you might create a policy manual introduction that includes more depth in the area of patient records. Next, reflect on how you would describe the purpose of patient record protection and explain its importance to the organization. Finally, think about how you would explain the legal requirements for protecting patient health records.
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Solution
Policy Manual Introduction on Protection of Patient Data at United General Hospital
Introduction
Nursing documentation is a knowledge source for the patient that demonstrates how decisions are made and how decision outcomes are recorded. As such, they constitute a vital part of clinical documentation. According to Samadbeik et al. (2015), the introduction of new technologies has led to several changes in healthcare organizations and practices as the documentation witnesses the transition from a paper-based electronic health record electronic-based health records (EHRs). (Policy Manual Introduction on Protection of Patient Data at United General Hospital)
The cited authors further define EHRs assets as components that comprise the mechanisms that facilitate the creation, usage, storage, retrieval, and location of patient records within a healthcare setting. As the usage of EHRs becomes entrenched in the 2020s and beyond, nurses can acquire most of the required patient information at the click of a button through computerized documentation. This ease of access means that the security management of EHRS is vital. While different health informatics experts may have different definitions of security, in the context of this paper, security means the protection of system items from accidental or malicious access, disclosure, use, destruction, or modification in ways that compromise confidentiality and privacy. Consequently, this paper aims to develop a draft of the policy manual introduction using the UGH patient privacy case study.(Policy Manual Introduction on Protection of Patient Data at United General Hospital)
Need Identification
In contemporary healthcare, the security of EHRs is threatened by hackers, adware, keystroke, rootkits, Trojans, and worms. Additionally, viruses and ransomware also include the methods used to compromise patient data security through cybercrimes (Daly, 2015). The rising number of patients whose patient data security is breached demonstrates the need for all hospitals to ensure confidentiality and privacy through controlled access to the intended patient health information.(Policy Manual Introduction on Protection of Patient Data at United General Hospital)
The Policy Manual Introduction
Like in any other hospital with acute care services, United General Hospital (UGH) must implement strategic measures through a policy manual. This is because healthcare services provide many complexities, and the hospital’s risk management team needs to take this seriously. To mitigate the issuer’s touches on accreditation, licensing standards, regulations, and third party requirements, the facility needs to introduce formal policies and procedures to help; promote patient data security and compliance to regulations. Implementing strict policies and procedures is bound to help UGH’s Information Technology security by keeping its networks secure, maintaining secure data transmission, and protecting their patients’ confidential records (Kruse et al., 2017). Suffice it to say that all the 42 HIPAA safeguards will be addressed.(Policy Manual Introduction on Protection of Patient Data at United General Hospital)
The policy manual’s first aspect focuses on access control whereby access to people like patients, visitors, and the hospital staff is either granted or denied throughout the hospital and specifically to its IT assets. The controlled access covers the emergency department, pediatric unit, wards, and intensive care unit. The second point of focus is staff, patient, and asset tracking. Tracking each of the staff and patient access to the hospital’s IT network will help technology identify, track, and locate individuals who try to gain illegal access to patient data. Tracking these individuals would protect t personal health information, also known as protected information ranging from past medical history to patient demographics to insurance information. (Policy Manual Introduction on Protection of Patient Data at United General Hospital)
All PHI helps the healthcare professional to identify and appropriate treatment. Similarly, protecting personally identifiable information that helps identify, contact, or locate a specific patient calls for controlled access. The third aspect of the policy manual is video surveillance. Improved technology has seen video surveillance cameras with embedded processors and videos that can be compressed and transmitted over Internet Protocol networks in real-time. The improved video surveillance cameras resolve the time-lapse of recorders of video cassettes that proved a significant challenge and were time-consuming for staff to identify specific incidents or events.(Policy Manual Introduction on Protection of Patient Data at United General Hospital)
Besides these measures, the hospital needs to be aware and align these strategies to the new guidelines of merit-based incentives and meaningful use as security requirements. By 2012, it was estimated that 63% of the physicians were still using fax machines as their primary means of communication, yet in today’s digital age, more and more practitioners are using EHRs (Riesman, 2017). This scholar notes that the government has offered HITECH Act more than $35 billion worth of incentives as one way of expanding and promoting the adoption and use of EHRs to healthcare facilities and professionals deemed eligible. Subsequently, our organization should integrate HITECH’s proposed five-year time starting 2021 included three-phase- stages. (Policy Manual Introduction on Protection of Patient Data at United General Hospital)
Each of the stages has its own set of measures demanding that providers adopt and demonstrate meaningful use of EHRs technology in ways that promote not just the quality and safety of patient care but also its efficiency. In summary, stage 1 will see the hospital embark on data capture and sharing, and stage 2 should target advancing clinical processes like more rigorous Health information exchange (HIE); and lastly, Stage 3 focal point will be the improved outcomes. From a legal perspective, Cleveland (2015) also weighs in by noting that the law can also be used as an incentive to correct the market dynamics on EHRs programs.(Policy Manual Introduction on Protection of Patient Data at United General Hospital)
Adhering to these and other policies will see UGH comply with HIPAA, which stipulates that all healthcare instructions like their counterparts in the insurance companies are not allowed to share or sell PHIU data except for treatment research, public health activity. To achieve the recommendation, the fourth aspect of the policy is to set out clear guidelines on how PHI data that is no longer required will be disposed of properly and make it unreadable through shredding, making it unable for reconstruction erased from the electronic systems using appropriate software. Most importantly, the three HIPAA security compliance rules outline the organizations’ exercise best practice in three security areas: administrative, physical security, and technical security. (Policy Manual Introduction on Protection of Patient Data at United General Hospital)
Put differently, organizations that deal with protected health information must ensure they have the physical, network, and process security measures put in place and adhere to them as stipulated in HIPAA Compliance. Despite the HIPAA, Rosenbloom et al. (2019) opine that there is a need to update HIPAA privacy to reflect the changing trends in healthcare. This emanates from the long-standing discordance between what federal policy requires and what both technology and organizational policies have achieved as part of HIPAA’s individual right of access. (Policy Manual Introduction on Protection of Patient Data at United General Hospital)
The proposed changes to HIPAA Privacy Rule include but are not limited to allowing patients to inspect their PHI in person and take notes or photographs of their PHI. Altering the maximum time to provide PHI access from 30 days to 15 days and requests by individuals to transfer ePHI to a third party be limited to the ePHI maintained in EHRs amongst other changes.(Policy Manual Introduction on Protection of Patient Data at United General Hospital)
Implementation of Information Best Security Practices
The IT security management team at UGH must remember that all stored data can be compromised and is vulnerable. To decrease and overcome vulnerability, the policy manual outlines ways to collect the least critical data and remove any unnecessary PII that has been collected from the EHRs (Keshta, 2020). The staff needs to be trained on de-identifying the patient data by making the patient feedback anonymous or tokenizing the information to help remove the data from the scope of HIPAA.(Policy Manual Introduction on Protection of Patient Data at United General Hospital)
In addition to implementing access control bound to ensure that unauthorized staff does not access sensitive information, the policy calls for encryption of all sensitive information. Doing so would mean hackers will not decipher PII even when they intercept it. The encrypted cloud storage and transmission of HIPAA- compliant email also constitute the information security best practices. (Policy Manual Introduction on Protection of Patient Data at United General Hospital)
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As outlined in the HIPAA, a covered entity includes health plans, healthcare clearinghouses, and healthcare providers who electronically transmit any health information linked to transactions for which HHS has adopted standards. Therefore, the policy manual has a component of security awareness and training. To maintain HIPAA compliance, security awareness and training are required. (Policy Manual Introduction on Protection of Patient Data at United General Hospital)
The subsection of the law dealing with this issue is 164.308(a) (5) and states that a covered must cover security reminders, malware protection, log-in monitoring, and password management at the very basic. This training will be conducted at UGH regularly at least once a year or more frequently whenever possible. Other policies include information encryption, securing copy/fax devices, initiating physical safeguards, and ensuring that covered entity staff lock their computers when they are not operating these devices.(Policy Manual Introduction on Protection of Patient Data at United General Hospital)
Who Will Take Lead Responsibility and Managerial Oversight
The risk management team at UGH will take lead responsibility and, together with information security experts, should see that the formalized policies and procedures promote patient data security and the delivery of safe, high-quality patients. According to Samadeik et al. (2015), once the appropriate policy measures are identified, the risk management team will inform all the affected personnel on the new policy’s effective date or its subsequent revisions after that. Managerial oversight is needed to secure effective implementation of the policy manual while legal counsel establishes the training type’s length of time to be maintained, factoring in the applicable statutes and limitations. (Policy Manual Introduction on Protection of Patient Data at United General Hospital)
The policy manual concisely and candidly defines all the terms used within the policy, refrains from using speculative words or statements besides exercising caution when using absolutes. Managerial oversight will also ensure that responsibility] for carrying out every action step is explicitly stated and not implied. Managerial oversight should also see that all the red rules are adhered to and the management sanctions noncompliance. Any covered entity that violates the red rules will be subjected to discipline unless the employee in context can provide a legitimate reason why the steps were skipped. (Policy Manual Introduction on Protection of Patient Data at United General Hospital)
Implementation of the Policy Manual and Emerging Technologies
The policy manual also outlines how to handle emerging threats paused by emerging technologies to ensure appropriate safeguards to mitigate the risk to the organization are implemented. The emergence of new cyber threats by initiating the appropriate safeguards. Simultaneously, the policy is to be monitored, reviewed, and revised as need be.(Policy Manual Introduction on Protection of Patient Data at United General Hospital)
Conclusion
In conclusion, this paper has established the need to introduce a policy manual on EHRs at UGH and those who will take lead responsibility. In the draft policy, the various policy strategies are outlined and, with a consultation to appropriate stakeholders, outlined the guidelines required. All the healthcare providers at the UGH will be communicated and the necessary training on patient data security awareness.(Policy Manual Introduction on Protection of Patient Data at United General Hospital)
References
Cleveland, B. (2015). Using the law to correct the market: The electronic health record (EHR) incentives program. Harv. JL & Tech., 29, 291.
Daly, P. (2015). Clinical nurses lead the charge with EHR. Nursing2020, 45(10), 25-26.
Keshta, I., & Odeh, A. (2020). Security and privacy of electronic health records: Concerns and challenges. Egyptian Informatics Journal.
Kruse, C. S., Smith, B., Vanderlinden, H., & Nealand, A. (2017). Security techniques for electronic health records. Journal of medical systems, 41(8), 1-9.
Lavin, M. A., Harper, E., & Barr, N. (2015). Health information technology, patient safety, and professional nursing care documentation in acute care settings. Online J Issues Nurs, 20(6).
Reisman, M. (2017). EHRs: the challenge of making electronic data usable and interoperable. Pharmacy and Therapeutics, 42(9), 572.
Rosenbloom, S. T., Smith, J. R., Bowen, R., Burns, J., Riplinger, L., & Payne, T. H. (2019). Updating HIPAA for the electronic medical record era. Journal of the American Medical Informatics Association, 26(10), 1115-1119.
Samadbeik, M., Gorzin, Z., Khoshkam, M., & Roudbari, M. (2015). Managing the security of nursing data in the electronic health record. Acta Informatica Medica, 23(1), 39.
Question
The Module Pre-Assessment is your opportunity to practice applying module content before submitting the final Competency Assessment.
In the Final Assessment, you will be asked to analyze the United General Hospital policy manual and develop a policy manual introduction.
To prepare for your Final Assessment, review the United General Hospital case study. Consider how you might create a policy manual introduction that includes more depth in the area of patient records. Next, reflect on how you would describe the purpose of patient record protection and explain its importance to the organization. Finally, think about how you would explain the legal requirements for protecting patient health records.(Policy Manual Introduction on Protection of Patient Data at United General Hospital)
For this Module Pre-Assessment, create a rough draft of your policy manual introduction. Be sure to review Part I of the Final Assessment Instructions for more details and reference the resources you used to support your introduction.(Policy Manual Introduction on Protection of Patient Data at United General Hospital)
Note that you do not have to resubmit your Pre-Assessment to address feedback.
part 2
The Module Pre-Assessment is your opportunity to practice applying module content before submitting the final Competency Assessment. In the Final Assessment, you will be asked to conduct a risk assessment to identify potential risks after a patient’s records were compromised and how the hospital and the primary care physicians may need to address the risks to protect patient records. You also will be asked to create policy statements that align with HIPAA regulations.
To prepare for Part II of your Final Assessment, consider the risks to both electronic and paper patient records. Next, reflect on what remedies you would recommend United General Hospital put in place to protect the records from compromise. Then, think about policy statements you could create that comply with HIPAA regulations that address access to and disclosure of electronic and paper patient records. Finally, think about relevant training topics that will educate the staff on accessing and disclosing patient records.
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To prepare for Part III of your Final Assessment, review the requirements of the HIPAA regulations and revisit your policy introduction draft from the Module 2 Pre-Assessment. Next, consider the areas in the United General Hospital case study that breached HIPPA regulations. Then, reflect on policy statements that would align with HIPPA regulations addressing patient healthcare record handling and disposal. Finally, think about relevant training topics for staff that would educate them on the handling and disposal of patient records.(Policy Manual Introduction on Protection of Patient Data at United General Hospital)
For this Module Pre-Assessment, create a draft of your risk assessment for Part II of your Final Assessment and a draft of your regulatory-aligned policy statement for Part III of your Final Assessment. Be sure to review the Final Assessment Instructions for both parts and reference the resources used to support your drafts.(Policy Manual Introduction on Protection of Patient Data at United General Hospital)
Part 3
The Module Pre-Assessment is your opportunity to practice applying module content before submitting the final Competency Assessment. In the Final Assessment, you will be asked to create the management oversight section of the management training manual and create a report that analyze emerging technologies.
To prepare for Part IV of your Final Assessment, consider clear instructions you could write for management oversight in the area of handling and accessing patient records. Then, reflect on policy statements you could create for role-based security level access to patient records. Finally, think about methods you would include to set security levels for accessing patient records to support the policy statements.
To prepare for Part V of your Final Assessment, consider the role that emerging technologies play in access to patient records. Then, reflect on policy statements you could create for the use of wireless technology and access. Finally, think about relevant training topics for staff that would introduce emerging technology and educate them regarding possibilities presented by emerging technology.(Policy Manual Introduction on Protection of Patient Data at United General Hospital)
For this Module Pre-Assessment, create a rough draft of your management oversight instructions for Part IV of your Final Assessment and create a rough draft of your emerging technologies report for Part V of your Final Assessment. Be sure to review both Part IV and Part V of the Final Assessment Instructions and reference resources used to support your drafts.(Policy Manual Introduction on Protection of Patient Data at United General Hospital)
Related FAQs
1. What are the security policies and procedures in a hospital?
Hospital Security Policies & Procedures 1 Access Control. Access control is the means by which access to people such as patients, visitors, and staff is granted or denied throughout the healthcare facility
2. Why are policies and procedures important in the healthcare industry?
These policies and procedures help promote safe and good quality care for patients, workplace safety, compliance to regulations, and, most of all, uniformity of healthcare practices across the hospital network.
3. How can I protect my patient data from being compromised?
All stored data has the potential to be compromised and is vulnerable. The best way to reduce and overcome the vulnerability is to collect the least required data and remove any unnecessary collected PII from the record. Wherever possible, de-identify the data by making patient feedback anonymous or tokenizing the information.(Policy Manual Introduction on Protection of Patient Data at United General Hospital)
4. How to ensure the security of your Hospital’s IT environment?
Developing such policies and procedures and conducting real-time monitoring and audit of security practices ensures the security of the hospital’s IT environment. It is important to allocate resources effectively and manage the IT environment proactively in order to curb ever-evolving threats and changing regulations.(Policy Manual Introduction on Protection of Patient Data at United General Hospital)
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