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How to Handle Patient Data: A Healthcare Professional's Guide

Patient records contain sensitive information, from private medical data to personal contact information.  Therefore, healthcare facilities should consider establishing best practice guidelines to maintain data in a secure manner, and employees must implement those guidelines. Knowledge of best practices for handling patient data for clinical professionals is critical. The below guide provides an introduction.

The Importance of Proper Handling of Patient Data

The Health Insurance Portability and Accountability Act (HIPAA) of 1996 is a federal statute enacted to protect patient privacy. HIPAA created national standards to safeguard sensitive patient data, including protected health information (PHI) and other confidential information (e.g., insurance information).

HIPAA covers two primary points:
  • The HIPAA Security Rule focuses on how healthcare entities use, receive, and maintain personal health information. The Security Rule provides standards for the technical, administrative, and physical handling of protected health information (PHI).
  • The HIPAA Privacy Rule restricts the information that may be disclosed to third parties without the patient’s knowledge and express authorization. It requires maintaining the privacy and confidentiality of PHI, such as insurance details and medical records.
These regulations seek to balance the need for information-sharing between healthcare professionals (which is often required to ensure quality patient care), with the goal to protect patient privacy.  HIPAA defines the organizations and individuals subject to these requirements as “covered entities.” They include healthcare providers, health plans, healthcare clearinghouses, and their business associates.

Covered entities are permitted to disclose PHI solely under defined circumstances – for example, in the case of organ donation or domestic violence or abuse. Therefore, strict privacy rules apply to patient data for healthcare professionals.

If you are a healthcare professional with access to patient data, you are subject to HIPAA guidelines. HIPAA violations can result in severe consequences, from losing your job to losing your license or even becoming subject to a lawsuit or substantial fines.

The rise of electronic health records has increased the risk surrounding potential HIPAA violations. There were numerous cyber-related patient data breaches in 2020, some of them resulting in lawsuits.

In one case, the plaintiffs alleged that a healthcare facility failed to exercise reasonable care to protect PHI. The data breach included names of medical treatments provided and diagnosis details. Personal data was also compromised, including driver’s license numbers, social security numbers, dates of birth, personal identification numbers, bank account details, and payment card information.

Best Practices for Handling Patient Data for Clinical Professionals

As a healthcare professional, your goal is to deliver quality patient care and compassionate treatment. Therefore, data must be managed in the most secure manner and in compliance with federal and state laws and regulations. Here are some best practice tips for handling patient data for clinical professionals. It is always recommended to get input from legal counsel as well.

Verify Your Record-Keeping

Careful record-keeping can help maintain a high standard of patient care and improve patient data security. Seemingly “small” details – like an incorrectly placed decimal point, wrong date, or incorrect patient identification number – can have a massive impact. Always update patient file notes promptly and double-check your data.

If information is input erroneously, the mistake should be noted according to the following guidelines. This also applies to hard copy note-taking. For example, if an error is made in a handwritten patient file, the best practice would be to draw a single line through the error and initial and date the error. Add the correct information in the next available space in the record, with the date of the correction. You may wish to clarify the reason for the correction. Completely removing information may result in problems related to data integrity if legal issues related to the patient’s care arise.

Know Your Employer’s Procedures

A healthcare practice should have written guidelines for employees regarding security protocols. Review this information carefully. Make sure to attend employer-provided security awareness training(s) and read updates regarding new measures. If something is ambiguous, ask for clarification. For example, if your employer sends an email warning about email phishing attacks and you still have questions, follow up in writing.

Respect Access Guidelines

Employer guidelines should address access, such as which employees are permitted access, and how employees are supposed to locate patient records, e.g., using a personal employee identification number and password. These authentication restrictions must be followed closely. A misstep – such as permitting a colleague to log into the system with your credentials – can result in liability in the event of a claim, as well as potential violations of state laws and regulations. Keep your access data (e.g., a security badge, PIN, password, key, etc.) secure.

Abide by Data Usage Controls

Most facilities implement data controls to limit data transfer, such as preventing certain internet downloads and prohibiting the use of external hard drives. Adherence to these guidelines is critical. For example, a seemingly insignificant act, such as downloading music on a work computer, may potentially open up the facility’s technical infrastructure to external third parties.

Log and Monitor Data Platform Use

Whenever you log into a patient data management platform or make any patient file changes, note this accordingly. A comprehensive record of log-in data is critical when tracking potential points of security concern. In the event of a cyberattack, IT professionals can more easily pinpoint a possible entry point by following the history of platform access.
Only Use Secure Technological Devices

If your employer provides digital tools for you to manage patient data, such as a tablet or laptop, make sure to use those tools solely for their intended purpose. Do not rely on external devices, which will not have the same security protection (e.g., software protection against malware or ransomware). Further, make sure to update those devices as needed. Do not ignore software updates. Take the time to install them.

Communicate Potential Issues Quickly

Even with the above tips for handling patient data, security incidents can potentially compromise patient data. If an issue arises, communicate the matter promptly to your employer, in accordance with the given security protocols. The earlier that any potential data issue is identified, the earlier it can be addressed.

Help Safeguard Your Role in the Healthcare Field with HPSO

Despite such precautions, security breaches may occur. Employer coverage has limitations, so it is wise to consider the purchase of individual professional liability coverage as well. As a healthcare professional, it is recommended to help protect your professional license – and your assets – in the event that a claim arises. Healthcare Providers Service Organization (HPSO) offers professional liability insurance to healthcare professionals across more than 100 fields.

Get a quote today.
This publication is intended to inform Affinity Insurance Services, Inc., customers of potential liability in their practice. This information is provided for general informational purposes only and is not intended to provide individualized guidance. All descriptions, summaries or highlights of coverage are for general informational purposes only and do not amend, alter or modify the actual terms or conditions of any insurance policy. Coverage is governed only by the terms and conditions of the relevant policy. Any references to non-Aon, AIS, NSO, HPSO websites are provided solely for convenience, and Aon, AIS, NSO and HPSO disclaims any responsibility with respect to such websites. This information is not intended to offer legal advice or to establish appropriate or acceptable standards of professional conduct. Readers should consult with a lawyer if they have specific concerns. Neither Affinity Insurance Services, Inc., HPSO, nor CNA assumes any liability for how this information is applied in practice or for the accuracy of this information.

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