HIPAA Training Requirements

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) aims to safeguard Protected Health Information (PHI) from theft and fraud. Not just doctors and nurses but anybody who handles medical records should undergo HIPAA training to be conversant with its requirements. 

Companies should conduct general awareness and role-specific HIPAA training programs. Should a breach occur and an Office for Civil Rights (OCR) investigation reveals that HIPAA training was not done, the penalty will be larger because the OCR will deem the breach to have been preventable through training.

In this article, we will discuss the various components of a HIPAA training program and what your employees should know to be HIPAA compliant.

TLDR: If you are looking to train your employees regarding HIPAA, then head on to the section titled HIPAA Employee Training Requirements: Most Important Topics. And if you are looking for an automated, smart, and cost-efficient solution to become HIPAA compliant in days, then head on to the last section.

What are HIPAA Training Requirements?

HIPAA training requirements are mentioned in the law and apply to different types of covered entities and business associates. The requirements are divided into privacy rule training standard and security rule training standard to safeguard PHI.

Only the covered entities are required to comply with the privacy rule training standard, while both covered entities and business associates need to comply with the security rule training standard. Let’s now check out these requirements.

What are HIPAA Privacy and Security Training Requirements?

HIPAA training is mandatory for members of the workforce of covered entities and their business associates. It is an Administrative Requirement of the Privacy Rule and an Administrative Safeguard of the Security Rule. 

Note that only covered entities are mandated to follow the Privacy Rule training standard, whereas both covered entities and their business associates must comply with the Security Rule training standard. This is because the Security Rule training standard applies to all employees—whether or not they have access to PHI.

• The Privacy Rule training standard requires covered entities to train their workforce about PHI-related policies and procedures and reporting breaches of unsecured PHI. 

• The Security Rule training standard requires covered entities and their business associates to put in place a security awareness and training program for all employees. 

HIPAA Privacy Rule mandates that new employees should receive compliance training “within a reasonable period of time” of joining a covered entity. Employees should get refresher training when “functions are affected by a material change in policies and procedures” – again within a decent amount of time.

HIPAA also requires training to be given “as necessary and appropriate”. So,  should the need for training arise such as when a patient complaint occurs or risk assessment has been done, HIPAA compliance training should be given soon after.

HIPAA Employee Training Requirements: Most Important Topics

Two kinds of topics are covered as part of HIPAA training: Basic and Advanced. 

• Basic topics serve as an introduction to HIPAA for a beginner or as refresher material to build on.
• Advanced topics deepen the learner’s HIPAA expertise or offer role-specific know-how.

Basic topics

Basic HIPAA compliance training includes an introduction to HIPAA, what makes up a HIPAA breach, and how HIPAA-compliant employees can avoid breaches. 

• Overview of HIPAA – Learners get an explanation of the objectives, who HIPAA it applies to (covered entities and their business associates), what it applies to (PHI), and in what manner it is enforced (by HIPAA-compliant policies and procedures). 

• HIPAA terminology – Learners get an explanation of the terms used in HIPAA such as PHI, the minimum necessary standard, and notices of privacy practices. 

• The HITECH Act – Learners get an introduction to the HITECH Act, a piece of legislation that motivated the use of healthcare IT, the requirement by business associate agreement to abide by a more rigorous enforcement of HIPAA.

• Important HIPAA regulations – Learners get an overview of the content of the five Rules established by HHS since HIPAA came into effect, even though learners may not need to know about the Breach Notification Rule or Enforcement Rule.

• HIPAA Omnibus Final Rule – Learners should know the Omnibus Final Rule because it gave patients more rights and raised the penalties for HIPAA violations. However, this Rule is more relevant to employees of business associates.

• HIPAA Privacy Rule basics – A necessary component of any HIPAA training program, learners must understand the Privacy Rule and which uses and disclosures of PHI it allows.

• HIPAA Security Rule basics – Learners should understand the Security Rule and how it aims to ensure that ePHI is available when required. Covered entities are required to have the technology to control access to ePHI. 

• HIPAA Patient Rights – Learners should know what rights patients have over their PHI and how to explain these rights to them, their family members, and parents of children receiving treatment.

• HIPAA Disclosure Rules – Learners should have a knowledge of the Disclosure Rules because healthcare workers sometimes use their discretion to decide if they should release PHI to a family member or other party.

• HIPAA Violation Consequences – Learners should understand the aftermath of a HIPAA violation and know the best ways to control the damage. It should also encourage them to promptly report HIPAA violations instead of hiding them.

• Preventing HIPAA Violations – Learners should realize the most common types of HIPAA violations and the best practices to prevent them. Social media disclosures, lost mobile phones, and accidental verbal disclosures are common among employees. 

• Being a HIPAA-compliant employee – It is legally mandated to be a HIPAA-compliant employee. They should know HIPAA Rules and the consequences of failing to abide by them.

Advanced Topics

Advanced HIPAA compliance training extends the learners’ knowledge of HIPAA Certification, so that they can act confidently in certain real-life situations. It also prevents learners from taking shortcuts to complete tasks within the purview of HIPAA.

• Timeline for HIPAA – By showing learners a timeline of HIPAA, they can understand what the Act aims to do and why the Rules were set up when they were. It also helps them understand that HIPAA evolves according to the situation.

• Threats to patient data – Patient data may face four major types of threats, but only one type is harmful. Learners should know what these threats are, how to prevent them if it is under their control, and how to act when they identify a threat.

• Computer security guidelines – Learners should be taught safe computer practices such as not leaving workstations and mobile phones unattended when logged into systems handling ePHI. 

• Social media and HIPAA – Accidentally sharing PHI over social media is a HIPAA violation. Learners should be made aware of their company’s social media policies to prevent such accidents.

• Emergency situations – Learners should know which PHI disclosures are allowed during emergency situations.

• HIPAA officer – Learners should know who their company’s HIPAA officer is and what their roles and responsibilities are.

• HIPAA compliance checklist – Cloud-hosted companies should create a checklist to test their employees’ understanding of the HIPAA Rules as it applies to them.

• HIPAA policy updates – Learners should get refresher training to understand the impact of HIPAA policy changes on their roles and responsibilities.

• Texas Medical Privacy Act and HB 300 – The Texas Medical Privacy Act and its updates in HB 300 preempt HIPAA. If it applies to the covered entity, its employees should be trained on both HIPAA and state law.

• Cybersecurity threats to healthcare workers – The Security Rule mandates teaching employees about cybersecurity threats as part of security awareness training. Learners should know how to prevent phishing, how to manage passwords, and how to browse securely.

• How to safeguard PHI from cyber threats – Learners should be taught about access controls, multi-factor authentication, and network monitoring.

Topics for healthcare students

Healthcare students should get HIPAA compliance training before they have access to PHI. They must know the PHI disclosure guidelines when they work with patients or use healthcare data for projects or reports.

• Electronic health record access by healthcare students – Students should know the allowable uses of PHI and the fact that using another person’s EHR login credentials to access PHI is a HIPAA violation.

• PHI & Student reports and projects – Unless patients have given informed consent or the PHI has been de-identified by removing identifying information, students cannot use it in their reports, case studies, and presentations.

• Being a HIPAA compliant student – Students should comply with the HIPAA policies and procedures of the covered entity where they’re training. They should also be able to identify HIPAA violations and know to whom to report them. 

Which industries require HIPAA training?

HIPAA training is necessary for everybody who comes into contact with PHI i.e. members of the workforce of covered entities and their business associates, contractors, students, and volunteers. 

Conclusion

Since HIPAA is ever-evolving, the workforce of covered entities and their business associates should get periodic HIPAA training to ensure their knowledge is up-to-date. HIPAA violations can prove ‌quite expensive for companies besides being financially and physically ruinous for patients. 

Sprinto can help your cloud-hosted company become HIPAA compliant in days instead of months. We help you craft policies, gather evidence, and establish the ‌controls quickly and accurately.

FAQ’s

When should employees be HIPAA trained?

When new employees join a covered entity or when significant changes are made to policies and procedures, the workforce needs to be trained to be HIPAA-compliant.

Is HIPAA training an annual requirement?

No, HIPAA training is not an annual requirement. It has to be provided within a reasonable period of time after an employee joins the organization. However, regular training sessions should be conducted to keep everyone in the workplace updated about the latest happenings.

How long is HIPAA training valid?

There is no certain validity period for HIPAA training as per the law. The Security Rule specifies that organizations should conduct training periodically. So, it is a best practice to provide HIPAA refresher training annually.

Who HIPAA training must be provided to?

HIPAA training must be provided to everyone who comes under HIPAA-covered entities and business associates. So, basically, everyone who handles protected health information (PHI) needs to undergo HIPAA training.