HIPAA Training for Medical Office Staff

What is HIPAA Certification?

Medical offices tend to have more access to PHI than most other healthcare departments and consequently HIPAA training for medical office staff may need to be more comprehensive – and more frequent – than the training typically provided to a Covered Entity´s workforce.

When you look at job descriptions for medical office assistants, specialists, and managers, they often include a wide range of interactions with patients and patients´ Protected Health Information (PHI).  Medical assistants, specialists, and managers can also be assigned multiple tasks involving the creation, verification, and communication of electronic PHI (ePHI).

The high level of contact with PHI means it is recommended medical office staff are well educated on HIPAA regulations relating to the confidentiality of PHI in order to avoid unintentional HIPAA violations. This recommendation not only applies to public-facing employees, but to all a medical office´s workforce – including staff who would not normally encounter PHI.

Training Beyond the HIPAA Requirements

The recommendation that staff are well educated on HIPAA implies that HIPAA training for medical office staff should go beyond the Administrative Requirements of the Privacy Rule which require a Covered Entity to “train all members of its workforce on the policies and procedures with respect to PHI […] as necessary and appropriate for members of the workforce to carry out their functions”.

Therefore, in addition to training on policies and procedures, HIPAA training for medical office staff should include advanced Privacy Rule training to include elements such as patients´ rights, disclosure rules, and how best to prevent HIPAA violations. In addition, providing a background to HIPAA via an explanation of the main regulatory rules can add context to the training to help with retention.

Members of staff with access to ePHI should also undergo more than the minimum security awareness training required by the Administrative Safeguards of the Security Rule – although this may become apparent when Covered Entities conduct risk analyses required by the Administrative Safeguards to identify vulnerabilities to the confidentiality, integrity, and availability of ePHI.

Training for Staff Who Would Not Normally Encounter PHI

In a medical office, PHI can be everywhere. Patients may walk into the office, phone conversations may be conducted in the office, and paperwork may remain in clear sight of staff who would not normally encounter PHI as they “carry out their functions” for the Covered Entity. Staff in this category might include cleaners, volunteers, students on work experience, and maintenance staff.

For this reason, it is important that all members of a medical office´s workforce undergo some level of HIPAA training to ensure that, if they see, hear, or have unintended access to PHI, they know not to share what they have seen/heard/accessed, and can alert supervisors to potential HIPAA violations such as a failure to comply with the Minimum Necessary Standard.

Providing different levels of HIPAA training for medical office staff to satisfy the training requirements of the Privacy and Security Rules, mitigate vulnerabilities identified in risk analyses, and ensure all members of the Covered Entity´s workforce have a basic understanding of the HIPAA regulations can be complicated. However, it is possible to overcome this challenge and increase the likelihood of a HIPAA-compliant workforce with modular HIPAA Training.

How Modular HIPAA Training for Medical Office Staff Works

Modular HIPAA training for medical office staff breaks down everything staff may need to know about the HIPAA regulations into small units that can be mixed and matched to meet the requirements of different workforce groups. This means that, once basic HIPAA training is provided, different groups can be trained on the areas of HIPAA that are relevant to their functions, that add context to what they have learned, and/or support security awareness training.

Modular training is not only easier to manage, but when new regulations are introduced or policies and procedures are affected by a material change, only the modules impacted by the new regulations or material change need to be updated. Similarly, if a risk analysis identifies a compliance issue with just one area of HIPAA, only the module relating to that area of HIPAA will need to be included in refresher training. It is recommended refresher training takes place at least annually.

One further advantage of modular HIPAA training for medical office staff is that it does not have to be presented in a classroom environment. Although some classroom training can be beneficial, modular HIPAA training is a lot more convenient to present online. It also facilitates the option for members of the workforce to complete the training modules when they have time in their schedules, rather than close the medical office to provide training en masse.

HIPAA Training for Medical Office Staff FAQs

Is it necessary to train medical office staff on all elements of the HIPAA Privacy Rule?

While it is only necessary to train medical office staff on the policies and procedures developed by the Covered Entity to protect PHI, providing all members of a Covered Entity´s workforce (Including cleaners, volunteers, students, maintenance staff, etc.) with a basic understanding of the Privacy Rule will help mitigate unintentional HIPAA violations attributable to a lack of knowledge.

However, training every member of a Covered Entity´s workforce on all elements of the HIPAA Privacy Rule would be counter-productive. The Privacy Rule consists of multiple standards and implementation specifications that are mostly administrative and only need to be understood by the organization´s HIPAA Privacy, Security, and Compliance Officers.

Does security awareness training have to be provided annually as well as Privacy Rule training?

The recommendation to provide annual refresher training is only a recommendation – it is not stipulated by HIPAA nor by the HHS´ Office for Civil Rights. Nonetheless, it is a good idea to provide annual refresher training on the HIPAA Privacy Rule because in busy medical offices it can be difficult to remember every compliant course of action and standards can slip.

With regards to security awareness training, the standard relating to security awareness training requires Covered Entities (and Business Associates) to implement a “security and awareness training program”. This – and the implementation specifications that support the standard – implies that security awareness training should be ongoing and not a one-off or periodic event.

What advantage is there is of providing a background to HIPAA in HIPAA training?

Providing a background to HIPAA provides context to HIPAA training inasmuch as staff will better understand why they have to comply with a policy or procedure rather than just being told they must do (a), (b), or (c) because that is what the HIPAA regulations mandate. If staff understand why the policies and procedures are in place, they are more likely to comply with them.

Do I need to document HIPAA training for medical office staff?

According to the Administrative Requirements of the Privacy Rule, HIPAA training has to be documented and the documentation retained for a minimum of six years. This is because, in the event of a HIPAA violation, data breach, or patient compliant, Covered Entities have a “burden of proof” to demonstrate they complied with the HIPAA training requirements.

If a member of staff has received HIPAA training in a role for a previous employer, is it necessary to provide it again?

Although the member of staff may have acquired an understanding of HIPAA from their previous employer, it is likely that the previous employer had different policies and procedures than the new employer. Furthermore, a risk analysis conducted by a previous employer may have identified more or fewer threats to the privacy of PHI compared to a risk analysis conducted by the new employer – in which case the training provided to the member of staff may have been much different.