How to write your patient data privacy policy

Protect your patients and your organization by developing effective information security policies.

August 11, 2021

Article highlights

As most in healthcare know, HIPAA is an expansive and sometimes exhausting set of guidelines governing how hospitals and medical facilities handle their patients’ private health information.

HIPAA was created in 1996 to set a national standard for protected health information. What is protected health information? It includes all individually identifiable health information of patients. Examples of this are: demographic data, medical histories, test results, and insurance information.

The HIPAA Privacy Rule establishes that patients have the right for this information to be protected, which means that it should not be shared, sold, or revealed without patient permission.

In a world in which almost all health systems keep and track patient information digitally, protecting that data is the task of your IT security team. And that starts with developing a patient data privacy policy.

A data privacy policy is your internal guidebook, informing your employees on how to handle private information while avoiding the dangers of phishing and hacking attempts. It’s the foundation of maintaining a safe, secure digital operation.

Further on in this article, we’ll explore in more depth just what a patient data privacy policy is, the requirements of HIPAA, and examples of data privacy policies. We’ll explain why it’s a key tool in protecting your patients and your organization.

What is a patient data privacy policy?

With HIPAA providing such extensive rules around patient information and privacy, you could wonder whether you really need additional rules for your organization.

It’s important to remember that HIPAA sets national standards, and those are by necessity broad. Every healthcare provider is unique in size and type of treatments offered, which means you need to develop specific guidance to fit those specific needs.

Also, while HIPAA sets out what you must do as a healthcare provider and what information is private, it does not tell you how to accomplish those requirements. The principal purpose of a patient data privacy policy is to give your employees clear steps to follow to maintain HIPAA compliance and to follow best practices.

A patient data privacy policy needs to cover all personal health information for all your patients. Think of personal health information as any information you capture that could identify your patients. This includes:

  • Names
  • Government ID numbers such as Social Security and driver’s license numbers
  • Contact information including phone and fax numbers and email addresses
  • Birth dates
  • Medical record numbers
  • Banking information
  • Health insurance ID or policy numbers
  • Vehicle license numbers
  • Internet Protocol (IP) addresses
  • Physical addresses, excluding the first three digits of a zip code
  • Photographs

A patient data privacy policy starts by capturing what protected health information your organization captures, where it is stored, and how and by whom it can be accessed. The policy then should include a risk assessment, looking at potential weak points that hackers might target.

Lastly, the policy should include controls. These are the means by which you protect those weak points. This can include administrative oversight, technical security resources, training of staff, and physical access restrictions. At the same time, strong encryption practices are needed to maintain data integrity when it is sent or received.

Together, these practices prepare you for the hacking attempts that only continue to increase.

Importance of patient data privacy policies

Private health information is a growing target for hackers, and protecting it is your responsibility. Suffering a data breach is damaging to your patients, it puts your compliance at risk, and it can bring a loss of reputation to your organization.

Unfortunately, hackers know the value of sensitive patient data and are specifically targeting healthcare operations. In just one attack through a third-party vendor in 2020, one health system was exposed, and as many as 10 million patients had their data breached.

Patient data privacy policies are important then for two key reasons: They protect your patients, and they’re required by HIPAA.

Protecting patient privacy

As recorded in the HIPAA Journal, healthcare records breaches have become steadily more common over the past decade. In 2009, there were 18 breaches involving more than 500 medical records. That grew to 642 breaches in 2020, a number that is only expected to increase.

“Our healthcare data breach statistics show HIPAA covered entities and business associates have got significantly better at protecting healthcare records with administrative, physical, and technical controls such as encryption, although unencrypted laptops and other electronic devices are still being left unsecured in vehicles and locations accessible by the public.”

While all private information is valuable to hackers, private health information is particularly valuable, because it is deeply personal information that can be used to exploit an individual.

For your patients, having their health data exposed can have ruinous effects, including being personally targeted and exploited, or having sensitive information revealed.

Meeting HIPAA requirements

Another very simple reason to implement a patient data privacy policy is that it’s a requirement of HIPAA. To stay within compliance, your organization must meet several standards around health IT security.

What are HIPAA patient data privacy requirements? There are a few components that we’ll look at one by one.

First, there is the Security Rule, which has provisions around administrative, technical, and physical safeguards, as discussed above. These are the elements used to secure protected health information. 

  • Administrative requirements include completing a Security Risk Analysis (SRA), designating a HIPAA compliance officer, establishing a training plan for staff, and forming security agreements with all vendors.
  • Technical requirements include establishing authorized access protocols for PHI, installing necessary security hardware and software, tracking user activity related to PHI, properly encrypting PHI, and disposing of PHI when required.
  • Physical requirements include physical access to servers and devices, authorization over who has such access, training those who have access, and maintaining a database of all devices with access.

What is protected health information? As a reminder, it is all identifying information around your patients and their treatment. Anything that could indicate who a patient is, as well as all information regarding their treatment, is protected and subject to HIPAA rules.

Examples of privacy policy guidelines for data collection

When creating your data privacy policy, you must take all of the above requirements into account to maintain HIPAA compliance. 

These requirements change depending on the size and specialization of your practice, but there are some things that any such policy should include:

  • A notice of privacy practices to inform patients of their HIPAA rights, and a patient consent form policy covering how and when to get permission from patients before using or sharing their PHI
  • A breach policy to indicate what to do in the event of a data breach
  • An agreement with third-art vendors to enforce PHI compliance
  • A request policy for what to do when requests from outside entities come in for your patients’ PHI
  • A training policy for your employees on PHI and HIPAA requirements

Just remember that your policies must be suited to your specific needs.

For more guidance on developing HIPAA-compliant policies, read our article HIPAA Policies and Procedures.

Protecting patients’ health information

All physicians know the axiom “Do no harm” in regards to patients. In the age of digital information, that extends to the electronic records known as protected health information. While HIPAA provides national standards, it is your responsibility to create guidelines for your practice and to put them into action.

Remember, hackers are actively attacking healthcare providers, seeking vulnerabilities in order to capture protected health information. That threat is only growing. Suffering a data breach can have devastating impacts for your patients, as well as to your institutional reputation.

By taking action today, you can be ready for those attacks when they come, keeping your organization safe all while staying compliant with HIPAA.

Now that you understand the importance of patient data privacy policies, read more about the 10 important policies and procedures for healthcare that will help you to protect your patients, your staff, and your organization.

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