Develop a risks versus benefits summary for the key stakeholders of the hospital to show why an EHR system should be invested in and implemented

Planning, Organizing, Directing, Controlling (PODC) HIPAA Training Model

Teaching Hospital Employees About HIPAA

To effectively educate hospital employees on HIPAA regulations, a comprehensive training program will be implemented. This program will include:

• Interactive Training Modules: Utilizing online platforms for flexible learning. Courses will cover the full scope of HIPAA, focusing on privacy and security rules, and the importance of protecting patient health information (PHI) [1][2].
• Role-Specific Training: Tailoring training content to specific roles within the hospital to ensure relevance and effectiveness [3][4].

Types of PHI That Can Be Shared

1. Patient Names: Essential for identification and care coordination.
2. Treatment Information: Necessary for continuity of care among healthcare providers.
3. Billing Information: Required for processing insurance claims.

Information Sharing Locations:

• Nursing Stations: For real-time updates on patient care.
• Staff Meetings: To discuss cases while ensuring confidentiality.
• Secure Digital Platforms: For electronic communication.

Individuals Authorized to Use and Disclose PHI:

1. Doctors: For treatment and consultation purposes.
2. Nurses: For patient care coordination.
3. Billing Staff: For processing claims and payments.

Penalties for Breaching Patient Information

1. Civil Penalties: Fines can range from $100 to $50,000 per violation, depending on the level of negligence [4].
2. Criminal Penalties: Individuals may face imprisonment for up to 10 years if found guilty of knowingly obtaining or disclosing PHI without authorization [4].

Securing Data Between Shifts

1. Locked Storage Areas: Physical records must be stored in locked cabinets when not in use.
2. Secure Electronic Systems: All electronic records should be encrypted and require secure login credentials to access.

Internal Audit Plan for Security Measures

Department Oversight

The Health Information Management (HIM) department will oversee the audit to ensure compliance with HIPAA regulations.

Security Practices Reviewed in the Audit

1. PHI Sign-Out Sheets: Monitoring who accesses patient information.
2. Secured Storage Locations: Verifying that physical records are stored securely.
3. Access Controls: Assessing who has access to electronic records.

Potential Changes Post-Audit

1. Enhanced Employee Education: Regular training sessions on HIPAA compliance.
2. Updated Security Protocols: Implementing stricter access controls.
3. Regular Audits: Establishing a schedule for ongoing audits to maintain compliance.

Risk Assessment Plan

Frequency of Assessment

The risk assessment should be conducted annually, with additional assessments following any significant changes in technology or policy.

Responsible Parties

The HIM director will lead the assessment team, which will include representatives from IT and nursing.

Financial Impact of New EHR System

Risks vs. Benefits Summary

Stakeholder	Risks	Benefits
Administration	High initial costs	Improved efficiency and patient care
Medical Staff	Learning curve associated with new system	Enhanced data sharing and collaboration
IT Department	Integration challenges	Streamlined operations and data management
Patients	Potential downtime during transition	Better access to personal health information

Key Decision Makers

1. Chief Medical Officer
2. Director of Nursing
3. Director of Support Services
4. HIM Director

CMS Requirements for EHR System

1. Interoperability standards must be met for data sharing.
2. Compliance with meaningful use criteria to qualify for federal incentives.

Hardware Components Required

1. Servers
2. Workstations
3. Network infrastructure (routers, switches)
4. Backup systems

Capital Investment Estimate

The potential capital investment for the new EHR system is estimated at approximately $500,000, covering hardware, software licenses, and implementation costs.

Recommended EHR System

After evaluating Cerner, Meditech, and Epic, Epic Systems is recommended due to its robust interoperability features and user-friendly interface that aligns well with our hospital’s needs.

Components Needed in EHR System

1. Patient Registration Module
2. Clinical Documentation Module
3. Billing and Coding Module

Key Security and Privacy Components of Epic EHR

• Role-based access controls ensure that only authorized personnel can access sensitive information.
• Advanced encryption protocols protect data both at rest and in transit.

Training Plan for EHR System Implementation

Estimated Training Hours Required

• Clinical Staff: Approximately 10 hours
• Non-Clinical Staff: Approximately 6 hours

Logistics for Training Sessions

Day-Shift Employees Training Sessions

For approximately 150 day-shift employees:

• Conduct 5 sessions, accommodating 30 employees per session.

Night-Shift Employees Training Sessions

For approximately 50 night-shift employees:

• Conduct 2 sessions, accommodating 25 employees per session.

Training Cost Calculation

Assuming an average wage of $21 per hour over a training length of 8 hours:
$$
\text{Total Cost} = (150 \text{ employees} \times 10 \text{ hours} + 50 \text{ employees} \times 6 \text{ hours}) \times \$21 = \$31,500
$$

Physician Training Plan Development

For 75 physicians:

• Schedule training sessions during off-peak hours while ensuring adequate coverage through a rotating schedule that allows all physicians to participate without compromising patient care.

Train-the-Trainer Program Implementation

A train-the-trainer program will be established where selected staff members receive advanced training on the EHR system, enabling them to provide ongoing support to their colleagues as new hires come on board.

Transition Plan from Old EHR System

Measuring Competency

Competency will be assessed through practical evaluations where employees demonstrate their ability to navigate the new system effectively.

Timing for Transition Initiation

The transition should occur during low patient volume periods, ideally on a weekend evening when staffing is sufficient but not overwhelming.

On-Site Leaders During Transition

1. Chief Medical Officer
2. Director of Nursing
3. HIM Director

Justification for Leader Selection

These leaders possess critical oversight capabilities that ensure clinical integrity, operational efficiency, and compliance with regulatory standards throughout the transition process.

Rewarding Staff for Successful Transition

To encourage staff engagement with the new EHR system, a recognition program will be established that includes incentives such as gift cards or additional time off for those who demonstrate proficiency within the first month post-implementation.

Collaboration with Administration Team

Collaboration will involve regular meetings with administration to discuss budget allocations for rewards and strategies for promoting staff participation in training initiatives effectively.

Citations:
[1] https://www.hipaaexams.com/compliance-training-courses/HIPAA-for-Health-Care-Workers-training
[2] https://sprinto.com/blog/hipaa-training-requirements/
[3] https://www.hipaajournal.com/hipaa-training-for-healthcare-workers/
[4] https://hsi.com/blog/hipaa-training-for-healthcare-professionals
[5] https://about.citiprogram.org/course/hipaa-basics-for-healthcare-professionals/
[6] https://www.stericycle.com/en-us/resource-center/info-sheet/hipaa-compliance-and-enforcement-staff-training
[7] https://www.hipaajournal.com/hipaa-training-requirements/
[8] https://www.accountablehq.com/post/hipaa-training-a-must-for-healthcare-businesses