Responsibilities of a HIPAA Privacy Officer

Under the HIPAA Privacy Rule, each company must nominate a specific “Privacy Officer” who maintains responsibility for developing and implementing any policies and procedures needed to become HIPAA compliant. Safeguarding Protected Health Information, or PHI, is an increasingly complex job, and the trend is likely to continue due to changes in the technological landscape, employee turnover, and updates to the HIPAA law itself. All of your questions about what this position entails, who this person should be & what they should have knowledge about will be answered here.

HIPAA Privacy Officer vs HIPAA Compliance Officer

When it comes to complying with The Healthcare Insurance Portability and Accountability Act, each covered entity or business associate is required to designate someone within the organization to take point  for all HIPAA questions and as the administrator for all HIPAA compliance actions. This position can be delegated to an existing employee or can be a new full-time position depending on the size of your organization and the time that it will take to manage the organization’s HIPAA compliance. Different HIPAA compliance programs and platforms have assigned different names: HIPAA security officer, privacy officer, HIPAA Compliance officer, etc. At Accountable, our goal has always been to simplify all the complicated expectations of HIPAA in order to ease the process of becoming compliant. Because of this, we refer to this important position as the Privacy Officer but all of these terms that are used refer to the same job in the end. 

The duties and expectations of a HIPAA Privacy Officer ranges depending on the size of the organization and the amount of PHI that it uses, creates or maintains. In larger organizations, there may even need to be multiple people that are dedicated to maintaining that company’s compliance. The Privacy Officer needs to have a great understanding of HIPAA and its role within the covered entity or business associate. Here are some of the many duties and responsibilities of the Privacy Officer for any organization which may help you understand who should be given this role in your company. 

Related: GDPR Data Protection Officer

Privacy Officer Responsibilities: 

The expectations and responsibilities of the Privacy Officer can vary depending on the size of your organization and the amount of PHI that you process. First off, the HIPAA Privacy Officer should be someone who has a great deal of knowledge about the ins and outs of the law and how it all applies to your specific organization. Once they have a great understanding of the law, they are tasked with identifying and evaluating threats to the confidentiality of PHI that could happen due to the processes of your company. Once these threats are identified, the HIPAA Privacy Officer is responsible for developing policies, standards, guidelines and procedures for minimizing these threats and ensuring protection of PHI. 

Since the Privacy Officer should be well versed in the policies and procedures needed to protect PHI within your organization, they will also be the person that develops and implements training for all incoming and existing employees. Training is a key aspect of maintaining HIPAA compliance as all employees must be aware of what PHI is, how it is allowed to be shared or disclosed and who may have access to that information. In-depth trainings should occur before new employees ever have access to PHI but there should also be regular updated trainings relating to changes to HIPAA or to the company’s policies and standards. 

Privacy Officers should periodically perform security audits of all technology and networks that employees use to ensure that all safety practices are being followed and are still the best procedure for the organization. In the event of a breach in the confidentiality or privacy of PHI, the Privacy Officer should be in contact with Health and Human Services (HHS) in notifying all the necessary parties of the information breach. As the head of HIPAA knowledge for the organization, the Privacy Officer should regularly educate themselves on any updates in policy or legislation as relating to HIPAA to keep the organization up-to-date on all security practices and training. 

Qualifications of a HIPAA Privacy Officer:

Leadership, both personal and organizational. Beyond knowing about HIPAA, your privacy officer should be a leader within your organization, such as a manager or an officer. Enabling them to construct and enact policies to protect your organization against unauthorized access of PHI.This avoids the mistake of nominating an individual for this role who is lacking the needed authority to serve effectively. They should be willing and able to enforce the rules and penalize employees when necessary. 

Attention to detail. Since the Privacy Officer’s job involves a long list of items they will need to address, they must be able to manage details thoroughly and successfully. Business Associate Agreements will have very specific language to outline how PHI can be shared and used between parties.

IT Management. If you are not using a company to help simplify the technical side of HIPAA compliance, then your Privacy Officer must be able to manage this side of HIPAA successfully It is important for them to be aware that any HIPAA violations your contractors create are legally your issues! 

Topics that the Privacy Officer should be knowledgeable about

What is and isn’t Protected Health Information (ePHI)

ePHI is any kind of PHI that is created, stored, transferred, or received electronically. The officer should be familiar with how ePHI is handled within their specific practice so that they can create an ePHI plan to maintain its security.  The HIPAA privacy officer should use their knowledge of state and federal HIPAA regulation and their knowledge of information systems to develop plans to protect the practice’s ePHI from risk.

For more information regarding what is and isn't PHI, read our breakdown of the topic.

Possess an understanding of Data Security Best Practices

Data Security is the practice of protecting information from unauthorized access, loss due to negligence, corruption, or theft. Data protection strategies will guard an organizations assets in the form of business data and personal health information. Odds are, if you are a Privacy Officer at a Business Associate you may find your organization needs to comply with the CPRA or GDPR in addition to HIPAA.

How to conduct and oversee an HIPAA compliance training program.

Creating and implementing employee training programs is an essential role of the Privacy Officer in leading the organization towards HIPAA compliance. This training program should focus on informing employees of all security risks to PHI and ePHI within the operations of their specific company. Training should include orientation sessions for new employees as well as maintaining regularly updated training for current employees as needed. 

Be able to conduct thorough internal security audits. 

The Privacy Officer should monitor internal audits that assess the status of a practice’s HIPAA compliance. Audits should be done regularly, quickly and easily with the help of a third-party service like the Online HIPAA Risk Assessment that Accountable offers. 

Incident management and remediation in the event of a data breach.

In the event of a breach, the HIPAA privacy officer is responsible for taking immediate action. The HIPAA privacy officer should have processes and plans in place that can be quickly and easily implemented should a breach occur. The team should investigate the breach, including why or how it occurred, and then take appropriate actions to correct it. 

As the Privacy Officer takes on the role of being the hub for HIPAA information, training and management within the organization, it is a very important responsibility. HIPAA is both long and confusing, presenting a challenge for the person who is assigned to be the Privacy Officer. With the help of a HIPAA compliance software, like Accountable, the Privacy Officer will have all the information and documents that are needed right at their fingertips plus an easily accessible resource to answer any questions they might have. It is vital for covered entities and business associates to maintain compliance in order to provide a high level of care while avoiding the many costs of noncompliance. Understanding the role of the Privacy Officer, the responsibilities that they will have, the qualities they should possess and the information they should know will all help to choose or hire the best fit for your organization.