Telehealth
HIPAA, Telehealth

Audio-Video Telehealth, Mobile Device Management & You

Written by: Joanne Byron, BS, LPN, CCA, CHA, CHCO, CHBS, CHCM, CIFHA, CMDP, COCAS, CORCM, OHCC, ICDCT-CM/PCS


This article addresses how to track telehealth policies while addressing HIPAA compliance and mobile device management as the United States enters into a post-pandemic era. The information is an overview and should not be used as legal or consulting advice. Health care providers need to look toward long-term telehealth policies, ensure compliance and realize there is remaining work to be done. 


Scroll to the end of this article for “Basic Telehealth Terminology” if you are new to telehealth or if you are a mobile device app developer!


Most Providers Utilize Audio-Only Telehealth


More than two-thirds of providers utilizing telehealth use audio-only, according to a recent Telehealth Survey conducted November 2021 through December 2021 by the American Medical Association (AMA). According to this survey, 85% of physician respondents indicate they currently use telehealth. Those reporting a decrease in use since first offering it, now indicate doing a mix of in-person and virtual care. Of physician’s using telehealth, the trend indicates 93% are conducting live, interactive video visits with patients and 69% are doing audio-only visits.  


Considering this survey and other reports on audio-video services, concerns seem to focus on potential overutilization, equity and quality of care. 


A concern expressed to AIHC, by our Compliance and HIPAA Officer members, surrounds mobile devices used by providers and practice managers and the organization’s responsibility to comply with applicable rules, regulations and mobile device policies.


So, how do policies apply? 

 

If your providers use a mobile device to access an organization’s internal network or system, the owner of that network or system’s policies and procedures apply to your use of the mobile device to gain such access. It is your organization’s responsibility to understand and follow the organization’s policies and procedures.


If an organization allows providers and professionals to use mobile devices for work, the organization should have reasonable and appropriate mobile device policies and procedures. The policies and procedures should describe any configuration requirements for mobile devices used by providers and professionals for work. It is your responsibility to understand and follow your organization’s mobile device policies and procedures. But, what about using personally owned mobile devices for work?

  • "Bring Your Own Device" or BYOD refers to using a personally owned mobile device for work. Providers should be reminded to let their organization know when they want to use a personally owned mobile device. Many organizations have centralized security management to make sure mobile devices accessing their internal networks or resources are compliant with their security policies. Centralized security management includes:

o Configuration requirements, such as installing remote disabling on all mobile devices; and


o Management practices, such as setting policy for individual users or a class of users on specific mobile devices.


It is the provider’s responsibility to understand and follow the organization’s mobile device policies and procedures. Registering the provider’s mobile device with the organization allows the organization to control who has access to its network or system and will keep unauthorized persons from accessing its network or systems.

  • Registering these mobile devices with your organization may also help the organization or law enforcement find your mobile device if it is lost or stolen. Providers should be directed to contact their organization’s Privacy Officer or Security Officer to register their mobile device.

Utilizing Step 4 from ONC’s 5-Step Process to Manage Mobile Devices Used by Health Care Providers & Professionals, the list of questions below is a way to take inventory of potential safeguards needed to address risk areas.


Mobile Device Management


 If your organization allows the use of mobile devices, what should the organization do about managing the use of mobile devices?


   o Has the organization identified all the mobile devices that are being used in the organization? How is the organization keeping track of them?


   o Has the organization assigned responsibility to check all mobile devices used for remote access, to find out if selected security/configuration settings are enabled?


   o Should there be a regular review and audit of the mobile devices? 


Misuse of Mobile Devices


 Does the organization have written procedures for addressing misuse of mobile devices?


   o If so, what are the consequences when a mobile device is misused and the incident poses risk of a data breach?


Should the Organization Allow BYOD?


 Is this a policy already in place, where providers are using their own devices?


   o Should the organization let providers and professionals use their personally owned mobile devices within the organization?


 Should providers and professionals be able to connect to the organization’s internal network or system with their personally owned mobile devices, either remotely or on site?


Restrictions on Mobile Device Use


 Does the organization restrict how providers and professionals can use mobile devices?


   o Can providers and professionals use mobile devices to access internal networks or systems, such as an EHR?


   o Are providers and professionals restricted from using mobile devices when they are away from the organization?


   o Can providers and professionals take their mobile devices home?


   o Should the organization allow texting or emailing of health information?


      Is there encryption allowing compliant texting and emailing from the mobile device?


Security/Configuration Settings for Mobile Devices


 Will the organization institute standard configuration and technical controls on all mobile devices used to access internal networks or systems, such as an EHR?


   o If so, is the organization's current mobile device configuration document, including connections to other systems/applications, inside and outside of the firewall.


Information Storage on Mobile Devices


 Are there restrictions on the type of information providers and professionals can store on mobile devices?


   o If so, where and for how long should the data be stored?


 Are providers and professionals allowed to download mobile applications to mobile devices? If so, what type(s) of applications are approved?


Recovery/Deactivation of Mobile Devices


 Does the organization have procedures to wipe or disable a mobile device that is lost or stolen?


 Does the organization have standard procedures to recover mobile devices from providers and professionals when their employment or association with the organization ends?


Mobile Device Training


Training is always a challenge, but if your organization cannot achieve effective training and compliance, you may need to reconsider how telehealth is delivered to your patient population.


 How is the organization training its workforce (management, doctors, nurses, and staff) on policies and procedures?


 How does the organization hold its workforce (management, doctors, nurses, and staff) accountable for non-compliance? 


What Additional Information Should I Know for Compliance?


Covered entities must comply with HIPAA Privacy and Security Rules to protect and secure health information, even when using mobile devices as described above. Taking it a step further, health care leaders are responsible to ensure that mobile device procedures and policies have been developed and properly implemented to protect the health information patients entrust to you.


Make Tracking Audio-Only Policy Easy


A great resource is utilizing the National Telehealth Policy Resource Center called “CCHP,” short for Center for Connected Health Policy. CCHP has been tracking audio-only policies across the country and offers access to state audio-only policies via CCHP’s Policy Finder Tool.


As AIHC advises, another resource is legal advice through your malpractice insurance company. At no additional charge, a risk attorney can be made available to help review which policies impact your type of practice and organization.


Free HIPAA Compliance Resources


Another reliable resource is found at HealthIT.gov, the official website of the Office of the National Coordinator for Health Information Technology, otherwise known as “ONC.” ONC offers basic guidance in these five steps 1) Decide; 2) Assess; 3) Identify; 4) Develop, Document and Implement; and 5) Train entitled “five steps organizations can take to manage mobile devices used by health care providers and professionals.”


Does Your Organization Have a Trained (Certified) HIPAA Privacy/Security Officer?


Your HIPAA Compliance Officer can serve as the best resource to help your organization navigate the telehealth and mobile device compliance issues facing your providers today. AIHC offers an online course covering both privacy and security with the option of certification (proctored and administered online).  The cost of certification is covered in the tuition price. Learn more.


It is highly recommended that mobile health app developers and Managed Service Providers (MSPs) have an in-house HIPAA Compliance Officer contributing input to ensure technology is compliant.


Are You a Mobile Health App Developer?


Integrating protections into your technology to create HIPAA compliant products is necessary for your company to succeed. Health care providers are subject to the HIPAA rules as covered entities to protect identifiable health information when it is created, received, maintained and/or transmitted. These protections are required under Federal and State Privacy, Security and Breach Notification Rules. A few basic resources to reference are:


The Office for Civil Rights (OCR) HIPAA website devotes a webpage under Special Topics entitled “Resources for Mobile Health Apps Developers.”


The Federal Trade Commission (FTC) offers a webpage entitled “Mobile Health Apps Interactive Tool” to help you locate federal laws to follow.


For Beginners - Basic Telehealth Concepts


Telehealth is also referred to as Telemedicine. It is the use of telecommunications technology to provide health care services to persons who are at some distance from the provider. This type of patient encounter involves a spectrum of technologies.


Coverage and payment for telehealth can include consultation, office visits, individual psychotherapy, pharmacologic management and other services delivered via an interactive audio and video telecommunications system.  

  • Providers are located at the distant site; and
  • Patients are located at the originating site.

Provider at the distant site - As stated above, providers are at the “distant site,” referring to where the provider is at time of service. The provider can communicate with the patient using an interactive audio and video telecommunication system that permits real-time communication with the beneficiary.


When telehealth is used, it is considered to be rendered at the physical location of the patient, and therefore a provider typically needs to be licensed in the patient’s state. During the COVID-19 public health emergency (PHE), many states waived this requirement or provided specific exceptions. Click Here for Cross-State Licensing information.


Medicaid programs often restrict the type of providers that can be reimbursed when delivering services via telehealth. During the COVID-19 PHE, the list of providers in Medicare and many state Medicaid programs expanded to include professionals such as occupational and physical therapists and speech-language pathologists. Federally Qualified Healthcare Centers (FQHCs) and Rural Health Clinics (RHCs) were also allowed to provide services in some cases. These policies are temporary and most will expire at the end of the PHE.


I also recommend utilizing the TELEHEALTH.HHS.GOV website for providers – “Getting Started with Telehealth.” This webpage provides many additional links to more resources your organization can use to navigate this complex topic.


Temporary telehealth policies during the PHE were implemented to provide improved access to health care during the COVID-19 pandemic. The federal government has been encouraging providers to use telehealth to conduct virtual appointments and has made the telehealth “rules” more flexible. For instance, audio-only delivery of care has rarely been reimbursed historically. But due to COVID and the PHE, temporary policies allow this modality to deliver some services.


The PHE is reviewed and potentially extended every 90 days. When the PHE ends, coverage for telehealth may change. Monitor these updates by using the CCPH website referenced earlier in this article found at https://www.cchpca.org/.

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HIPAA

Healthcare Apps and Data Privacy/Security Risks

Written by Susan Walberg, JD MPA CHC




Healthcare apps have become increasingly prevalent, with people using them for counting steps, monitoring their calories, or linking to various medical devices, to name just a few examples. Since the COVID outbreak, however, and the explosion of telehealth as a healthcare option, these apps have proliferated at an insane rate. As of 2020, there were 325,000 healthcare apps on the market, with more coming all the time.


Whether you are a consumer who uses such apps, or a provider who wants to develop an app for patients to use, it’s important to understand some of the privacy and security risks that may accompany the use of such tools and what to watch out for.


What Are Healthcare Apps?


An ‘app’ is a small program that can be loaded onto a phone or mobile device to perform a specialized function. There are two main types of healthcare apps in terms of privacy and security regulations, and the rules governing them vary accordingly.


The first type are the applications that are used by your healthcare provider. They may be used to store your lab or radiology results or might be integrated with a medical device for tracking/monitoring purposes, such as an electrocardiography device that monitors heart activity. Or they may be used to coordinate your care.


The second type are personal or private healthcare apps, those that an individual can get at an app store to track and manage their diet, exercise, or specific health conditions. There are apps for mental health, diabetes, and, of course, COVID, to name just a few. Many of these apps are free.


Nothing in Life Is Free


First, let’s talk about those ‘free’ apps.


Free apps, how cool is that? Depending on your view, an application that tracks and shares your personal information might not really be ‘free’.


If you go online and look for a free app to help you count calories or manage your diet, for instance, the odds are good that there are advertisements on the app, right? Well, most of those ‘free’ apps, with the ads included, will be sharing your information with the advertisers and perhaps even with other companies, such as the ‘big tech’ companies or other stakeholders or investors.


You may expect this, and you might not care. After all, any online Google search leads to targeted Facebook ads relating to that same subject matter, as many of us have noticed. We may not like it, but we are getting used to the fact that our online activity is not really private.


But when you choose one of those apps, think about what information you are entering, because it is probably not private. How much of your medical information is being collected in order to help you manage your diabetes or exercise program? And do you know where that information might be shared? You may accept the fact that your use of the app is not private, just like your Google searches seem to have a direct pipeline to Facebook. But think about the data collected, because that’s not private either. And that’s not illegal in this situation.


But…But…HIPAA


How can this health information NOT be private? There must be regulations protecting your privacy, especially when it comes to your healthcare information, right? We hear all the time about HIPAA (The Health Insurance Portability and Accountability Act of 1996) and how your health information can’t be shared.


Just to be clear, in a nutshell, HIPAA only applies to those apps that are used and offered by your healthcare provider or insurance company (or some similar organization that is regulated by HIPAA). Those organizations are subject to the HIPAA Privacy and Security regulations (as well as the HITECH and Omnibus laws that followed), so any product they offer in conjunction with their regulated services would typically be subject to the same laws. This does not mean that if your doctor tells you there are apps in the marketplace to monitor your diabetes that they would be subject to HIPAA. But if your insurance company, for instance, offers you a tool as part of your plan that will help you manage a chronic health condition, HIPAA would generally apply. You may not be sure, so it’s important to ask.


If the app is, indeed, regulated under HIPAA, that means that privacy and data security controls must be in place. There should be a privacy/security policy that you can review, and you have specific rights with respect to your information and how it’s used. There are limitations around, for instance, how your data can be used or shared for marketing purposes. It also means that there must be a designated privacy and security ‘official’ who has oversight of compliance with these regulations. A company that provides a healthcare app to physician practices, insurance companies, or similar organizations would be considered a ‘Business Associate’ of that provider or insurance company, which means they are subject to the same requirements. HIPAA does provide a broad range of protections, but they are limited to those specific scenarios.


The reality is that few laws govern the privacy of information you voluntarily share in one of these publicly-available apps, so if you go online and pick an app to track or monitor your own health condition or information…most are not subject to privacy laws.


Apps Provided by Your Physician, Insurance Company, Etc.


The apps used by your doctor’s office or insurance company are subject to much tighter regulation, but also often contain more personal data. Especially with the increased use of telehealth services, provider’s offices are relying on various applications and platforms to facilitate the provision of healthcare services. These apps, and the companies that offer them, are covered under HIPAA as ‘Business Associates’ of the provider or insurance company if the app uses, stores, or transmits patient health information on behalf of the healthcare organization.


Due to COVID, the government has loosened up the privacy regulations in order to allow greater flexibility in providing telehealth services. While this is good news for providers and the patients needing those services, it also means more potential risk to protected health information (PHI). It’s important to keep in mind that, in addition to whatever information you enter online, a telehealth application likely has requested permission to access your calendar, camera, and microphone.


The good news is that, although providers may have been using some of the less secure apps in the beginning of COVID, just out of necessity, those providers who plan to continue providing telehealth services are working to ensure compliance with privacy and security requirements. App developers are busy developing apps to accommodate this changing market, and compliance is a top concern.


Apps as Mobile Devices


There is one type of application which is actually considered by the Food and Drug Administration (FDA) to be a medical device, in addition to being covered under HIPAA (because they are provided in conjunction with healthcare services). Those are the apps that are intended to be used ‘for the diagnosis of disease or other conditions, or the cure, mitigation, treatment, or prevention of disease, or is intended to affect the structure or any function of the body of man’ under section 201(h) of the Food, Drug, and Cosmetic Act. In general, if the purpose or function of the app is to assist in performing a medical device function, it will be treated as a medical device under the FDA. For instance, if the app can be run on a smart phone or other hand-held device and analyzes and interprets EKG waveforms to monitor cardiac irregularities, it would be considered analogous to those software programs that perform the same function and are otherwise regulated as a medical device.


The intent of the FDA is to ensure patient safety related to the use of those devices that could compromise or risk patient health. This oversight is limited to those devices marketed and offered to perform these medical device functions.


Although the FDA purview is not privacy or data security, the FDA jurisdiction is noteworthy in terms of regulatory oversight. For purposes of HIPAA, these devices would typically be subject to the Privacy and Security rules as they are used in conjunction with your provider or insurance company, as discussed above.


How Do You Know if Your Data Is Secure?


Apps in the marketplace that are available to help track health-related information should have a privacy policy, although at the current time it is not required by law for apps that are not considered a medical device or are subject to HIPAA. It is highly recommended that you find those policies and read them, even though some may be lengthy and not written clearly (might be overly technical or legalistic).


Even if the apps have privacy policies, those policies might not be easy to find, and you might discover that the policy does state the ways in which they do share your information. There is no law against the sale or disclosure of data from independent apps to third parties and those apps are being funded somehow (data is valuable). In addition to data sharing, the privacy policy should explain how it safeguards your data. There should be information security measures in place to prevent breaches of your data. And lastly, even if the privacy policy sounds good, the app developer may not necessarily follow their own policies. This is not to say that an app developer is deliberately being deceptive; a developer or their sponsoring company may adopt a policy from another app they are familiar with or may bring in a consultant to write their policy, but the specific terms in the policy aren’t implemented during development. It can happen. And this isn’t limited to app developers; any organization can fall short of following its own policies. Many app developers have a technical or clinical background and may not fully understand the healthcare regulatory framework.


You can also check an app’s automatic settings and look for those that impact privacy, such as location tracking. Beware, though, that in some instances turning those options off will make it more difficult to use the app.


The bottom line here is caveat emptor…buyer beware. Especially if you’re not ‘buying’ and it’s ‘free’.


How Can Data Be Compromised?


Even when providers, insurance companies, and app developers are focused on compliance with the various privacy and security requirements, PHI can still be compromised, but it is less likely. Common mishaps occur in a number of ways:

  • Employee errors. Human errors can occur in any setting. It can be an employee discussing patient information out loud in a non-private setting, clicking on a link that allows a virus or ransomware attack, or accidentally entering an incorrect phone number and sending information to the wrong person. This isn’t limited to technology-related issues but privacy in general.
  • Poor access controls. There needs to be a solid process, that is followed religiously, to ensure that only individuals who need access are given access, and that former employees or business associates are promptly removed when they no longer have a need for access. This also includes business partners who have employees who need access in order to provide services to another company or practice. These employees need their own access, not a universal access that cannot be tracked.
  • Failure to monitor. Any organization that maintains PHI electronically should have a process for routinely reviewing who is accessing sensitive information and following up on any questionable access. Audit trails are part of any good security structure.
  • Failure to securely store data. Not only should data be stored in a secure manner, it should also be consistently destroyed/removed when applicable retention periods have expired.
  • Inadequate encryption.
  • Workstation and device security. Applications should time-out when not in use, rather than rely on users to remember to do so.
  • Failure to conduct a comprehensive risk assessment that includes the various apps and networked devices where PHI is stored or transmitted.
  • Increased remote workers. Employees working from home are more likely to use personal devices that don’t have proper levels of encryption and that are, by definition, less private due to the offsite location. Access is much harder to control and networks may not be secure.

The above issues do not pertain only to apps, but in general to information privacy and security, especially in the new era of increased telehealth services. Those issues are also the types of failures HIPAA was designed to prevent and would likely be considered violations, depending on the specific facts. If you are considering using an app or electronic platform where personal information will be entered, it’s recommended that you ask your provider or insurance company who is offering this tool what their privacy and security policies are. If their organization is using and recommending such a tool, they have almost certainly done the review of privacy and security controls. And if you are a provider considering using an app, or an app developer, the above list is for you. You should have designated ‘privacy and security officials’ who ensure the above risk areas are addressed.


What Are the Risks?


Most people care about the privacy of their health information just because it’s private and not other people’s business. But there are actual risks to consider, which users of these apps should understand:

  • Data is shared with third parties for sales and marketing, increasing the targeting of ads you receive.
  • Even information that is supposedly ‘de-identified’ can include enough information to make users identifiable, and it may be very sensitive information, for instance relating to mental health or substance abuse.
  • Medical identity theft, which can result in someone using your identity to receive free healthcare services or to file fraudulent claims. Healthcare data is valuable for those reasons, which is why it is often targeted by hackers.
  • Additional outside companies, such as Facebook or Google, may acquire the information and build user profiles. Once the information is out there in that environment, there is little control over it and it’s difficult to know who could access it or how it could be used.
  • Your PHI could be acquired by insurance companies or other healthcare companies that could use it against you in underwriting or pricing determinations. Who else would you not want knowing your private information? An employer? The possibilities are frightening, especially considering that once the information is out there, it’s out there. You can’t put the genie back in the bottle.

Conclusion


Telemedicine and the use of online applications has exploded in recent years, particularly in relation to the COVID pandemic and the resulting changes in the delivery of healthcare. The regulatory framework has not necessarily caught up to technology yet, so while HIPAA laws apply to some applications, many that are out there being used by consumers are not regulated in terms of protecting sensitive information. Health information can be bought and sold in the marketplace, it has a value for advertisers, thieves, and others.


For consumers, just be aware of the potential risks before you start using an app; check the app’s privacy and security policies and consider carefully what information you are comfortable exposing. If the app comes from your provider or insurance company, ask about the security controls and how they are protecting your data.


For providers, consider your own liability in terms of recommending an app and make sure your organization has done its due diligence to ensure proper security measures are in place. You should have your own privacy and security experts evaluate the tool before offering it to patients.


For app developers, be aware that technical security isn’t your only concern; you will want to have assistance from someone with healthcare privacy and security regulatory expertise. This will be something that potential clients and investors will be asking about.


Susan Walberg is a healthcare consultant who works with providers and healthcare start-ups. She can be reached at https://www.susanwalberg.com/

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