Protecting Client’s Confidentiality in Mental Health Practice

Mental health practice or dental practice, HIPAA compliance is de rigueur if an organization create, store, maintain, or transmit protected health information (PHI). As sensitive as protected health information is, mental health patients’ data are even more delicate.

The primary purpose of HIPAA is to protect the privacy of people receiving health treatment. HIPAA not only protects the people who receive therapy but also those who provide the treatment like psychologists, psychiatrists, and other mental health professionals. In addition to protecting the confidentiality of people receiving mental healthcare services, HIPAA protections also lead to improved treatment through collaboration between professionals and family members.

The 3 Important Security Safeguards

On that note, here are three HIPAA Security Rulesafeguards that you should consider implementing in your mental health practice:

Administrative Safeguards

Administrative safeguards are all about knowing the privacy and security risks and managing them well. Here are nine standards of administrative safeguards that will help your practice comply with the law:

Risk analysis and management

This aspect is critical to HIPAA compliance because this standard helps to identify vulnerabilities and ways to mitigate them. The following steps are mandatory:

  • Performing risk analysis to identify potential risks and assess their severity;
  • Preparing risk management plans to determine the steps you will take to mitigate the identified risks;
  • Establishing a sanction policy to make everyone aware of the consequences of non-compliance;
  • Reviewing information systems regularly to check if any patient information has been breached, leaked, or inadvertently destroyed.

Security & Privacy Officer

Designating security and privacy officer is another critical step for HIPAA compliance. These individuals are responsible for putting the law into privacy. Primarily, there are two roles – Security Officer and Privacy Officer.

The Security Officer is responsible for overseeing all the security practices with regards to electronic protected health information. The Privacy officer is generally responsible for overseeing the internal policies regarding the use and disclosure of protected health information.

It is also not unusual for one individual to assume both roles.

Authorization and Access Management

According to this standard, only authorized personnel should have access to patient’s protected health information. To ensure that, you must:

  • Determine who gets access to what information and the level of access.
  • Implement proper procedures to prevent unauthorized access to ePHI. You must also block off access to ePHI of employees who left the practice.
  • Log policies that create and modify access to ePHI.

Workforce training

Employees should learn about security practices and procedures they have to follow. Regular training and retraining is the most effective way to achieve this feat. Furthermore, employees should be taught how to recognize phishing or breach attempts, encouraged to install and update antivirus software, and the best practices to handle their clients’ data.

Employer Identification Number (EIN) and National Provider Identifier (NPI)

NPI is a 10 position, intelligence-free numeric identifier (10-digit number). Providers must apply for the NPI to remain accountable before patients and the government. NPI is a standardized identifier used in all administrative and financial transactions, including billing of patients, insurance-related payments, and daily operations.

The Internal Revenue Service Issues Employee Identification Number is for employment purposes. This number helps to identify an individual in employment-related issues. The number should exist in the payroll and other direct or indirect employer-employee transactions.

Internal Policies and Security Incident Procedures

The corporate policy should include rules on the use, sharing, and security of information. A step-by-step plan of action should be outlined in the documents focusing on:

  • Processing and disclosure of information
  • Complying with patient requests and legal requirements (including breach notification)
  • The use of information for your own purposes
  • Guidelines on how to deal with security incidents
  • Procedures for documentation

Policies and procedures are not the end of the paperwork. In order to comply with HIPAA, all actions towards compliance with the act must be documented. Furthermore, the documentation must be retained for six years from the date of its creation.

Contingency plan

A contingency plan defines a set of approaches in case of emergency with ePHI like power outages, fire, etc. The plan should include:

Data backup

How to recover lost data

Reminders to regularly test and review the contingency plan

A list of all apps used in the practices and which to recover first


The last standard under the HIPAA administrative safeguard requires organizations to evaluate how the HIPAA standards are being implemented, and when necessary, make adjustments to account for changes due to external or internal factors.

Physical Safeguards

Physical safeguards are all about implementing measures to protect physical access to ePHI. It includes devices that carry this information and facilities where these devices are located. There are four standards under this safeguard. Let’s go over each of them.

Facility Access Controls

This standard is about procedures to provide access to areas to authorized individuals only and restricting access for unauthorized individuals. This involves contingency operations, a facility security plan, access control, and validation procedures, and keeping records of all maintenance activities related to the facilities, equipment, and security repairs.

Workstation Use and Workstation Security

This standard requires organizations to have clear rules and procedures for the use of workstations. Workstations are any device that employees can use to access ePHI, such as laptops, mobile phones, tablets, etc.

Device and Media Controls

This standard requires implementing security mechanisms on all data storage devices that mental health professionals and their staff use to store ePHI, including memory cards, and hard drives that can be used on workstations.

Technical Safeguards

Technical safeguards are requirements and policies for technologies that mental health service providers use to store and transmit ePHI. The rule does not mandate the use of any specific technology or application but rather provides a few guidelines.

Let’s take a look at each of the standards for this safeguard.

Access Controls

This standard requires implementing technical policies and procedures for electronic information systems that maintain ePHI so that only authorized individuals can access the information or software programs with proper access controls.

Here are four implementation specifications mental health practices can adopt:

  • Unique User Identification like passwords and unique login codes that can be used to track user’s activity
  • Determine who can access ePHI in case of emergencies and how the individuals should access the information.
  • Implement automatic log-offs when the workstation is idle
  • Use encryption in part or all of the information

Audit Controls

Mental health service providers will need to log everything in the information system and review those logs regularly. This can be done by implementing software, hardware, or other procedural mechanisms. Here are some things to consider:

  • Information and system activities that need to be audited
  • Which audit mechanisms are reasonable for your practice?
  • Does your EMR have audit functionality? If it does, is it enough for compliance?


Inaccurate health information can lead to all sorts of problems. The situation is particularly more sensitive for mental health patients. For this reason, this standard requires mental health service providers to protect the integrity of patient information, preventing it from being improperly changed or deleted. To do this, you can implement a procedure to authenticate electronic health information to automatically check whether the data has been altered or not.

Person or Entity Authentication

It is very important to verify an individual’s identity before access the data to make sure that the person is who he says he is. Here are some ways you can authenticate users:

  • Implement a biometric identification system like iris recognition or fingerprint
  • Use passwords or pin codes
  • Implement a two-step authentication process

Transmission Security

And finally, it’s important to ensure that your patients’ information is safe when it is being transmitted online or via some private networks. Here’s what you can do:

  • Implement security mechanism in personal devices and for emails
  • When deemed appropriate encrypt ePHI without corrupting the integrity of the data


As a mental health service provider, it is important to make sure you understand HIPAA requirements and how they apply to your practice. Complying with HIPAA increases the likelihood of successful mental health treatment. People who reluctant to share personal information may be more likely to reach out for help, knowing that their information is fully protected. Similarly, if a therapist had a reasonable concern about a patients’ risk can, in compliance with HIPAA, share information to protect the safety of the patient or someone else. Complying with HIPAA goes both ways, protecting both the patients and the mental health service provider.

Author Bio: Shaon Shahnewaz is a digital marketer, tech enthusiast & blogger who enjoys reading & spending time with his kid.


Tech Biz Ideas is a platform for providing business ideas full of techy thoughts which helps the audience to get benefit from this.

Related Articles

Leave a Reply

Your email address will not be published.

Back to top button