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INSTRUCTIONS Submission Your final submission should include: A key passage of at least five sentences from one of your sources, inside quotation marks with an APA style in-text citation. Your paraphrase of the quotation in two to three sentences with a properly formatted APA style in-text citation at the end of the paragraph. A short (one sentence or less) quotation that includes an introduction, APA style in-text citation, and a one sentence explanation afterward. A list of references for your four sources in proper APA format with a URL at the end. (Note: URLs are not required for all sources in APA format, however, for this assignment, you must include one so your instructor can review your sources) using this template.[Student Name] Instructions: Replace the example wording in brackets below with your wording for each prompt. IND101 Milestone 4 Template Paraphrasing activity: Quote from source (at least 5 sentences): [Example: "The transition to electrification of vehicles will probably be gradual, for three primary reasons: consumer caution when it comes to large purchases, the high initial cost of manufacturing electric vehicles, and pushback from vested interests. There will be special circumstances, such as in Norway, where rapid transitions are possible. But in places such as the United States, where the automotive market is large and diverse, and many players are involved including the thousands of cities and states that impose rules and offer incentives the pace will be slower. Cost reductions will take time. Gasoline cars have benefited from a century of intensive development, while electric cars have been the focus of major manufacturers on a commercial scale only since about 2010" (Sperling, 2018, p. 15).] Paraphrase of the quote above (2-3 sentences): [Example: The shift from traditional vehicles to EVs (electric vehicles) was rapid in Norway, but the same pace is not expected in the United States, which has a much higher population, state and local laws to contend with, and a large and diverse auto industry. In addition, consumers are often hesitant about large purchases. This hesitance, along with the high costs for EV production, and pressure from oppositional groups, will slow the transition. While the cost of EV production will eventually decrease, this will take time; in comparison to gas-powered cars' long history, EVs have only been widely available since 2010 (Sperling, 2018).] Integrating a short quote activity: [Example: As Sperling (2018) argues, “petroleum-powered motor vehicles are a major contributor to climate change, emitting about 20 percent of all greenhouse gases worldwide” (p. 12). Reducing reliance on gasoline-powered vehicles by investing in the shift to electric vehicles can have a significant impact on climate change.] Current list of 4 references in APA format (with a URL included): [Examples: Dua, R., & White, K. (2020). Understanding latent demand for hybrid and plug-in electric vehicles using large-scale longitudinal survey data of US new vehicle buyers. Energy Efficiency, 13(6), 1063-1074. http://vlib.excelsior.edu/login?url=https://search.ebscohost.com/login.aspx?direc t=true&db=asn&AN=145259635&site=eds-live&scope=site Graham, J. D., Belton, K. B., & Suri, X. (2021). How China beat the US in electric vehicle manufacturing and why it's time for the United States to get serious about industrial policies. Issues in Science & Technology, 37(2), 72–79. http://vlib.excelsior.edu/login?url=https://search.ebscohost.com/login.aspx?direc t=true&db=tfh&AN=149318105&site=eds-live&scope=site Noori, M., & Tatari, O. (2016). Development of an agent-based model for regional market penetration projections of electric vehicles in the United States. Energy, 96, 215-230. http://vlib.excelsior.edu/login?url=https://search.ebscohost.com/login.aspx?direc t=true&db=edselp&AN=S0360544215016606&site=eds-live&scope=site Sperling, D. (2018). Electric vehicles: Approaching the tipping point. Bulletin of the Atomic Scientists, 74(1), 11–18. http://vlib.excelsior.edu/login?url=https://search.ebscohost.com/login.aspx?direc t=true&db=ulh&AN=127161734&site=eds-live&scope=site]/n ARTICLE HIPAA and Telehealth Protecting Health Information in a Digital World Author_ Melissa Kovac (melissa.kovac@terumobct.com), Terumo Blood and Cell Technologies In 1996, the Healthcare Information Portability and Accountability Act (HIPAA) was enacted to protect the privacy and security of patients' protected health information. Since then, technology has taken health information far beyond paper medical records and grainy faxes. As telehealth, in the forms of electronic health records, virtual visits, apps, and wearable devices, has increased in popularity, HIPAA clearly is no longer sufficient to guarantee the privacy of the health information it was enacted to protect. Updates to HIPAA are necessary, and those updates should be made with future technological advance- ments in mind. Telehealth, broadly defined as healthcare provided via telecommunication and dig- ital technologies, has in recent years been promoted as a way to increase access to healthcare services for rural, under-resourced, and underserved populations (Enlund 2020, 1–2). Telehealth services range from simple administrative patient portals and conve- nient apps to telephone and video visits with otherwise inaccessible specialists (US Department of Health and Human Services [HHS], n.d.). When available, it offers patients greater control and can be a convenient, time-saving, and cost-effective way to obtain medical care. Unfortunately, it also puts protected health information (PHI) at risk and is vulnerable to privacy and security breaches (Gajarawala 2021, 218-19). In the United States, the vanguard of electronic health- care information privacy regulation is the Healthcare Information Portability and Accountability Act of 1996 (HIPAA). HIPAA guarantees that individuals' PHI is kept private and secure as it travels to and from patients, health care providers, insurance companies, and approved busi- ness associates (HHS 2013). Patients have a right to access their PHI, and it may not be shared with others without the patient's explicit permission, with few exceptions. Protected health information includes medical records, reports of conversations about patient care, and insurance and billing information (HHS 2020a). There have, not surprisingly, been violations of the patient confidentiality and information security JOURNAL OF INTELLECTUAL FREEDOM AND PRIVACY _ SUMMER 2021 6 HIPAA AND TELEHEALTH_COMMENTARY guaranteed by HIPAA—messages left with the wrong per- son, PHI shared by healthcare providers outside of work, lax risk analysis and management, outright theft and penalties have included job loss, fines, and criminal pros- ecution (Tariq 2020). A 2019 review of breaches affect- ing more than five hundred patients in the United States found that 53 percent of breaches were "attributable to internal mistakes or neglect" while 47 percent of breaches were from external sources and primarily the result of hacking or other IT incidents (Jiang 2019, 266). HIPAA, however, was only the first step on the road to protecting electronic PHI, and that first step was taken twenty-five years ago. Banerjee explains: When HIPAA was enacted, healthcare service provider's medical record documents were the primary, if not the only, sources of health information. This is the reason why non- healthcare entities were not included in the purview of the law. However, increased penetration of technologies capable of generating PHI, the lack of laws to protect user data from [non-covered entities], and the increasing diversity of non- healthcare providers with access to such information, have together increased the risks of consumer data breaches and misuse. (Banerjee 2018, 7) Subsequent federal legislation has "failed to address the new privacy and security challenges presented by the dig- itization of health information" (Theodos 2021, para. 7). Notably, these new technologies function outside the purview of HHS and are not required to protect health information (Theodos 2021). According to Rosenbloom (2019), “advances in technology, diffusion of health IT across diverse sectors of health care, [and] patients' expec- tations," such as immediate availability of information and apps on mobile devices, contribute to compromises in privacy (1118, 1115). Many apps neither transmit data over a secure connection nor encrypt it, and they may legally sell to data brokers what would in other contexts be PHI (Galvin 2020, 36). Wearable devices are also of concern. Wearables mea- sure and report physiological and behavioral informa- tion as varied as heart rate, amount of sweat, and seizure activity, but that data does not belong to the user; rather, it belongs to the companies that manufacture the devices and store the data (Theodos 2021). Unfortunately, most people who use the devices are unaware of that. In one study, while 70 percent of respondents said confidentiality was important, only 28 percent reported that they were familiar with how their devices protected their privacy, and only 24 percent were familiar with how their devices transmitted and stored their data (Cilliers 2020, 4–5). The incremental growth in the use of telehealth, par- ticularly virtual visits, was upended in 2020. To limit the transmission of COVID-19, healthcare providers instituted virtual visits, either by phone or by video. Concerns about privacy were quickly acknowledged by HHS. In February 2020, the department announced that despite the pan- demic, HIPAA privacy and security rules would for the most part remain in effect (Bassan 2020, 2). However, only a month later and with the goal of encouraging the use of telehealth, HHS changed course and issued a Noti- fication of Enforcement Discretion that relaxed HIPAA rules (Bassan 2020, 5; Mortell 2020, 390). The relaxed standards apply to technologies that “include video-con- ferencing, the internet, asynchronous imaging, streaming media, landline, and wireless communications" (Bassan 2020, 5). HHS specifically stated that a healthcare pro- vider may use technologies that "may not fully comply with the requirements of the HIPAA rules," if the pro- vider makes a good faith effort to keep patient data pri- vate. Included among these technologies are FaceTime, Facebook Messenger video chat, Google Hangouts video, Zoom, and Skype (HHS 2021). As of June 2021, the Notification of Enforcement Discretion has no expiration date (HHS 2020b). The use of telehealth has increased exponentially during the COVID-19 pandemic; in some hospi- tal systems, the use increased by thousands of percent (Ramaswamy 2020, 1). As Bassan writes, "Given the implementation of the technology during the pandemic, it is unlikely that the use of telehealth would disappear after the pandemic” (Bassan 2020, 11). Perhaps most impor- tantly for the future of telemedicine, outpatients were significantly more satisfied with virtual visits during the pandemic than they were with in-person visits prior to it (Ramaswamy 2020, 5); even before COVID-19, one study showed that while fewer than 4 percent of people had had a video visit with a healthcare provider, almost 50 percent were willing to do so (Fischer 2020, 5). The use of wearable devices is also increasing: in 2020, 29.8 percent of Americans reported using an electronic wearable device to track health or activity, compared with 26.7 percent in 2019 (US National Cancer Institute 2020). According to a recent Gallup poll, 32 percent of Ameri- cans have at some point tracked health data using an app (McCarthy 2019). HIPAA, even with its privacy and secu- rity rules in place, is not a sufficient guarantor of health-care information privacy and should be updated to better align “individual access to health data with the current JOURNAL OF INTELLECTUAL FREEDOM AND PRIVACY _ SUMMER 2021 7 HIPAA AND TELEHEALTH_COMMENTARY realities of electronic medical records and the expectations of modern, engaged patients" (Rosenbloom 2019, 1118). It is unreasonable to expect that patients will under- stand or even read-complicated privacy statements. Bassan suggests that HHS institute regulations like those in the California Consumer Privacy Act: companies must disclose what information they're collecting, what they're doing with it, and whether they're selling it to third par- ties, and patients should have access to all collected infor- mation and the opportunity to opt out of sharing (Bas- san 2020, 9). All healthcare providers should invest in cybersecurity and build videoconferencing products that include "security features such as encryption and may offer additional configuration settings that can be stan- dardized for the entire organization, such as requiring a waiting room with every teleconference" (Jalali 2021, 672). HHS should also extend HIPAA's existing rules to References Banerjee, Syagnik, Thomas Hemphill, and Phil Longstreet. 2018. “Wearable Devices and Healthcare: Data Sharing and Pri- vacy." The Information Society 34, no. 1: 49–57. Bassan, Sharon. 2020. "Data Privacy Considerations for Telehealth Consumers Amid COVID-19." Journal of Law and the Biosci- ences 7, no. 1: 1-12. Cilliers, Liezel. 2020. "Wearable Devices in Healthcare: Privacy and Information Security Issues." Health information Manage- ment Journal 49, no. 2-3: 150–56. Enlund, Sydne. 2020. "Tapping Into Telehealth to Expand Care." LegisBrief 28, no. 5: 1–2. Fischer, Shira H., Kristin N. Ray, Ateev Mehrotra, Erika Lit- vin Bloom, and Lori Uscher-Pines. 2020. "Prevalence and Characteristics of Telehealth Utilization in the United States." JAMA Network Open 3, no. 10: e2022302-e2022302. Gajarawala, Shilpa N., and Jessica N. Pelkowski. 2021. "Telehealth Benefits and Barriers." The Journal for Nurse Practitioners 17, no. 2: 218-21. Galvin, Hannah K., and Paul R. DeMuro. 2020. "Developments in Privacy and Data Ownership in Mobile Health Technologies, 2016-2019." Yearbook of Medical Informatics 29, no. 1: 32-43. Jalali, Mohammad S., Adam Landman, and William J. Gordon. 2021. “Telemedicine, Privacy, and Information Security in the Age of COVID-19." Journal of the American Medical Informatics Association 28, no. 3: 671–72. Jiang, John Xuefeng, and Ge Bai. 2019. “Evaluation of Causes of Protected Health Information Breaches." JAMA Internal Medi- cine 179, no. 2: 265–67. noncovered entities, wearable devices, and apps (Rosen- bloom 2019, 1116). Banerjee recommends that HHS cre- ate "a ‘watchdog' unit that is charged with identifying and monitoring types of new behavioral data that can be cap- tured by wearable technology," determining whether that data is identifiable, and, if necessary, adding it to HIPAA's catalog of technologies that can be used to identify a spe- cific patient (Banerjee 2018, 7). Telehealth products and services will undoubtably pro- liferate and mature over the next twenty-five years, much as they have in the twenty-five years since HIPAA was first enacted. Any new laws, regulations, and government and industry cooperative agreements must be developed with that growth in mind. Health information is some of the most intimate information there is, and patients' right to privacy and the security of their data must be preserved, no matter what the technology. McCarthy, Justin. 2019. "One in Five U.S. Adults Use Health Apps, Wearable Trackers." Gallup, December 11. https://news.gallup.com/poll/269096/one-five-adults-health-apps-wear able-trackers.aspx. Mortell, Thomas J., and Austin T. Strobel. 2020. "Changes in the Office for Civil Rights Enforcement Policy on Telehealth Remote Communications in Response to COVID-19." Journal of Pediatric Rehabilitation Medicine 13, no. 3: 389-92. Ramaswamy, Ashwin, Miko Yu, Siri Drangsholt, Eric Ng, Patrick J. Culligan, Peter N. Schlegel, and Jim C. Hu. 2020. “Patient Satisfaction With Telemedicine During the COVID-19 Pan- demic: Retrospective Cohort Study." Journal of Medical Internet Research 22, no. 9: e20786. Rosenbloom, S. Trent, Jeffery R. L. Smith, Rita Bowen, Janelle Burns, Lauren Riplinger, and Thomas H. Payne. 2019. “Updating HIPAA for the Electronic Medical Record Era." Journal of the American Medical Informatics Association 26, no. 10: 1115–19. Tariq Rayhan A., and Pamela B. Hackert. 2018 Patient Confidential- ity. Treasure Island, FL: StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK519540/. Theodos, Kim, and Scott Sittig. 2021. "Health Information Privacy Laws in the Digital Age: HIPAA Doesn't Apply.” Perspectives in Health Information Management 18 (Winter). US Department of Health and Human Services (HHS). n.d. “Tele- health." Accessed May 11, 2021. https://www.hhs.gov/hipaa /for-professionals/faq/telehealth/index.html. JOURNAL OF INTELLECTUAL FREEDOM AND PRIVACY__SUMMER 2021 8 HIPAA AND TELEHEALTH _ COMMENTARY 2013. "Summary of the HIPAA Privacy Rule.” https:// www.hhs.gov/hipaa/for-professionals/privacy/laws-regula tions/index.html. 2020a. "Your Rights Under HIPAA." https://www.hhs .gov/hipaa/for-individuals/guidance-materials-for-consumers /index.html. 2020b. "When Does the Notification of Enforcement Dis- cretion Regarding COVID-19 and Remote Telehealth Com- munications Expire?" https://www.hhs.gov/hipaa/for-pro fessionals/faq/3020/when-does-the-notification-of-enforce ment-discretion-regarding-covid-19-and-remote-telehealth -communications-expire/index.html. -. 2021. "Notification of Enforcement Discretion for Tele- health Remote Communications During the COVID-19 Nationwide Public Health Emergency." https://www.hhs.gov/hipaa/for-professionals/special-topics/emergency-pre paredness/notification-enforcement-discretion-telehealth /index.html. US National Cancer Institute. 2020. “Health Information National Trends Survey: In the Past 12 Months, Have You Used an Electronic Wearable Device to Monitor or Track Your Health or Activity?" https://hints.cancer.gov/view-questions-topics /question-details.aspx?qid=1746. JOURNAL OF INTELLECTUAL FREEDOM AND PRIVACY SUMMER 2021 9 Copyright of Journal of Intellectual Freedom & Privacy is the property of American Library Association and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.