The Myth of Having All the Answers

And if I didn’t have all the answers, well, by no means let the kids know, right?!!  Because then they’d take advantage.  They would run amok!  Gone would be any control I’d have over therapy sessions.

It’s been 24 years, ya’ll.  I don’t have all the answers.  Sorry to disappoint.  LOL.  Seems I’ve got fewer answers each year!  And you know what else?  Not only am I not a failure, not only do the kids not run amok. It seems to increase our rapport when I admit I don’t know something or show them a flaw.

Lessons in Vulnerability: My Stutter and More

For example, I have more stutterers this year than I’ve ever had before.  I also have recently suffered Post Concussive Disorder, which seems to have increased my “normal” stuttering.  So I have gotten into the habit of pointing out my repeated sounds and words to my students. 

I just shrug and say, “Look, there I stuttered again.” As if it was a hiccup.  Because, really, that pretty much describes what it feels like for me.  Take a moment and imagine how that would affect a middle school stutterer. Perhaps you could show them this TedxTalk video, about “The Power of a Stutter.”

Or maybe I have a question that they don’t answer correctly.  Sometimes I realize I didn’t ask it well – and I tell them that.  Sure, I’m an adult, and I may know more than they do, but I’m not infallible. They need to see me admit that with grace and humor. Have you ever tried to work with someone who can’t admit they were wrong?  Or tried to have a relationship with one?  I’m showing these kids they can admit they made an error with no judgement.

Beyond Perfection: Growth, Resilience, and Acceptance

This goes far beyond the concept of ableism.  This is the idea of teaching children that it is ok not to be perfect.  Some may call it Growth Mindset, some may call it resilience. There are many names for it.   It’s been recycled through the years.  Why?  Because we have tried to reach perfection from the dawn of history.

For years, I chased the elusive notion of perfection as an SLP, only to realize it hindered my connection with my students. I was so preoccupied with trying to be flawless that I forgot to truly engage during out sessions.  If I wasn’t engaged, then my students sure weren’t!  And what life lessons were they learning?  That they weren’t good enough the way they were?  That mistakes were bad?

Teaching Embracing Imperfection By Modeling

Each time I make a mistake, and show my students how to accept it with grace, I am teaching them that they don’t have to be perfect.  Giving them resilience so that their inevitable mistakes don’t push them down. They can work to be better. Yet, they are wonderful the way they are.  You know why AI generated people always look weird – it’s because they are too perfect!  We need our little idiosyncrasies!

So, forget about achieving 100 speech goals. What truly matters is nurturing a culture of acceptance and growth—one mistake at a time. After all, isn’t that the greatest lesson of all?

Love yourselves, my e-speechies!  ‘Till next time,

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I put this on my board one school day. See, for the last 5 or so years, I’d had a poster-size white erase board in the hallway of my school. It was beside the entrance to the cafeteria. Therefore, every student would have a chance to see it during the day. I then sit in my room and listen to the conversations in the hallway. The children, I think, would have voted this joke as the best one that year.

But my board had a purpose beyond the amusement of everyone in the school. Not only did it lighten the mood and start the day with fun, every child in that school knew who I was. I wasn’t just an unknown adult that pulled kids out of classes. I raised the bar for vocabulary for the entire school. It gave everyone a common thing to talk about, and (let’s be honest) identified students that likely would need my services at one time or another.

The Therapeutic Value of Humor

Most of us feel better after a good laugh, and it’s not all in your head. Laughter increases those feel good chemicals in your brain. It boosts the immune system and relieves stress.  It gives us a social connection and helps shift perspectives into a lighter side of life. It even improves circulation and gives your tummy a bit of a workout. I have no doubt it created a happier, more connected school environment than there otherwise would have been.

Academic Benefits of Humor

Most of us have thought about how jokes can address multiple speech and language skills. To understand humor, students have to understand nuances, multiple meanings, and wordplay. Often jokes rely on figurative language. They involve cognitive processes like inference, prediction, and abstract thinking. 

Jokes help students practice social skills such as turn-taking, perspective taking, and understanding social cues. They build rapport. When telling a joke, students are practicing fluency skills like pacing and intonation, as well as articulation skills. Students are encouraged to commit the joke to memory so they can retell it. This helps them work on memory skills as well.

Building Rapport and Engagement:

Humor builds a bridge between students and teachers. It makes school a more light-hearted place.  Having a joke to share gives shy or anxious children a low-pressure way to engage in conversation.  The kids would tell the jokes to each other, and talk about whether it was funny or not. They discussed what made it a joke. I often heard teachers using the jokes as a teaching opportunity in the hallways.

As I talked with others about why I had the joke board, it raised awareness with teachers. They realized that what I did with students inside my little room wasn’t just working on /r/ and /s/. When I called it my “school-wide intervention,” it highlighted how essential speech and language skills are for daily communication.  Students in the school knew who I was, and saw me as a positive person in the school.  I had teachers and students alike bringing me jokes.

Addressing Challenges and Limitations:

So, what is the problem with using humor? I did have to be careful that the jokes were school appropriate, of course. No jokes about “two guys walk into a bar.” They had to be age-appropriate as well, so I skipped over a lot of jokes. Some of these the students at my school might not have the context or vocabulary for. And some kids just didn’t get the jokes (and they were usually on my list for MTSS interventions).

Finding enough jokes for the entire year was a bit difficult the first year. I then had to keep track of them somehow. Now I have It’s So Punny, a document that is over 50 pages long, full of jokes appropriate for school, which you can find in my TPT store.

The board itself was an issue at some points through every school year.  There is always that one student who finds it entertaining to erase it with their fingers. I would switch from dry erase to wet erase to whiteboard crayons throughout the year. Having a transparent cover might have helped that problem. I had to get permission to hang the whiteboard on the wall (I used removable adhesive strips).

Two Thumbs Up

In conclusion, though, I would highly recommend a joke board in your school or classroom. There are so many reasons to incorporate humor in the school day. The conversations I heard outside of my room were often the best part of the day. Hearing the students comment as they walked by was truly enjoyable. 

If you’d like to hear more about what skills a simple joke can address, see my article Why Jokes Are the Best Zero-Prep Language Tool You’re Not Using.

Keep that funny bone tickled,

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I’ve dealt with chronic teeth grinding (bruxism) and jaw pain (temporomandibular joint disorder, or TMJD) for most of my life. (Read here about how it increased my empathy!) It wasn’t until I was 48 that I learned a surprising possible contributor: a mild, previously undiagnosed, posterior tongue tie.

What is posterior tongue tie?

A posterior tongue tie is further back under the tongue than we traditionally think of a tongue tie.  It is not as easily seen and was previously thought to not have much of an impact on an individual’s health or well-being. I know I’d never heard of it, even as an SLP.

Apparently, I had been compensating for the difficulty in raising my tongue. I was using other parts of my mouth in ways they weren’t meant to be used. For example, while I could move my tongue tip to the spot just behind my teeth, even with my mouth open. However, when I did so, my tongue pulled all the fascia in the floor of my mouth, like the salivary glands, with it. This made the movement much more effortful. 

I could definitely feel the pull when I tried to open wide and touch my tongue tip to the top. To stick my tongue outside of my mouth, especially to the side, I had to compensate. I was using my jaw and lips to increase the range of motion. To swallow, my tongue thrust forward, compensating for the decreased mobility of the back of my tongue.

I share my experience to raise awareness about the complexities of tongue tie. My hope is to encourage others to explore potential connections between speech, swallowing, and other oral health issues with this often-overlooked condition. This information can empower individuals to seek appropriate evaluation and treatment.

What exactly is Tongue Tie?

Traditionally, we think of tongue tie (ankyloglossia) as a simple condition. It involves a short, tight band of vertical tissue running from the bottom of the tongue to the floor of the mouth (the lingual frenulum), which restricts tongue movement. You can see an example of the traditional concept in the picture on the left.  

But the reality is much more nuanced. Current research is beginning to recognize that tongue tie can present in various forms. This includes subtle limitations and attachments further back in the tongue (posterior tongue tie), which may not be immediately apparent.

For years, the focus was on severe limitations, primarily impacting breastfeeding. When I was in graduate school (a quarter of a century ago!), tongue tie was briefly mentioned. At that time, it was considered to impact an individual only if the tip of the tongue could not reach the alveolar ridge. Basically, if the child could breastfeed and say /t/ or /th/, it was considered sufficient.  Which explains why I was first identified as having a tongue tie at 48!

The recognition and understanding of tongue tie are continuously expanding. As we delve deeper, its potential impact on overall health is also becoming clearer. This is an evolving field, with ongoing research to refine assessment and classification methods. Currently, there is no single, universally accepted evaluation protocol. This can sometimes lead to varying interpretations and approaches among healthcare professionals.

However, emerging evidence suggests that even subtle restrictions can have significant, often overlooked, consequences.

New tongue tie assessment protocol 

• Length between tongue tip and the attachment of the frenum to the tongue (Kotlow Free Tongue Measurement)
• Difference between maximum opening of mouth and maximum opening with tongue tip to just behind top teeth
• Difference between maximum opening of mouth and maximum opening with tongue suctioned to roof of mouth
• Compensations – floor of mouth, jaw, lips, neck
• Tension – present or absent in mouth, jaw, neck, etc.

It is the presence of the compensations and tension more than the measurements that are more indicative of a problem with the tongue tie, especially in adults.  And yet, those are the most difficult to consistently “measure,” especially between professionals.

How does posterior tongue tie affect feeding and swallowing?

A posterior tongue tie affects the mid and back of the tongue. It can interfere with the proper movement of the tongue and cause issues with proper feeding and swallowing.  Some experts even argue that a posterior tongue tie is more detrimental than an anterior!

Babies:

• creating the seal needed for breastfeeding
• fussy feeding
• choking, coughing, gurgle sound
• inefficient sucking, can lead to increased air intake during feeding causing excessive spitting up
• Feeding fatigue
• Cracked, bleeding, or severely bruised nipples

Children (and adults):

• poor chewing movement and control of food bolus (clump), which can cause food spillage and/or food left in pockets of mouth
• Poor movement of food bolus to the back of the mouth for swallowing
• Increased risk of choking or gagging
• may result in reluctance to try new textures

The Lesser-Known Impacts of Tongue-Tie

Feeding and swallowing difficulties are well-known to be symptoms of tongue tie in babies. However, the impact of tongue tie can extend far beyond infancy and feeding. It can affect various aspects of oral health and well-being.

Research on the long-term consequences of tongue tie in adults is still ongoing. Furthermore, there is no standardized assessment and classification system for tongue tie, especially posterior. This presents a challenge in consistently identifying and understanding its impact across different individuals.

Oral Motor and Articulation Challenges

• Oral Motor Challenges: Restricted tongue movement can affect oral motor skills crucial for chewing, swallowing, and even breathing.  This may present as difficulty licking lips, blowing bubbles, or clicking the tongue.
• Speech (Articulation) Difficulties:  Because posterior tongue tie is often overlooked, it may be a hidden contributor for children who have trouble with back sounds, such as /k,g,r,sh/.

Dental and Jaw Health

• Dental Issues: Some studies suggest that tongue tie and the resulting poor oral posture can contribute to dental problems. These include crowding, misalignment, and even underbite or overbite.  Tongue positioning has also been suggested to affect the way the upper and lower jaws grow and develop.  This can occur because the tongue plays a crucial role in proper tooth and jaw development and alignment.
• Jaw Pain and Dysfunction: My experience highlights a potential link between undiagnosed tongue tie and TMJ problems. Symptoms include as jaw pain, ear pain, clicking, locking, and limited jaw movement.
• Bruxism (tooth grinding):  Studies suggest abnormal tongue posture and function may exacerbate, or even cause, bruxism. This could potentially contribute to TMJD. A current theory is that some, if not all, bruxism arises from the jaw’s attempt to find a comfortable resting position. Proper tongue posture can naturally provide this comfortable resting position for the jaw.  The exact relationship between tongue tie, tongue posture and bruxism is still under investigation.
• Breathing, Snoring, and Sleep Apnea: While tongue tie can sometimes contribute to sleep-disordered breathing, such as upper airway resistance syndrome (UARS), it’s not a direct cause of sleep apnea. However, good resting oral posture, often compromised by tongue tie, is crucial for healthy breathing. This can lead to mouth breathing, impacting oxygen intake among other things.

Breathing and Sleep Issues

• Mouth Breathing: Good resting oral posture is important for healthy breathing. However, posterior tongue tie can compromise oral posture and can contribute to mouth breathing. Studies have shown that mouth breathing may impact oxygen intake, among other things.
• Snoring: Many people with tongue tie may also have a longer velum (uvula), or soft palate. This soft tissue is likely stretched to compensate for restricted posterior tongue movement, which can increase the risk of snoring.
  • Regular snoring, in both children and adults, should be evaluated by a medical professional.
  • Snoring can significantly disrupt sleep quality, leading to daytime fatigue, difficulty concentrating, and an increased risk of accidents.
  • Furthermore, chronic snoring can increase the risk of serious health problems, including high blood pressure, heart disease, stroke, and type 2 diabetes.
• Sleep Apnea: While tongue tie can, in some cases, contribute to sleep-disordered breathing, such as upper airway resistance syndrome (UARS), it’s not a direct cause of sleep apnea.

The Importance of Early Recognition

Early identification and intervention are crucial. For infants, addressing tongue tie can improve breastfeeding, speech development, and overall oral health. However, it’s important to remember that tongue tie can still be addressed in adults.

My personal journey has been eye-opening. While I may not be able to completely reverse the effects of years of undiagnosed tongue tie, I’m exploring treatment options. My goal is to improve my oral function and overall well-being.

Treatment team can include:

• Pediatrician or General Practitioner: Often the first point of contact for tongue-tie concerns, they can conduct initial assessments. They also refer to other specialists as needed.
• Orofacial Myofunctional therapist – Most often a specially certified dental tech or SLP, they specialize in correcting improper function of the oral and facial muscles. This includes tongue posture and movement.
• Otolaryngologist (ENT) – Specializes in disorders of the ear, nose, and throat. They can diagnose and treat tongue-tie, including performing surgical procedures.
• Dentist – an assess tongue-tie’s impact on oral health, including dental development and alignment. They may also perform tongue-tie release procedures (frenectomy).
• Physical therapist (PT) –  Tongue-tie can sometimes contribute to postural imbalances. PT can help address these issues, such as forward head posture, which can impact oral function.
• Lactation Consultant – Assists with breastfeeding challenges related to tongue-tie, providing guidance to both mother and infant.
• Speech-Language Pathologist (SLP) – Evaluates and treats speech, language, and feeding/swallowing difficulties related to tongue-tie. They can also provide oral motor exercises and therapy to improve tongue function.

A Call to Awareness

This experience has reinforced the importance of:

• Broadening our understanding of tongue tie.
• Early identification and intervention.
• Considering tongue tie as a potential factor in a wider range of oral health and developmental issues.
• More research on classifying tongue tie and how it impacts daily life.

If you have concerns about your child’s speech, feeding, or oral motor skills, consult a qualified healthcare professional. This includes a pediatrician, dentist, or speech-language pathologist. The same applies if you experience any of the issues mentioned above.

Resources:

• Tongue Tie
• Tongue Tie Images, including TRMR-TIP and TRMR-LPS Classifications, and links to information
• How tongue mobility changes face and jaw development
• Correct Tongue Posture: Why correct tongue posture affects your whole face (including your teeth!)
• “Do I Have A Tongue-Tie?” – 5 dimensions of tongue-tie assessment, Dr. Zaghi – The Breathe Course (mostly for professionals, very in-depth)
• Pediatric Sleep-Disordered Breathing and Obstructive Sleep Apnea: The Role of the Speech-Language Pathologist
• Tongue Tie, Airway, & TMJD – Priya Mistry, DDS (the TMJ doc) #tonguetie #airway #tmjd
• What is a Tongue Tie? – Priya Mistry, DDS (the TMJ doc) #tonguetie #nursing #tonguetied

I hope this article provides valuable information and encourages further discussion about this under-taught and often-overlooked condition.

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Hey everyone, today I want to talk about hidden battles that many of us, and our students, face.

Lately, I’ve been navigating a bit of a hidden battle: my jaw has decided to stage a protest. Turns out, I’ve been dealing with some pretty significant Temporomandibular Joint (TMJ) issues for the past six months. It’s been… eye-opening, to say the least.

Living on a diet that mostly resembles baby food has been an adventure in itself. But the real, though invisible, struggle has been navigating my work as a speech-language pathologist. This is challenging while my jaw feels like it’s constantly seizing up. Talking, which is kind of my main gig, has become a surprisingly painful endeavor. 

And smiling? Well, let’s just say my attempts probably look more like a polite wince, because that hurts too. Even simple things like brushing my teeth have become a daily debate with my pain levels. A full day of therapy often leaves my jaw joint feeling like it’s full of glass shards. What’s more, the muscles in my jaw and neck are usually screaming by the time I get home.  And as a delightful bonus – it gives me a fantastic headache as well!

The “Janky Jaw” Connection: Our Students’ Overload

And as I’ve been navigating this constant discomfort, especially the pain that flares up with every word and forced smile, I’ve been struck by a profound thought: This has to be what so many of our amazing students and clients experience every single day.

Think about it. For me, this jaw thing is (hopefully!) a temporary invisible challenge. But for so many of the people we work with, their “janky jaw” might be sensory overload. It makes the classroom feel like a constant buzzing nightmare. It might be the anxiety that makes even showing up feel like climbing Mount Everest.

For our students with ADHD, the very act of sitting still for extended periods can feel physically and mentally exhausting. It is a constant battle against their natural inclination to move and explore. Or perhaps there’s an emotional weight that makes it hard to even crack a smile, no matter how much they might want to.  Even something as routine as braces might impact a student’s day.  And it all adds up until something fizzles.

It’s Not Just About Diagnoses: The Universal Hidden Struggle

And honestly, it’s not just our students with specific “diagnosed” challenges that may be overlooked. Think about all our students. When was the last time any of us spent a full seven-hour day crammed into a hard, probably not-ergonomically-designed student desk? Even at professional conferences, where they usually at least give us padded chairs, we’re all groaning and stretching by the end of the day!

Imagine that discomfort multiplied for a kid trying to learn and focus for hours on end. They are trying to absorb material they didn’t ask for, and are going to be judged on later.  Oh, and if attention wanes, they will definitely be called out on it.  Guess what – it doesn’t end with the dismissal bell – they also have homework.

The Hidden Battle Lens of Empathy

Just like my “smiling through the pain” to do my job, our students are often putting in this incredible, unseen effort just to get through the day. They’re navigating a world that wasn’t necessarily built for their unique needs (or even adult comfort!), and they’re doing it with a level of resilience that honestly blows me away.

This personal experience has given me just the tiniest glimpse into what it feels like to have your body actively fight against the demands of the day. It’s made me even more determined to approach everyone we work with – and even just observe the school environment – with extra doses of empathy, patience, and understanding. Because you never really know what kind of “janky jaw” someone else is dealing with. It could be physical, sensory, emotional, neurological, or just the plain discomfort of being a kid in a system that asks a lot of them.

Your Thoughts on Hidden Battles?

What are your thoughts? What other often-overlooked challenges do you think are important for us to keep in mind in our work?

Want more SEL content? Try these articles!

• The Real Language of Emotions: Teaching Feelings
• Empowering Kids Who Stutter: Knowledge, Acceptance, and Practical Resources
• Speech Therapy Wins! Building Progress Power in Kids

Keep Speechifying!

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Hey fellow SLPs and healthcare pros! Today, I want to share some insights from my personal journey towards HIPAA compliance.

In my last two posts, we delved into the crucial topic of HIPAA compliance for telepractice. They covered the “what” and the “why.”

• HIPAA Compliance At Home: Cloud, Schools, Teletherapy & PHI Security
• Navigating Business Associate Agreements as an SLP: Your HIPAA BAA Guide

Today, I want to share the “how” – my personal journey of putting these principles into practice! I’ve been diving deep into my tech setup to make sure it’s not just functional, but also rock-solid HIPAA compliant. For example, as a teletherapist, some of my schools don’t invite me into their workspace. This leaves it up to me to securely manage all my client notes and materials. This kind of gap is precisely what drove me to build a truly robust system.

It might sound daunting, but trust me, it’s all about peace of mind for both you and your clients. I wanted to share a rundown of what I’ve done. More importantly, I want to share why I’ve done it, in case it helps you level up your practice too!

The “Why” Behind My Personal HIPAA Compliance Journey

My biggest drive was simple. I needed to know, without any doubt, that I was protecting my clients’ sensitive information to the highest standard. HIPAA isn’t just a checkbox; it’s about building trust. First, conducted a thorough risk analysis of my setup to identify any potential vulnerabilities.

I’ve now meticulously created and am maintaining a detailed “Security Policies and Procedures” document that guides all my practices. Plus, having everything clearly documented helps me sleep better at night!

Honestly, it wasn’t that long ago, a few weeks, that I wasn’t even aware of all of this. I didn’t know about Business Associate Agreements (BAAs), or their critical role. My previous security stance of “just don’t share client info” felt sufficient. Since then, I’ve realized how nebulous and insufficient that really was for both cloud-based and desktop information. 

How It All Started

So, if I wasn’t born with this wealth of knowledge, and it wasn’t covered in grad school, what happened? Well, I discovered that simply removing what I thought was identifying information was not sufficient for HIPAA de-identification. That realization truly sent me down this “rabbit hole” of learning and implementing everything you’re about to read!

Honestly, as a single user, all this might seem like overkill at times. That is, until I really think about the potential cost and repercussions of a HIPAA violation. That quickly puts things into perspective!

Here’s information and tips I’ve learned on this individual HIPAA compliance trek. (No, I’m not affiliated with, or sponsored by, Google in any way, it was just easier to work with.)

The Secure Foundation: My Google Workspace Enterprise Standard

Before even setting up my specific security rules, choosing the right Google Workspace edition was crucial. There are several tiers, and it’s not just about how many emails you can send! For me, picking Enterprise Standard was absolutely essential because of the level of HIPAA security I was comfortable with.

• Pro-Tip on Choosing a Platform: I actually considered Microsoft 365 Business plans, as they also offer BAAs. However, I was already using and familiar with Google’s interface. More importantly, I found it much easier to get clear information about Google’s BAA and HIPAA-included functionality upfront. Microsoft seems to hide their BAA documentation behind a subscriber wall, making it difficult to fully vet before committing. This ease of information access, combined with my familiarity, ultimately swayed my decision towards Google.  Basically, it looks like any paid workspace can have a BAA:   https://support.google.com/a/answer/2888485?sjid=14092164238884574583-NC

Here’s why I landed on it during my own HIPAA compliance trip, and what foundational elements it provides:

The Non-Negotiable BAA

This was the top priority. Enterprise Standard definitely comes with a Business Associate Agreement (BAA). This gives me that crucial legal agreement with Google to handle Protected Health Information. This is absolutely non-negotiable for anyone handling PHI with Google Workspace. (You can find Google’s BAA here: https://workspace.google.com/terms/2015/1/hipaa_baa/).

• Pro-Tip on Choosing a Tier – I actually started with the cheapest business tier (Business Starter $7/mo), which I can confirm offers a BAA. However, after really digging into the features, I chose to upgrade to Enterprise Standard. It offered much better control over information and more robust policy enforcement options. These ultimately felt essential for protecting client PHI effectively.  Google Tiers & Pricing 
• Don’t Forget Your Domain Name! A domain name is an additional, but necessary, cost for any Google Workspace Business account. While Google offers to sell you one directly, I opted to buy my domain through Cloudflare for just $10.44/year. This was a cost-effective choice since I already used Cloudflare for other services.

Serious Pooled Storage

Enterprise Standard offers a massive 5 TB of pooled storage per user. (Just a heads-up: This pooled storage gets released in stages after payments, so my Drive initially showed less!). This is more than enough space for all my therapy materials and client files.

Google Vault for Ironclad Data Retention

This was a game-changer! Enterprise Standard includes Google Vault, which allows me to set an indefinite retention policy for all my Google data. This ensures I meet and exceed HIPAA’s minimum six-year data retention requirement. It’s like a super-secure, always-on backup for everything.

Advanced Data Loss Prevention (DLP)

This tier gives me access to advanced DLP rules for Gmail and Drive, which are central to my security strategy. These are the powerful rules that can warn me if I try to share sensitive files externally.

Comprehensive Security Controls

Enterprise Standard unlocks a lot of the granular administrative controls I needed. This allowed me to configure things like forcing 2FA, setting strong password policies, and disabling third-party apps.

Basically, for handling PHI and needing robust, auditable security features, Enterprise Standard provided the comprehensive toolkit I needed to feel confident and stay compliant. It’s an investment at $27/mo, but one that’s absolutely worth it for peace of mind and professional responsibility.

The Core Pillars of My Personal HIPAA Compliance Policy:

Here’s a look at the specific configurations I implemented (See Google’s HIPAA Implementation Guide:  https://services.google.com/fh/files/misc/gsuite_cloud_identity_hipaa_implementation_guide.pdf):

1. Bulletproof Access Control (Who Gets In? Only Me!)

• 2-Step Verification (2FA) is Mandatory: No exceptions! I enforced 2FA for all account access. This is your absolute best defense against unauthorized logins.
• Strong Passwords, Always: My system enforces strong password policies, requiring a minimum length of 16 characters and prompting for a refresh every 180 days. No weak links here!

• Third-Party Apps? Deny by Default! My policy is strict: all third-party app access is blocked by default. If I ever need an app, it goes through a security review and is force-installed by me, the admin. This prevents unvetted apps from touching my client data.
• Strictly BAA-Covered Services Only: As part of my setup, I went into my Google Admin Console and literally turned OFF any Google services that aren’t explicitly covered by the BAA (like Google Photos, YouTube, etc.). Why? To make sure no PHI accidentally ends up in a non-compliant service. (You can find a list of Google’s HIPAA Included Functionality and BAA-covered services here: https://workspace.google.com/terms/2015/1/hipaa_functionality/).

2. Smart Data Protection (No Accidental Leaks!)

• Gmail Content Compliance: I set up an automated rule in Gmail that quarantines any outbound email containing PHI-related keywords if it’s addressed to a domain not on my pre-approved “Trusted School Districts” list. It’s a huge safety net!
• Drive DLP (Data Loss Prevention) Rule: For Google Drive, I have a rule that gives me a real-time warning if I ever try to externally share a file containing PHI keywords. It’s an extra “Are you sure?” before a potential mishap.
• Always Use Secure Communication Channels: Beyond these automated rules, I always ensure that any direct client communication involving PHI occurs only through secure, HIPAA-compliant platforms (like my employer’s therapy portal). I now avoid using regular email, text messages, or consumer video calls for sensitive information.

3. Endpoint & Browser Security (My Laptop & Chrome)

• My Laptop is Encrypted & Protected: My main computer has full-disk encryption (BitLocker/FileVault) and a robust antivirus solution. I’m currently using Norton Small Business ($59/1st year with $119/year renewal) for this, primarily for its strong endpoint protection. While I’m actively looking into BAA-covered antivirus and endpoint detection & response (EDR) solutions, it’s been a real challenge to find providers willing to work with a single user. For now, Norton Business helps secure my device itself. I had to specifically disable its cloud backup features to prevent any PHI from being stored on non-BAA servers.  I’ve also upgraded my mouse to use Logi Bolt technology for a more secure wireless connection.
• Physical Security for My Home Office: Beyond digital protection, I also ensure any limited physical PHI (like printed notes) is kept in a locked file box when unattended, and my work area is secured to prevent unauthorized access. I’ve even rearranged my office so that my computer screen is not visible from the doorway, even though I always make sure to close the door when I’m with clients.
• Dedicated Chrome Profiles: This is a big one! I have separate Chrome browser profiles. One just for my professional Workspace (where I handle PHI), and others for personal stuff or employer-provided Outlook/therapy portals. This completely isolates data and workflows.
  • Updated to add – I’ve now gone a step farther and added another Windows user to my computer. This way all therapy stuff stays in the therapy user.
• Chrome Policies Enforced: My professional Google Workspace Chrome profile has Enhanced Safe Browse, “Always use secure connections” (HTTPS), and strict extension blocking enforced by policy. This means my browser is secured from the top down.
• Windows Settings Tuned: Beyond the basics, I dove into Windows settings to ensure my device is locked down. Strong PIN/Windows Hello, Dynamic Lock (locks when I walk away), automatic screen lock, firewall active, and app permissions reviewed app-by-app.

4. Tackling Existing Data & Migration

This was a big project, especially for older files, and probably the hardest part in my HIPAA compliance trek!

• Consolidating All My Data (PHI & Non-PHI): I meticulously went through all my files, both on my computer’s desktop and in my Drive. I identified any possible PHI or general therapy materials. That data was then securely moved to my professional Drive, ensuring it was consolidated into my compliant environment.
• No More OneDrive Sync: I’ve also disabled Microsoft OneDrive’s automatic PC folder backup. I’m in the process of moving those files from the OneDrive synced location back to my local user’s root folders. This ensures no client data is inadvertently stored or synced to a non-BAA cloud service.

Google Drive Settings and Workarounds

• Google Drive for Desktop (Strategically!): I used Google Drive for Desktop for efficiency with many files, but with a key rule. I keep it on “stream files” mode. This means files are only downloaded when I open them, minimizing PHI stored locally on my hard drive. I also keep its “offline access” feature for PHI files disabled in the Admin Console to prevent local copies, unless absolutely necessary and then with extreme care.
• Native Google Docs/Sheets/Slides: This was tricky! I learned you can’t just drag-and-drop native Google files between different accounts using Drive for Desktop. For these, especially if they contained PHI, I had to download them in Microsoft Office format from my personal Drive. Then I re-uploaded them to my professional Google Workspace Drive. This ensured ownership transferred correctly and, crucially, kept the PHI handling within my secured processes.
• Unzipping Files: Since Google Drive doesn’t have a built-in unzipper, I securely downloaded ZIP files to my local, encrypted computer. I unzipped them using Windows’ built-in function, and then re-uploaded the extracted files to my professional Google Workspace Drive.
• Disconnecting My Personal Drive: Once the transfer was done, I disconnected my personal Google Drive account from Google Drive for Desktop. Why? Fewer accounts connected equals less potential risk.
• Cleaning Up My Personal Drive (Carefully!): After moving all PHI, I used a cloud cleaner like Norton Cloud Cleaner on my personal Google Drive to remove duplicates and old non-PHI files. NEVER use such a tool on any PHI files or folders due to compliance risks, if it’s not covered by a BAA.

Involving Others in My Personal HIPPA Journey

• Dealing with Shared PHI from Others: I found some old PHI-containing files in my personal Gmail’s “Shared with me” section, shared by a school district. I immediately downloaded these to my professional Google Workspace Drive, securely deleted them from my personal Drive and my local computer. Then I reached out to the owner (politely!) asking them to remove my personal Gmail from the access list. This is an active and ongoing effort where I’m proactively contacting owners to ensure my access is removed. I’m documenting all my attempts as part of my due diligence, especially if I encounter non-responsive contacts or technical difficulties.
• Updating My Employer: I proactively contacted my employer to update my email address for all Google Drive file sharing. I specifically requested that anything with sensitive client info go to my new, secure professional email address (e.g., your.professional.email@yourdomain.com). This helps them send things to the right place from the start.

My Ongoing Commitment:

This isn’t a one-and-one project! I’ve also built in:

• Annual Policy Review: I’ll review my entire security policy document at least once a year.
• Self-Education: Staying informed about HIPAA and cybersecurity is an ongoing task. I’ve even been learning about specific processes like the HIPAA de-identification process.
• Basic Incident Response: I have a plan for what to do if something ever goes wrong, including who to notify.
• Learning Curve: I won’t lie, all these tech skills required some serious reading up and a lot of help (shout out to Gemini! ?). It’s a journey, not a sprint, but totally doable!

Setting all this up has been a journey, but it’s given me immense confidence in my practice’s security. If you’re an SLP (or any healthcare professional) using tech in your practice, I highly encourage you to take a look at your own setup. It’s worth every bit of effort for your peace of mind and, most importantly, for your clients’ privacy!

Here’s to HIPAA Happiness!

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