1 Presentation for HIPAA Summit X Baltimore, MD April 7, 2005 The HIPAA Security Rule: Theory and Practice Sam Jenkins Privacy Officer TRICARE Management Activity (TMA) Dan Steinberg Senior Consultant Booz Allen Hamilton HEALTH AFFAIRS TRICARE Management Activity
2 1 Theory of the HIPAA Security Rule: Presentation Objectives Discuss the flexibility and adaptability of the HIPAA Security Rule Review HIPAA covered entities need for further guidance Describe the role of National Institute of Standards and Technology (NIST) in providing security guidance to the federal government Provide an overview of NIST Special Publication , An Introductory Resource Guide for Implementing the HIPAA Security Rule Describe covered entities need to apply guidance judiciously
3 2 The HIPAA Security Rule was intended to provide covered entities with flexibility and adaptability Section 1173(d) of the Act required HHS to take into account the needs and capabilities of small and rural health providers HHS relied on basic concepts in drafting the rule that included: Scalability, so that it could be effectively implemented by covered entities of all types and sizes Not be linked to any specific technologies, allowing covered entities to make use of future technology advancements. 2,300 comments received reinforced that entities affected by the Security Rule are so varied in terms of installed technology, size, resources, and relative risk that it would be impossible to dictate a specific solution or set of solutions that would be useable by all covered entities HHS declined to certify software, develop compliance checklists, or certify programs or tools Advised covered entities to identify white papers, tools, and recommended best practices, but cautioned that HHS does not rate or endorse any such guidelines and/or modelsand the value of [their] content must be determined by the user.
4 3 In response to a FAQ, HHS stated that no standard policy, procedure, or methodology can guarantee compliance for all covered entities FAQ 3230: How will we know if our organization and our systems are compliant with the HIPAA Security Rule s requirements? Answer: Compliance is different for each organization and no single strategy will serve all covered entities. Compliance is not a one-time goal, it must be maintained. Compliance with the evaluation standard at (a)(8) will allow covered entities to maintain compliance. By performing a periodic technical and nontechnical evaluation a covered entity will be able to address initial standards implementation and future environmental or operational changes affecting the security of electronic PHI.
5 4 The National Institute of Standards and Technology (NIST) is charged with developing security standards and guidelines for federal agencies Under the Federal Information Security Management Act of 2002 (FISMA), NIST is charged with developing standards and guidelines, including minimum requirements, for providing adequate information security for all agency operations and assets apart from national security systems NIST is cited four times in the preamble to the HIPAA Security Rule as an authority and potential source for more information on the security management process, evaluation, training programs, and auditing NIST s Computer Security Division (CSD) produces the Special Publication 800 series on information technology security topics of general interest to the computer security community.
6 5 NIST s challenge was to assist federal agencies with understanding the HIPAA Security Rule without creating new requirements Drafting of Special Publication was guided throughout development by our stated intent: To identify activities relevant to each standard and implementation specification of the HIPAA Security Rule, and provide direction to more extensive guidance. Special Publication states multiple times that this guide is offered as an aid, but does not create new requirements Development further governed by the goals of of writing in an accessible, clear style and defining all technical terms Written for NIST s audience of federal agencies pursuant to its mandate, but private and commercial entities may voluntarily consult it and adapt it for their purposes Not subject to copyright, although attribution to NIST is appreciated.
7 6 Special Publication discussed HIPAA within a federal framework of other information security requirements and NIST publications FISMA directs heads of federal agencies and their chief information officers (CIOs) to: Ensure that each agency has an information security program in place Ensure trained personnel are assigned to manage and support the program Fully integrate security into their business processes Prepare security plans and certification and accreditation for all agency systems. NIST developed a suite of publications relevant to addressing these FISMA requirements Appendix ( E of current draft) identifies opportunities for aligning FISMA and HIPAA activities in order to maximize efficiency Emphasis throughout document on availability of other NIST publications which address certain security issues in greater detail.
8 7 Each administrative, technical, and physical standard was addressed in an educational module Components of each module: Citation for the standard A reprinting of the exact text of the standard Introductory reference Key activities Description (of key activities) Sample Questions Supplemental references Examples Explanation
9 8 Each administrative, technical, and physical standard was addressed in an educational module (continued) omponents of each module: Citation for the standard A reprinting of the exact text of the standard Introductory reference Key activities Description (of key activities) Sample Questions Supplemental references Examples Explanation
10 9 Each module begins with an Introductory Reference, and most also include Secondary References at the end of the module table Each Introductory Reference is the NIST Special Publication that will be the most informative to a covered entity on the security issue raised by that particular specification In some cases, only part of the Introductory Reference will be relevant to that particular standard; users will need to review the document to identify the relevant portion Supplemental References may also be helpful; some are written on more general topics than the standard and will provide a context for the standard and/or a background on information security A review of all references identified for each standard is provided in Appendix D of Special Publication
11 10 The Key Activities suggest actions that are usually associated with the security function or functions for each HIPAA Security Rule standard In final draft, Key Activities will include all implementation specifications of each standard, and note whether each is required or addressable Other Key Activities are not specifically discussed or required by the HIPAA Security Rule NOT meant to expand upon the intent of the Security Rule, but are usually included in a robust security process Some are required of federal entities under other federal laws, regulations, or procedures. Each entity will need to identify what activities are necessary and appropriate in its environment, implement those activities, and document them.
12 11 The Description is a description of possible actions to take to address each Key Activity Includes an expanded explanation of the Key Activity Includes types of activities an organization may pursue in addressing a specific security function Abbreviated explanations designed to help get an organization started in addressing the HIPAA Security Rule The NIST publications identified as Introductory References for the HIPAA Security Rule can be consulted for more detailed information about the security topic.
13 12 Sample Questions are those that covered entities may ask themselves while determining whether Key Activities have been adequately considered or completed List of Sample Questions is not exhaustive, but merely representative Affirmative answers to these questions do not imply that an organization is meeting all of the requirements of the HIPAA Security Rule Negative answers to these questions should prompt the covered entity to consider whether it needs to take further action in order to comply with the standards Many organizations with existing information security infrastructure already in place will have considered most of the Sample Questions Sample Questions should be tailored to fit the unique circumstances of each entity.
14 13 The Examples describe the efforts of two hypothetical federal agencies that are also HIPAA covered entities The Examples describe how two hypothetical covered entities has chosen to address standards and implementation specifications of the HIPAA Security Rule Should be read in context of the overview of each entity s environmental and information systems characteristics The Examples are representative of what actions and issues may arise, but are not comprehensive descriptions of the actions an organization must perform The actual activities necessary to implement the standard requirement for any given entity may vary substantially depending on organization mission, size, and scope Each Example is followed by an Explanation detailing how the covered entity approached the HIPAA standard, containing references and citations to provisions of the HIPAA Security Rule.
15 14 NIST Special Publication was intended to be a helpful, educational document Explanations of terms and concepts used in the rule Builds a bridge to other NIST documents that will be helpful in understanding the significance of each standard Not a checklist, a methodology or an approach, but a resource Individual compliance will require an understanding of security and alignment with the entity's: Risk analysis Risk mitigation strategy Security measures already in place Cost of implementation of particular security measures Size, complexity, capabilities Technical infrastructure, hardware, and software capabilities Probability and criticality of potential risks to electronic protected health information Other factors.
16 15 HEALTH AFFAIRS Practice of the HIPAA Security Rule: Presentation Objectives TRICARE Management Activity Provide overview of Military Health System (MHS) scope and structure as they relate to HIPAA Relate where the Military Health System is now in their compliance efforts Provide the steps and timeline for HIPAA compliance Review lessons learned
17 16 HEALTH AFFAIRS Background TRICARE Management Activity Department of Defense (DoD) MHS mission and care environments Complex organizational structure Treats both military personnel and civilian family members, retirees and others Variety of settings - military and civilian treatment facilities Echelons of care - deployed and non-deployed o Specialty and multi-service o Community hospitals o Clinics o Operation and deployed units
18 17 HEALTH AFFAIRS Compliance Date TRICARE Management Activity April 20, 2005 Only 13 days from today
19 18 Where are we now and how did we get here Major milestones for HIPAA Security Implementation OCTAVE tool development 1st Quarter 2000 P3WG kick off March 2000 finished April 2003 MISRT formation and initial training WIPT/IPT formation January 2002 OCTAVE training Final Rule published Feb 2003 IPT development of prgm and implementation products Appoint CE HIPAA Security Officers Attend Security Officer Training Train workforce on HIPAA Security HIPAA Security Awareness Campaign Kick-Off Conduct Organizational Risk Assessments (OCTAVE) Conduct compliance gap analysis (HIPAA Basics) Develop and implement mitigation plan Evaluation Oversight and Compliance Compliance date April 20, qtr 2 qtr 3 qtr 4 qtr 1qtr 2 qtr
20 19 HEALTH AFFAIRS The key to compliance is risk management TRICARE Management Activity To correctly implement the security standards and establish compliance, each covered entity must: Assess potential risks and vulnerabilities to EPHI Develop, implement, and maintain appropriate security measures given those risks Document those measures and keep them current Implementing HIPAA Security is meant to be flexible and scalable
21 20 HEALTH AFFAIRS Preparation prior to final rule TRICARE Management Activity Development and selection of Operationally Critical Threat, Asset and Vulnerability Evaluation (OCTAVE ) as risk assessment methodology DoD and Service level policy gap analysis Integrated Process Team and Medical Information Security Readiness Team (MISRT) formation Initial training in HIPAA and OCTAVE
22 21 HEALTH AFFAIRS TRICARE Management Activity and Service Implementation Actions TRICARE Management Activity Development of HIPAA Security Program and Strategy Program Management Plan Training and Awareness Program Policy development (Directive, Regulation and Implementation Guides) Oversight and Compliance (Compliance Assurance Framework, Compliance and reporting tools) Incident Response
23 22 HEALTH AFFAIRS Military Treatment Facility Implementation Actions TRICARE Management Activity Implementation of treatment facility HIPAA Security Program Appointment of Security Official and MISRT Workforce training and awareness program Perform HIPAA risk assessment Perform HIPAA compliance gap analysis Mitigation plans Implementation strategies Evaluation and documentation
24 HIPAA Security Awareness Posters (1 of 3) 23
25 HIPAA Security Awareness Posters (2 of 3) 24
26 HIPAA Security Awareness Posters (3 of 3) 25
27 26 HEALTH AFFAIRS Oversight and Compliance (1 of 2) TRICARE Management Activity Compliance is established and maintained by implementing business practices including measurement against metrics and periodic reports through an appropriate reporting structure Measuring success Completion percentages Identifying areas for improvement Preparations and contingencies Communication of issues
28 27 HEALTH AFFAIRS Methodologies Oversight and Compliance (2 of 2) TRICARE Management Initial requirements Reports that provide information on compliance within organizations and across the Military Health System Metrics to gauge compliance performance and monitor the progress of HIPAA privacy and security programs Activity
29 28 Reporting Requirements HEALTH AFFAIRS Type and frequency: Training Reports Monthly or as needed to verify compliance Compliance Reports Baseline for HIPAA Security and then monthly during the implementation phase (December TBD) Phased decrease to a quarterly or less often report for HIPAA Security Compliance after implementation phase TRICARE Management Activity
30 29 HEALTH AFFAIRS Tools for Compliance Reporting TRICARE Management Activity TRICARE Management Activity has provided 2 centrally funded and managed HIPAA Security tools to facilitate compliance reporting efforts across the Military Health System Training Tool Plateau s Learning Management System (LMS) Compliance Tool Strategic Management Systems, Inc HIPAA BASICS TM
31 30 HEALTH AFFAIRS Are You Ready? Remember - compliance is required by every covered entity in 13 days TRICARE Management Activity
32 31 HEALTH AFFAIRS Resources Title 45, Code of Federal Regulations, Health Insurance Reform: Security Standards; Final Rule, Parts 160, 162 and 164, current edition Special Publication : An Introductory Resource Guide for Implementing the HIPAA Security Rule, National Institute of Standards and Technology available at For TMA Healthplan, DoD, and Uniformed Service use only for subject matter questions for tool related questions Service HIPAA security representatives TRICARE Management Activity
33 32 HEALTH AFFAIRS TRICARE Management Activity Our Commitment The TRICARE Management Activity (TMA) Privacy Office is committed to ensuring the privacy and security of patient information at every level as we deliver the best medical care possible to those we serve.
NIST Special Publication 800-66 An Introductory Resource Guide for Implementing the Health Insurance Portability and Accountability Act (HIPAA) Security Rule Joan Hash, Pauline Bowen, Arnold Johnson, Carla
Lessons Learned from OCR Privacy and Security Audits Program Overview & Initial Analysis Linda Sanches, MPH Verne Rinker, JD MPH Presentation to IAPP Global Privacy Summit March 7, 2013 Program Mandate
The HIPAA Audit Program Anna C. Watterson Davis Wright Tremaine LLP The U.S. Department of Health and Human Services (HHS) was given authority, and a mandate, to conduct periodic audits of HIPAA 1 compliance
NIST Special Publication 800-66 An Introductory Resource Guide for Implementing the Health Insurance Portability and Accountability Act (HIPAA) Security Rule Pauline Bowen, Arnold Johnson, Joan Hash Carla
Report No. D-2010-058 May 14, 2010 Selected Controls for Information Assurance at the Defense Threat Reduction Agency Additional Copies To obtain additional copies of this report, visit the Web site of
NIST Special Publication 800-66 Revision 1 An Introductory Resource Guide for Implementing the Health Insurance Portability and Accountability Act (HIPAA) Security Rule Matthew Scholl, Kevin Stine, Joan
Information Security Compliance System Owner Training Richard Gadsden Information Security Office Office of the CIO Information Services Sharon Knowles Information Assurance Compliance MUSC Medical Center
U.S. ENVIRONMENTAL PROTECTION AGENCY OFFICE OF INSPECTOR GENERAL Briefing Report: Improvements Needed in EPA s Information Security Program Report No. 13-P-0257 May 13, 2013 Scan this mobile code to learn
General HIPAA Implementation FAQ What is HIPAA? Signed into law in August 1996, the Health Insurance Portability and Accountability Act ( HIPAA ) was created to provide better access to health insurance,
O FFICE OF I NSPECTOR GENERAL Audit Report 2014-IT-B-019 2014 Audit of the Board s Information Security Program November 14, 2014 B OARD OF G OVERNORS OF THE F EDERAL R ESERVE S YSTEM C ONSUMER FINANCIAL
HIPAA: Compliance Essentials Presented by: Health Security Solutions August 15, 2014 What is HIPAA?? HIPAA is Law that governs a person s ability to qualify immediately for health coverage when they change
it ort YEAR 2000 COMPLIANCE OF THE STANDARD ARMY MAINTENANCE SYSTEM-REHOST Report Number 99-165 May 24, 1999 Office of the Inspector General Department of Defense Additional Copies To obtain additional
Office of the Secretary Office for Civil Rights () Overview of the HIPAA Security Rule Office for Civil Rights Region IX Alicia Cornish, EOS Sheila Fischer, Supervisory EOS Topics Upon completion of this
Independent Evaluation of NRC s Implementation of the Federal Information Security Modernization Act of 2014 for Fiscal Year 2015 OIG-16-A-03 November 12, 2015 All publicly available OIG reports (including
OFFICE OF THE CHIEF INFORMATION OFFICER Date of Issuance: May 22, 2009 Effective Date: May 22, 2009 Review Date: Section I. PURPOSE II. AUTHORITY III. SCOPE IV. DEFINITIONS V. POLICY VI. RESPONSIBILITIES
BNA s Health Law Reporter Reproduced with permission from BNA s Health Law Reporter, 20 HLR 1272, 08/18/2011. Copyright 2011 by The Bureau of National Affairs, Inc. (800-372-1033) http://www.bna.com HHS
2012 HIPAA Privacy and Security Audit Readiness Mark M. Johnson National HIPAA Services Director Table of contents Page Background 2 Regulatory Background and HITECH Impacts 3 Office of Civil Rights (OCR)
Fiscal Year 2015 Information Security for Managers Introduction Information Security Overview Enterprise Performance Life Cycle Enterprise Performance Life Cycle and the Risk Management Framework Categorize
Department of Defense INSTRUCTION NUMBER 6010.23 January 23, 2012 Incorporating Change 1, Effective October 3, 2013 USD(P&R) SUBJECT: DoD and Department of Veterans Affairs (VA) Health Care Resource Sharing
TREASURY INSPECTOR GENERAL FOR TAX ADMINISTRATION Insufficient Attention Has Been Given to Ensure States August 31, 2007 Reference Number: 2007-20-134 This report has cleared the Treasury Inspector General
How to prepare your organization for an OCR HIPAA audit Presented By: Mac McMillan, FHIMSS, CISM CEO, CynergisTek, Inc. Technical Assistance: 978-674-8121 or Amanda.Howell@iatric.com Audio Options: Telephone
OCR Audits of HIPAA Privacy, Security and Breach Notification, Phase 2 Linda Sanches, MPH Senior Advisor, Health Information Privacy HCCA Compliance Institute March 31, 2014 Agenda Background Audit Phase
Department of Defense INSTRUCTION NUMBER 8580.02 August 12, 2015 USD(P&R) SUBJECT: Security of Individually Identifiable Health Information in DoD Health Care Programs References: See Enclosure 1 1. PURPOSE.
Page 1 of 9 Pages Standard Operating Procedure Information Security Compliance Requirements under the cabig Program This cover sheet controls the layout and components of the entire document. Issued Date:
Hosting for Healthcare: ADDRESSING THE UNIQUE ISSUES OF HEALTH IT & ACHIEVING END-TO-END COMPLIANCE [ Hosting for Healthcare: Addressing the Unique Issues of Health IT & Achieving End-to-End Compliance
NASA OFFICE OF INSPECTOR GENERAL OFFICE OF AUDITS SUITE 8U71, 300 E ST SW WASHINGTON, D.C. 20546-0001 April 14, 2016 TO: SUBJECT: Renee P. Wynn Chief Information Officer Final Memorandum, Review of NASA
Department of Defense INSTRUCTION NUMBER 6025.13 February 17, 2011 Incorporating Change 1, Effective October 2, 2013 USD(P&R) SUBJECT: Medical Quality Assurance (MQA) and Clinical Quality Management in
Testimony of: Kay Daly Assistant Inspector General for Audit Services Office of Inspector General, U.S. Department of Health and Human Services Hearing Title: The Threat to Americans Personal Information:
The Information Assurance Process: Charting a Path Towards Compliance A white paper on a collaborative approach to the process and activities necessary to attain compliance with information assurance standards.
HEALTHCARE SECURITY AND PRIVACY CATALOG OF SERVICES OCTOBER 2014 3300 North Fairfax Drive, Suite 308 Arlington, Virginia 22201 USA +1.571.481.9300 www.lunarline.com OUR CLIENTS INCLUDE Contents Healthcare
NATIONAL CREDIT UNION ADMINISTRATION OFFICE OF INSPECTOR GENERAL INDEPENDENT EVALUATION OF THE NATIONAL CREDIT UNION ADMINISTRATION S COMPLIANCE WITH THE FEDERAL INFORMATION SECURITY MANAGEMENT ACT (FISMA)
Department of Defense DIRECTIVE NUMBER 8140.01 August 11, 2015 DoD CIO SUBJECT: Cyberspace Workforce Management References: See Enclosure 1 1. PURPOSE. This directive: a. Reissues and renumbers DoD Directive
Electronic Health Records: Data Security and Integrity of e-phi Worcester, MA Wednesday, 2:15pm 3:30pm Agenda Introduction Learning Objectives Overview of HIPAA HIPAA: Privacy and Security HIPAA: The Security
HIPAA Security Risk Analysis for Meaningful Use NOTE: Make sure your computer speakers are turned ON. Audio will be streaming through your speakers. If you do not have computer speakers, call the ACCMA
5 FAH-11 H-500 PERFORMANCE MEASURES FOR INFORMATION ASSURANCE 5 FAH-11 H-510 GENERAL (Office of Origin: IRM/IA) 5 FAH-11 H-511 INTRODUCTION 5 FAH-11 H-511.1 Purpose a. This subchapter implements the policy
Department of the Interior Security Control Standard Program Management April 2011 Version: 1.1 Signature Approval Page Designated Official Bernard J. Mazer, Department of the Interior, Chief Information
Department of the Interior Security Control Standard Security Assessment and Authorization January 2012 Version: 1.2 Signature Approval Page Designated Official Bernard J. Mazer, Department of the Interior,
CyberSheath Healthcare Compliance Paper www.cybersheath.com -65 Bridging the HIPAA/HITECH Compliance Gap Security insights that help covered entities and business associates achieve compliance According
Compliance Risk Management IT Governance Assurance Solutions That Matter Introduction to Federal Information Security Management Act (FISMA) Without proper safeguards, federal agencies computer systems
Office of the Chief Information Officer Office of the Assistant Secretary for Resources and Technology Department of Health and Human Services HHS OCIO Policy for Information Technology (IT) Enterprise
Office of the Secretary Office for Civil Rights (OCR) 2012 HIPAA Privacy and Security Audits Linda Sanches OCR Senior Advisor, Health Information Privacy Lead, HIPAA Compliance Audits OCR 1 Agenda Background
Page 1 of 5 Applies to: faculty staff students student employees visitors contractors Effective Date of This Revision: October 19, 2006 Contact for More Information: Chief Privacy Officer 1303 A West Campus
O FFICE OF I NSPECTOR GENERAL Audit Report 2014-IT-C-020 2014 Audit of the CFPB s Information Security Program November 14, 2014 B OARD OF G OVERNORS OF THE F EDERAL R ESERVE S YSTEM C ONSUMER FINANCIAL
HIPAA Compliance: Are you prepared for the new regulatory changes? Baker Tilly CARIS Innovation, Inc. April 30, 2013 Baker Tilly refers to Baker Tilly Virchow Krause, LLP, an independently owned and managed
SEPTEMBER 16, 2010 AUDIT REPORT OFFICE OF AUDITS REVIEW OF NASA S MANAGEMENT AND OVERSIGHT OF ITS INFORMATION TECHNOLOGY SECURITY PROGRAM OFFICE OF INSPECTOR GENERAL National Aeronautics and Space Administration
Department of Defense INSTRUCTION NUMBER 6040.42 June 10, 2004 SUBJECT: Medical Encounter and Coding at Military Treatment Facilities ASD(HA) References: (a) DoD Instruction 6040.40, "Military Health System
Concept of Operations (CONOPS) Version 1.0 February 7, 2012 Overview Cloud computing technology allows the Federal Government to address demand from citizens for better, faster services and to save resources,
Audit Report OIG-05-040 INFORMATION TECHNOLOGY: Mint s Computer Security Incident Response Capability Needs Improvement July 13, 2005 Office of Inspector General Department of the Treasury Contents Audit
A smarter way to protect your brand Minimizing Compliance Risks of Proactive OCR HIPAA Audits Copyright 2012 Compliance 360 All Rights Reserved Compliance 360 at a Glance Compliance, Risk and Audit Solutions
Inspector General U.S. Department of Defense Report No. DODIG 2015 008 OCTOBER 23, 2014 Followup Audit: Enterprise Blood Management System Not Ready for Full Deployment INTEGRITY EFFICIENCY ACCOUNTABILITY
2012 FISMA Executive Summary Report March 29, 2013 UNITED STATES SECURITIES AND EXCHANGE COMMISSION WASHINGTON, D.C. 20549 OI'!'ICEOI' lnstfl! C1'0R GENERAt MEMORANDUM March 29,2013 To: Jeff Heslop, Chief
Get Confidence in Mission Security with IV&V Information Assurance September 10, 2014 Threat Landscape Regulatory Framework Life-cycles IV&V Rigor and Independence Threat Landscape Continuously evolving
Deputy Chief Financial Officer Peggy Sherry And Chief Information Security Officer Robert West U.S. Department of Homeland Security Testimony Before the Subcommittee on Government Organization, Efficiency
Privacy and Security Meaningful Use Requirement HIPAA Readiness Review REACH - Achieving - Achieving meaningful meaningful use of your use EHR of your EHR Patti Kritzberger, RHIT, CHPS ND e-health Summit
Interpreting the HIPAA Audit Protocol for Health Lawyers This webinar is brought to you by the Health Information and Technology Practice Group (HIT), and is co-sponsored by the Business Law and Governance
Executive Order 13636: The Healthcare Sector and the Cybersecurity Framework September 23, 2014 Executive Order: Improving Critical Infrastructure Cybersecurity It is the policy of the United States to
Regulatory Compliance Solutions for Microsoft Windows IT Security Controls Supporting DHS HIPAA Final Security Rules Health Insurance Portability and Accountability Act Enterprise Compliance Auditing &
Meaningful Use as it Relates to HIPAA Compliance Sunday March 30, 2014, 9am noon HCCA Conference, San Diego CLAconnect.com Objectives and Agenda Understand the statutory and regulatory background and purpose
ITL BULLETIN FOR MARCH 2012 GUIDELINES FOR IMPROVING SECURITY AND PRIVACY IN PUBLIC CLOUD COMPUTING Shirley Radack, Editor Computer Security Division Information Technology Laboratory National Institute
This (Second) DRAFT of Special Publication 800 16 Revision 1 document has been superceded by the following draft publication: Publication Number: Third Draft Special Publication 800 16 Revision 1 Title:
U.S. DEPARTMENT OF THE INTERIOR OFFICE OF INSPECTOR GENERAL Verification of Previous Office of Inspector General Recommendations September 2009 ISD-EV-MOA-0002-2009 Contents Acronyms and Other Reference
VA Office of Inspector General OFFICE OF AUDITS AND EVALUATIONS Department of Veterans Affairs Audit of Office of Information Technology s Strategic Human Capital Management October 29, 2012 11-00324-20
AN OVERVIEW OF INFORMATION SECURITY STANDARDS February 2008 The Government of the Hong Kong Special Administrative Region The contents of this document remain the property of, and may not be reproduced
Providers Business Name: Providers Business Address: City, State, Zip Acronyms NIST FIPS PHI EPHI BA CE EHR HHS IS National Institute of Standards and Technology Federal Information Process Standards Protected
Conducting due diligence and managing cybersecurity in medical technology investments 2015 McDermott Will & Emery LLP. McDermott operates its practice through separate legal entities in each of the countries
TREASURY INSPECTOR GENERAL FOR TAX ADMINISTRATION Improvements Are Needed to the Information Security Program March 11, 2008 Reference Number: 2008-20-076 This report has cleared the Treasury Inspector
Developing HIPAA Security Compliance Trish Lugtu CPHIMS, CHP, CHSS Health IT Consultant Learning Objectives Identify elements of a HIPAA Security compliance program Learn the HIPAA Security Rule basics
TABLE OF CONTENTS University of Northern Colorado HIPAA Policies and Procedures Page # Development and Maintenance of HIPAA Policies and Procedures... 1 Procedures for Updating HIPAA Policies and Procedures...
How to Use the NYeC Privacy and Security Toolkit V 1.1 Scope of the Privacy and Security Toolkit The tools included in the Privacy and Security Toolkit serve as guidance for educating stakeholders about
EVALUATION REPORT Weaknesses Identified During the FY 2014 Federal Information Security Management Act Review March 13, 2015 REPORT NUMBER 15-07 EXECUTIVE SUMMARY Weaknesses Identified During the FY 2014
Value to the Mission FEA Practice Guidance Federal Enterprise Program Management Office, OMB November 2007 FEA Practice Guidance Table of Contents Section 1: Overview...1-1 About the FEA Practice Guidance...
policy awareness and training Policy summary This policy specifies an information security awareness and training program to inform and motivate all workers regarding their information security obligations.
Department of Defense INSTRUCTION NUMBER 8440.01 December 24, 2015 DoD CIO SUBJECT: DoD Information Technology (IT) Service Management (ITSM) References: See Enclosure 1 1. PURPOSE. Pursuant to the authority
January 30, 2015 Karen DeSalvo, MD, MPH, MSc National Coordinator Office of National Coordinator for Health IT Department of Health and Human Services 200 Independence Ave, SW Washington, DC 20201 Dear
DEPARTMENT OF THE NAVY BUREAU OF MEDICINE AND SURGERY 7700 ARLINGTON BOULEVARD FALLS CHURCH, VA 22042 IN REPLY REFER TO BUMEDINST 7000.9A BUMED-M843 BUMED INSTRUCTION 7000.9A From: Chief, Bureau of Medicine
FREQUENTLY ASKED QUESTIONS Continuous Monitoring 1. What is continuous monitoring? Continuous monitoring is one of six steps in the Risk Management Framework (RMF) described in NIST Special Publication
HEALTH AFFAIRS MILITARY HEALTH SYSTEM NOTICE OF PRIVACY PRACTICES Effective April 14, 2003 THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO
NATIONAL CREDIT UNION ADMINISTRATION OFFICE OF INSPECTOR GENERAL FY 2015 INDEPENDENT EVALUATION OF THE EFFECTIVENESS OF NCUA S INFORMATION SECURITY PROGRAM UNDER THE FEDERAL INFORMATION SECURITY MODERNIZATION
CISM (Certified Information Security Manager) Document version: 6.28.11 Important Note About CISM PDF techexams CISM PDF is a comprehensive compilation of questions and answers that have been developed
Health Insurance Portability and Accountability Act (HIPAA) Compliance Audit Final Report April 2009 promoting efficient & effective local government Background The Health Insurance Portability and Accountability
This is the third and final presentation on HIPAA Security Administrative Safeguards. This presentation focuses on the last 2 standards under the HIPAA Security rule: Contingency planning and evaluation.
Department of Veterans Affairs VA Directive 6004 Washington, DC 20420 Transmittal Sheet September 28, 2009 CONFIGURATION, CHANGE, AND RELEASE MANAGEMENT PROGRAMS 1. REASON FOR ISSUE: This Directive establishes
EXECUTIVE OFFICE OF THE PRESIDENT OFFICE OF MANAGEMENT AND BUDGET WASHINGTON, D.C. 20503 June 2, 2016 M-16-12 MEMORANDUM FOR THE HEADS OF DEPARTMENTS AND AGENCIES FROM: Anne E. Rung United States Chief
The OCR Audit Protocol a first look On June 26, 2012, the Office for Civil Rights published its Audit Protocols for HIPAA Security, HIPAA Breach and Privacy at http://ocrnotifications.hhs.gov/hipaa.html.
OFFICE OF INSPECTOR GENERAL Audit Report Evaluation of the Railroad Retirement Board Medicare Contractor s Information Security Report No. 08-04 September 26, 2008 RAILROAD RETIREMENT BOARD INTRODUCTION
HIPAA/HITECH PRIVACY & SECURITY CHECKLIST SELF ASSESSMENT INSTRUCTIONS Thank you for taking the time to fill out the privacy & security checklist. Once completed, this checklist will help us get a better