Securing Health Data. Melina Scotto CISSP, CISA, HCISPP. Sr. Network Security Engineer NIH SRA International
|
|
- Eugenia Bradford
- 8 years ago
- Views:
Transcription
1 Securing Health Data Melina Scotto CISSP, CISA, HCISPP Sr. Network Security Engineer NIH SRA International
2 Course Overview Securing Medical Data presents the history of medical data regulations, explains the technical details of the regulations from a network engineering perspective and develops a deep understanding of medical data risk management.
3 Training Audience Technical staff on Healthcare networks Privacy Officers, Privacy Regulation Enthusiasts Project Managers in Healthcare sector Clinicians (Extensive technical background not required)
4 Introductions and Ice Breaker Write these words on the notecards at your table. Each word on one notecard. RISK THREAT EVENT VULNERABILITY THREAT SOURCE exploits causing initiates producing ADVERSE IMPACT
5 Agenda Pre Lunch Introductions Risk icebreaker. General Healthcare IT Environment Knowledge baseline quiz. (Audience response clickers if possible) Healthcare Regulatory Environment Review Resource Packet True stories from the field Health data security failures from the HHS Wall of Shame Lunch Break
6 Agenda Post Lunch Risk Management and Mitigation Information Risk Assessment from NIST Sp (rev 1) groups work in teams to apply appropriate technical controls to stories from the field. HCISPP certification topics: 3 rd party Risk Management, Cloud computing and International Health data standards.
7 HIPAA Terms HIPAA HITECH/ARRA ephi Privacy Security CFR CE BA HHS ONC OCR NIST CMS
8 HIPAA Terms CFR - Code of Federal Regulations
9 HIPAA Terms HIPAA
10 HIPAA Terms HIPAA HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996 Public Law th Congress An Act To amend the Internal Revenue Code of 1986 to improve portability and continuity of health insurance coverage in the group and individual markets, to combat waste, fraud, and abuse in health insurance and health care delivery, to promote the use of medical savings accounts, to improve access to long-term care services and coverage, to simplify the administration of health insurance, and for other purposes. Be it enacted by the Senate and House of Representatives of the United States of America in Congress assembled
11 HIPAA Terms HIPAA Covered Entities (CE) CE Covered Entity BA Business Associate
12 HIPAA Terms HIPAA Business Associate (BA)
13 HIPAA Terms HITECH (ARRA) DEPARTMENT OF HEALTH AND HUMAN SERVICES Office of the Secretary 45 CFR Part 160 RIN 0991 AB55 HIPAA Administrative Simplification: Enforcement AGENCY: Office of the Secretary, HHS. ACTION: Interim final rule; request for comments SUMMARY: The Secretary of the Department of Health and Human Services (HHS) adopts this interim final rule to conform the enforcement regulations promulgated under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) to the effective statutory revisions made pursuant to the Health Information Technology for Economic and Clinical Health Act (the HITECH Act), which was enacted as part of the American Recovery and Reinvestment Act of 2009 (ARRA).
14 HIPAA Terms HITECH
15 HIPAA Terms PHI Protected Health Information 18 Protected Identifiers Names; All geographic subdivisions smaller than a State, including street address, city, county, precinct, and their equivalent geocodes; All elements of dates (except year) for dates directly related to an individual, including birth date, admission date, discharge date, date of death; Telephone numbers; Fax numbers; Electronic mail addresses; Social security numbers; Medical record numbers; Health plan beneficiary numbers; Account numbers; Certificate/license numbers; Vehicle identifiers and serial numbers, including license plate numbers; Device identifiers and serial numbers; Web Universal Resource Locators (URLs); Internet Protocol (IP) address numbers; Biometric identifiers, including finger and voice prints; Full face photographic images and any comparable images; Any other unique identifying number, characteristic, or code.
16 HIPAA Terms Location of ephi EMRs Backups Mobile Devices such as laptops/tablets/cell phones Digital Copiers PC Hard Drives Embedded Flash devices Biomedical Devices
17 HIPAA Terms Privacy The HIPAA Privacy Rule regulates the use and disclosure of Protected Health Information (PHI) held by "covered entities" (generally, health care clearinghouses, employer sponsored health plans, health insurers, and medical service providers that engage in certain transactions. Privacy is a right. Privacy Rule covers written, print and oral disclosures. Security. Security Rule covers electronic PHI or ephi. With respect to HIPAA, the term security is used for policies, mechanisms or systems which keep ephi confidential using Administrative, Technical and Physical controls. Security is the mechanism that maintains privacy.
18 HIPAA Terms HHS US Department of Health and Human Services ONC Office of the National Coordinator for Health Information Technology OCR Office for Civil Rights NIST National Institutes for Standards and Technology CMS Centers for Medicare and Medicaid Services
19 Quick Check-in. True or False? Under HIPAA, Privacy ensures Security. Recommended Resource. Herzig s Information Security in Healthcare, Managing Risk Introduction of Privacy by Sheila Searson
20 Medical Data Regulatory Environment Overlaps in Medical Organizations with other Data Security and Privacy Laws 1974 Privacy Act Computer Fraud and Abuse Act Grahm Leach Bliley SOX GINA
21 HIPAA Breaches
22 HIPAA Breaches VIOLATION California Department of Developmental Services Stolen laptop and iphone containing Names, Social Security numbers, and other personal information. Laptop unnencrypted. AFFECTED Over 18, 000 patients. The program served disabled infants and toddlers.
23 HIPAA Breaches VIOLATION Massachusetts General Hospital employee printed the records of 192 infectious disease patients before going on holiday. Left the printed records on the RedLine public transit system. OCR Settlement $1M
24 HIPAA Breaches VIOLATION Utah Department of Health confirmed that a server containing personal health information (PHI) of some 780,000 patients had been actively hacked into starting in March. Officials reported that thieves had begun removing information from the server. Addresses, dates of birth, Social Security numbers, diagnoses codes, national provider identification numbers, billing codes and taxpayer identification numbers were all Included on the server. OCR PENALTY Not yet assessed.
25 HIPAA Breaches VIOLATION Affinity impermissibly disclosed the protected health information of up to 344,579 individuals when it returned multiple photocopiers to a leasing agent without erasing the data contained on the copier hard drives. Affinity failed to incorporate copier hard drives in its analysis of risks and vulnerabilities as required by the Security Rule, and failed to implement policies and procedures when returning the hard drives to its leasing agents. OCR PENALTY $1.2M + Corrective Action Plan
26 HIPAA Breaches Corrective Action Plan 1. Within five (5) days of the Effective date, AHP shall use its best efforts to retrieve all photocopier hard drives that were contained in photocopiers previously leased by AHP that remain in the possession of Canon Financial Services, and safeguard all EPHI contained therein from impermissible disclosure. If AHP cannot retrieve said hard drives, AHP shall provide OCR with documentation explaining its best efforts and the reason it was unable to retrieve said hard drives. If AHP retrieves said hard drives, AHP shall provide OCR written certification that it has completed the requirements specified in this paragraph. AHP s compliance with this corrective action will be based on the Region s review and approval of the documentation explaining why its efforts failed to retrieve the hard drives. 2. Within thirty (30) days of the Effective Date, AHP shall conduct a comprehensive risk analysis of the EPHI security risks and vulnerabilities that incorporates all electronic equipment and systems controlled, owned or leased by AHP. AHP shall also, within this time period develop a plan, to address and mitigate any security risks and vulnerabilities found in this analysis and, if necessary, revise its present policies and procedures. The plan and any revised policies and procedures shall be forwarded to OCR for its review consistent with paragraph 3 below. 3. OCR shall review and recommend changes to the plan and any revised policies and procedures specified in paragraph 2. Upon receiving OCR s recommended changes, AHP shall have thirty calendar days to provide a revised plan and any revised policies and procedures to OCR for review and approval. AHP shall implement the plan and distribute and train staff members on any revised policies and procedures within thirty (30) calendar days of OCR s approval.
27 HIPAA Breaches VIOLATION Cignet Health Care (Prince Georges County, MD) denied 41 patients access to their medical records when requested between September 2008 and October These patients individually filed complaints with OCR, initiating investigations with each complaint. The HIPAA privacy rule requires that a covered entity provide a patient a copy of their medical records no later than 60 days of the patient s request. OCR PENALTY $4.3 Million The fine for these violations alone is $1.3M. A $3M fine was imposed for obstructing the HHS investigation. It is believed that Cignet failed to provide the requested records because it could not locate the medical records. DOJ then opened an investigation to criminal fraud charges.
28 HIPAA Breaches VIOLATION TRICARE contractors had no encryption in place for backup tapes. Unencrypted tapes with the ephi of 4.9M military clinic and hospital patients were stolen from the back of a car. OCR PENALTY Not yet assessed. CIVIL PENALTY 7 lawsuits are seeking $1000/record or $4.9B in damages.
29 HIPAA Breaches
30 Regulation Details CFR Code of Federal Regulations HIPAA CFR Health Insurance Portability and Accountability Act HITECH (ARRA) Health Information Technology for Economic and Clinical Health Act NIST MU - Meaningful Use meaningful_use_announcement/2996
31 Lunch Break
32 Risk Assessment
33 Threat Threat Source: The intent and method targeted at the intentional exploitation of a vulnerability or situation and method that may accidentally exploit a vulnerability. Threat Event: An event or situation that has the potential for causing undesirable consequences or impact.
34 Threat Landscape Examples of threats: Fire Flood Power Outage Snooping Theft Acts of war/terrorism
35 Vulnerability Vulnerability is a flaw or weakness in a system security procedure, design, implementation, or internal control that could result in a breach or violation.
36 Information Risk Assessment Where do threats attack a network?
37 Vulnerability
38 Likelihood The likelihood of occurrence is a weighted risk factor based on an analysis of the probability that a given threat is capable of exploiting a given vulnerability (or set of vulnerabilities).
39 Likelihood
40 Adverse Impact An adverse impact is a failure of data availability, integrity or confidentiality.
41 Risk Definition The probability that a particular threat will accidentally trigger or intentionally exploit a particular vulnerability. Risk = Threats x Asset Value x Vulnerability
42 Risk Framing
43 Risk Management
44 Risk Management Security Control Assessment
45 Risk Assessment Resources
46 Security Rule Toolkit
47 Security Rule Toolkit
48 Demo Security Rule Toolkit
49 NIST Risk Assessment Tools
50 Risk Assessment Tools
51 Risk Management Cloud Data
52 RISK ASSESSMENT ACTIVITY We will break into small groups and complete mock risk assessments for our organizations based on true breach events. Discuss each events threat source, liklihood, vulnerability and technical controls. Indicate appropriate adverse impact. Finally assess risk in a qualitative table.
53 Risk Assessment Findings From Groups Tell us a little about your breach and what technical controls you would recommend to reduce risk.
54 HCISPP
55 HCISPP Domains Include: 1. Healthcare Environment 2. Regulations 3. Privacy and Security in Health Care 4. Information Governance and Risk Management 5. Information Risk Assessment 6. Third Party Risk Management
56 HCISPP Study Resources Health Insurance Portability and Accountability Act of 1996 (HIPAA), 42 U.S.C. Subtitle F (1996). Health Information Technology for Economic and Clinical Health Act of 2009 (HITECH), 42 U.S.C (2009). Information Commissioner s Office (2008). Data Protection Act The Eighth Data Protection Principle and international data transfers. f National Health Service (2009). NHS Information Risk Management. London: Author. Organization for Economic Co-operation and Development (1980). OECD Guidelines on the Protection of Privacy and Transborder Flows of Personal Data. Paris: Author. Scholl, M., Stine, K., Hash, J., Bowen, P., Johnson, A., Smith, C. D., and Steinberg, D. I. (2008). NIST Special Publication (Rev.1), An Introductory Resource Guide for Implementing the Health Insurance Portability and Accountability Act (HIPAA) Security Rule. Gaithersburg, MD: National Institute of Standards and Technology. The European Data Protection Directive
57 HCISPP Study Outline International Privacy Regulations Safe Harbor Allows for transfer of EU data to US for commerce, without application of full EU privacy measures. Must follow Safe Harbor Framework to provide adequate privacy. In affect since 1998 (though EU is voting to revoke)
58 HCISPP Study Outline International Privacy Regulations European Commission EU Privacy Purpose of data collection Relevance of collected data Data storage limits Access to collected data
59 HCISPP Know what SNOMED and HL7 are
60 HCISPP Risk Equations Total Risk = Threats x Asset Value x Vulnerability Residual Risk = (Threats x Asset Value x Vulnerability) * control gap
61 HCISPP Sample Questions from ISC2 Which layer of the OSI model is responsible for determining the best route through a network? 1) Network layer 2) Physical layer 3) Session layer 4) None of the above
62 HCISPP Sample Questions from ISC2 What is different about wireless networks versus wired networks? 1. A wireless network is constrained to a 1-meter radius versus a wired network that can span rooms or city blocks. 2. The OSI stack is different for a wireless network versus a wired network. 3. Wired networks use radio waves to communicate. 4. Wireless networks use radio waves to communicate.
63 HCISPP Sample Questions HL7 is mainly a. 1. messaging standard 2. an XML variant 3. a programming language 4. None of the above
64 HCISPP Sample Questions What is the correct order of risk components? 1. Threat event, threat source, risk, likelihood, vulnerability 2. Vulnerability, adverse impact, threat event, likelihood, risk. 3. Likelihood, threat source, risk, vulnerability, threat event. 4. Threat source, threat event, vulnerability, adverse impact, risk
65 HCISPP Examination Details Test sites at Pearson VUE 125 questions Bring 2 types of ID Palm Print/Biometrics taken
66 Questions?
67 Thank You
8/3/2015. Integrating Behavioral Health and HIV Into Electronic Health Records Communities of Practice
Integrating Behavioral Health and HIV Into Electronic Health Records Communities of Practice Monday, August 3, 2015 1 How to ask a question during the webinar If you dialed in to this webinar on your phone
More informationInformation Security and Privacy. WHAT is to be done? HOW is it to be done? WHY is it done?
Information Security and Privacy WHAT is to be done? HOW is it to be done? WHY is it done? 1 WHAT is to be done? O Be in compliance of Federal/State Laws O Federal: O HIPAA O HITECH O State: O WIC 4514
More informationHIPAA OVERVIEW ETSU 1
HIPAA OVERVIEW ETSU 1 What is HIPAA? Health Insurance Portability and Accountability Act. 2 PURPOSE - TITLE II ADMINISTRATIVE SIMPLIFICATION To increase the efficiency and effectiveness of the entire health
More informationOCR/HHS HIPAA/HITECH Audit Preparation
OCR/HHS HIPAA/HITECH Audit Preparation 1 Who are we EHR 2.0 Mission: To assist healthcare organizations develop and implement practices to secure IT systems and comply with HIPAA/HITECH regulations. Education
More informationPresented by Jack Kolk President ACR 2 Solutions, Inc.
HIPAA 102 : What you don t know about the new changes in the law can hurt you! Presented by Jack Kolk President ACR 2 Solutions, Inc. Todays Agenda: 1) Jack Kolk, CEO of ACR 2 Solutions a information security
More informationHIPAA Privacy and Security Rules: A Refresher. Marilyn Freeman, RHIA California Area HIPAA Coordinator California Area HIM Consultant
HIPAA Privacy and Security Rules: A Refresher Marilyn Freeman, RHIA California Area HIPAA Coordinator California Area HIM Consultant Objectives Provide overview of Health insurance Portability and Accountability
More informationTrust 9/10/2015. Why Does Privacy and Security Matter? Who Must Comply with HIPAA Rules? HIPAA Breaches, Security Risk Analysis, and Audits
HIPAA Breaches, Security Risk Analysis, and Audits Derrick Hill Senior Health IT Advisor Kentucky REC Why Does Privacy and Security Matter? Trust Who Must Comply with HIPAA Rules? Covered Entities (CE)
More informationInformation Security and Privacy. WHAT are the Guidelines? HOW is it to be done? WHY is it done?
Information Security and Privacy WHAT are the Guidelines? HOW is it to be done? WHY is it done? 1 WHAT are the guidelines O Be in compliance of Federal/State Laws O Federal: O HIPAA 1996 2 3 WHAT are the
More informationInformation Security and Privacy. WHAT are the Guidelines? HOW is it to be done? WHY is it done?
Information Security and Privacy WHAT are the Guidelines? HOW is it to be done? WHY is it done? 1 WHAT are the guidelines O Be in compliance of Federal/State Laws O Federal: O HIPAA - 1996 O HITECH - 2009
More informationEverett School Employee Benefit Trust. Reportable Breach Notification Policy HIPAA HITECH Rules and Washington State Law
Everett School Employee Benefit Trust Reportable Breach Notification Policy HIPAA HITECH Rules and Washington State Law Introduction The Everett School Employee Benefit Trust ( Trust ) adopts this policy
More informationHIPAA Enforcement. Emily Prehm, J.D. Office for Civil Rights U.S. Department of Health and Human Services. December 18, 2013
Office of the Secretary Office for Civil Rights () HIPAA Enforcement Emily Prehm, J.D. Office for Civil Rights U.S. Department of Health and Human Services December 18, 2013 Presentation Overview s investigative
More informationHIPAA 101. March 18, 2015 Webinar
HIPAA 101 March 18, 2015 Webinar Agenda Acronyms to Know HIPAA Basics What is HIPAA and to whom does it apply? What is protected by HIPAA? Privacy Rule Security Rule HITECH Basics Breaches and Responses
More information12/19/2014. HIPAA More Important Than You Realize. Administrative Simplification Privacy Rule Security Rule
HIPAA More Important Than You Realize J. Ira Bedenbaugh Consulting Shareholder February 20, 2015 This material was used by Elliott Davis Decosimo during an oral presentation; it is not a complete record
More informationHIPAA WEBINAR HANDOUT
HIPAA WEBINAR HANDOUT OCR Enforcement Tools Voluntary corrective action Resolution Agreement and Payment CMPs Referral to DOJ for criminal investigation Resolution Agreements Contract signed by HHS and
More informationHow To Understand And Understand The Benefits Of A Health Insurance Risk Assessment
4547 The Case For HIPAA Risk Assessment Leader s Guide IMPORTANT INFORMATION FOR EDUCATION COORDINATORS & PROGRAM FACILITATORS PLEASE NOTE: In order for this program to meet Florida course requirements,
More informationHIPAA Compliance for Students
HIPAA Compliance for Students The Health Insurance Portability and Accountability Act (HIPAA) was passed in 1996 by the United States Congress. It s intent was to help people obtain health insurance benefits
More informationPatient Privacy and HIPAA/HITECH
Patient Privacy and HIPAA/HITECH What is HIPAA? Health Insurance Portability and Accountability Act of 1996 Implemented in 2003 Title II Administrative Simplification It s a federal law HIPAA is mandatory,
More informationAnnual Report to Congress on HIPAA Privacy Rule and Security Rule Compliance. For Calendar Years 2009 and 2010
Annual Report to Congress on HIPAA Privacy Rule and Security Rule Compliance For Calendar Years 2009 and 2010 As Required by the Health Information Technology for Economic and Clinical Health (HITECH)
More informationNationwide Review of CMS s HIPAA Oversight. Brian C. Johnson, CPA, CISA. Wednesday, January 19, 2011
Nationwide Review of CMS s HIPAA Oversight Brian C. Johnson, CPA, CISA Wednesday, January 19, 2011 1 WHAT I DO Manage Region IV IT Audit and Advance Audit Technique Staff (AATS) IT Audit consists of 8
More informationArt Gross President & CEO HIPAA Secure Now! How to Prepare for the 2015 HIPAA Audits and Avoid Data Breaches
Art Gross President & CEO HIPAA Secure Now! How to Prepare for the 2015 HIPAA Audits and Avoid Data Breaches Speakers Phillip Long CEO at Business Information Solutions Art Gross President & CEO of HIPAA
More informationHIPAA Privacy Keys to Success Updated January 2010
HIPAA Privacy Keys to Success Updated January 2010 HIPAA Job Specific Education 1 HIPAA and Its Purpose What is HIPAA? Health Insurance Portability and Accountability Act of 1996 Title II Administrative
More informationHIPAA Security Rule Compliance
HIPAA Security Rule Compliance Caryn Reiker MAXIS360 HIPAA Security Rule Compliance what is it and why you should be concerned about it Table of Contents About HIPAA... 2 Who Must Comply... 2 The HIPAA
More informationHIPAA: Breach Notification By: Office of University Counsel For: Jefferson IRB Continuing Education. September 2014
HIPAA: Breach Notification By: Office of University Counsel For: Jefferson IRB Continuing Education September 2014 Introduction The HIPAA Privacy Rule establishes the conditions under which Covered Entities
More informationData Security and Integrity of e-phi. MLCHC Annual Clinical Conference Worcester, MA Wednesday, November 12, 2014 2:15pm 3:30pm
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
More informationSunday March 30, 2014, 9am noon HCCA Conference, San Diego
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
More informationUniversity of Cincinnati Limited HIPAA Glossary
University of Cincinnati Limited HIPAA Glossary ephi System A system that creates accesses, transmits or receives: 1) primary source ephi, 2) ephi critical for treatment, payment or health care operations
More informationTools to Prepare and Protect Your Practice for HIPAA and Meaningful Use Audits
Tools to Prepare and Protect Your Practice for HIPAA and Meaningful Use Audits Presented by: Don Waechter, Managing Partner Health Compliance Partners Ann Breitinger, Attorney Blalock Walters Legal Disclaimer
More informationHIPAA TRAINING. A training course for Shiawassee County Community Mental Health Authority Employees
HIPAA TRAINING A training course for Shiawassee County Community Mental Health Authority Employees WHAT IS HIPAA? HIPAA is an acronym that stands for Health Insurance Portability and Accountability Act.
More informationBUSINESS ASSOCIATE AGREEMENT HIPAA Protected Health Information
BUSINESS ASSOCIATE AGREEMENT HIPAA Protected Health Information I. PREAMBLE ( Covered Entity ) and ( Business Associate ) (jointly the Parties ) wish to enter into an Agreement to comply with the requirements
More informationHIPAA Compliance: Are you prepared for the new regulatory changes?
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
More informationWhy Lawyers? Why Now?
TODAY S PRESENTERS Why Lawyers? Why Now? New HIPAA regulations go into effect September 23, 2013 Expands HIPAA safeguarding and breach liabilities for business associates (BAs) Lawyer is considered a business
More informationHIPAA Security Risk Analysis for Meaningful Use
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
More informationHosting 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 [ Hosting for Healthcare: Addressing the Unique Issues of Health IT & Achieving End-to-End Compliance
More informationHIPAA-P06 Use and Disclosure of De-identified Data and Limited Data Sets
HIPAA-P06 Use and Disclosure of De-identified Data and Limited Data Sets FULL POLICY CONTENTS Scope Policy Statement Reason for Policy Definitions ADDITIONAL DETAILS Web Address Forms Related Information
More informationOverview of the HIPAA Security Rule
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
More informationWhat Health Care Entities Need to Know about HIPAA and the American Recovery and Reinvestment Act
What Health Care Entities Need to Know about HIPAA and the American Recovery and Reinvestment Act by Lane W. Staines and Cheri D. Green On February 17, 2009, The American Recovery and Reinvestment Act
More informationCREATIVE SOLUTIONS IN HEALTHCARE, INC. Privacy Policy
CREATIVE SOLUTIONS IN HEALTHCARE, INC. Privacy Policy Amended as of February 12, 2010 on the authority of the HIPAA Privacy Officer for Creative Solutions in Healthcare, Inc. TABLE OF CONTENTS ARTICLE
More information6/17/2013 PRESENTED BY: Updates on HIPAA, Data, IT and Security Technology. June 25, 2013
Updates on HIPAA, Data, IT and Security Technology June 25, 2013 1 The material appearing in this presentation is for informational purposes only and should not be construed as advice of any kind, including,
More informationHIPAA COMPLIANCE. What is HIPAA?
HIPAA COMPLIANCE What is HIPAA? The Health Insurance Portability and Accountability Act (HIPAA) also known as the Privacy Rule specifies the conditions under which protected health information may be used
More informationHIPAA 101: Privacy and Security Basics
HIPAA 101: Privacy and Security Basics Purpose This document provides important information about Kaiser Permanente policies and state and federal laws for protecting the privacy and security of individually
More informationGAO PRESCRIPTION DRUG DATA. HHS Has Issued Health Privacy and Security Regulations but Needs to Improve Guidance and Oversight
GAO United States Government Accountability Office Report to Congressional Committees June 2012 PRESCRIPTION DRUG DATA HHS Has Issued Health Privacy and Security Regulations but Needs to Improve Guidance
More informationHIPAA Happenings in Hospital Systems. Donna J Brock, RHIT System HIM Audit & Privacy Coordinator
HIPAA Happenings in Hospital Systems Donna J Brock, RHIT System HIM Audit & Privacy Coordinator HIPAA Health Insurance Portability and Accountability Act of 1996 Title 1 Title II Title III Title IV Title
More informationWhat s new In the News Data Breach Discussion The 5 W s Risk Analysis: Why, What, how, When, and Who Common Issues Observed Q / A Session Purdue
What s new In the News Data Breach Discussion The 5 W s Risk Analysis: Why, What, how, When, and Who Common Issues Observed Q / A Session Purdue Healthcare Advisors The # of data breaches is climbing The
More informationHIPAA 100 Training Manual Table of Contents. V. A Word About Business Associate Agreements 10
HIPAA 100 Training Manual Table of Contents I. Introduction 1 II. Definitions 2 III. Privacy Rule 5 IV. Security Rule 8 V. A Word About Business Associate Agreements 10 CHICAGO DEPARTMENT OF PUBIC HEALTH
More informationACCOUNTABLE HEALTHCARE IPA HIPAA PRIVACY AND SECURITY TRAINING. By: Jerry Jackson Compliance and Privacy Officer
ACCOUNTABLE HEALTHCARE IPA HIPAA PRIVACY AND SECURITY TRAINING By: Jerry Jackson Compliance and Privacy Officer 1 1 Introduction Welcome to Privacy and Security Training course. This course will help you
More informationThe Basics of HIPAA Privacy and Security and HITECH
The Basics of HIPAA Privacy and Security and HITECH Protecting Patient Privacy Disclaimer The content of this webinar is to introduce the principles associated with HIPAA and HITECH regulations and is
More informationDonna S. Sheperis, PhD, LPC, NCC, CCMHC, ACS Sue Sadik, PhD, LPC, NCC, BC-HSP Carl Sheperis, PhD, LPC, NCC, MAC, ACS
Donna S. Sheperis, PhD, LPC, NCC, CCMHC, ACS Sue Sadik, PhD, LPC, NCC, BC-HSP Carl Sheperis, PhD, LPC, NCC, MAC, ACS 1 DISCLAIMER Please review your own documentation with your attorney. This information
More informationRaymond: Beyond Basic HIPAA - GSHA Convention 2-28-15 1 HIPAA HIPAA HIPAA. Financial. Carol Ann Raymond, MBA, Ed.S., CCC-SLP
Carol Ann Raymond, MBA, Ed.S., CCC-SLP Associate Clinical Professor/Clinic Director Department of Communication Sciences and Disorders Financial o Employed by the University of Georgia o Non-Financial
More informationHIPAA Privacy, Security, Breach, and Meaningful Use. CHUG October 2012
HIPAA Privacy, Security, Breach, and Meaningful Use Practice Requirements for 2012 CHUG October 2012 The Health Insurance Portability and Accountability Act of 1996 (HIPAA) Standards for Privacy of Individually
More informationHIPAA Privacy & Breach Notification Training for System Administration Business Associates
HIPAA Privacy & Breach Notification Training for System Administration Business Associates Barbara M. Holthaus privacyofficer@utsystem.edu Office of General Counsel University of Texas System April 10,
More informationWhat s New with HIPAA? Policy and Enforcement Update
What s New with HIPAA? Policy and Enforcement Update HHS Office for Civil Rights New Initiatives Precision Medicine Initiative (PMI), including Access Guidance Cybersecurity Developer portal NICS Final
More informationDecrypting the Security Risk Assessment (SRA) Requirement for Meaningful Use
Click to edit Master title style Decrypting the Security Risk Assessment (SRA) Requirement for Meaningful Use Andy Petrovich, MHSA, MPH M-CEITA / Altarum Institute April 8, 2015 4/8/2015 1 1 Who is M-CEITA?
More informationHIPAA & HITECH Privacy and Security Concerns : Are You Covered?
HIPAA & HITECH Privacy and Security Concerns : Are You Covered? Insurance Accounting and Systems Association Chicagoland Chapter Conference April 17, 2014 Colin Gainer & Tim Lessman SmithAmundsen, LLC
More informationWelcome to ChiroCare s Fourth Annual Fall Business Summit. October 3, 2013
Welcome to ChiroCare s Fourth Annual Fall Business Summit October 3, 2013 HIPAA Compliance Regulatory Overview & Implementation Tips for Providers Agenda Green packet Overview of general HIPAA terms and
More informationNetwork Security and Data Privacy Insurance for Physician Groups
Network Security and Data Privacy Insurance for Physician Groups February 2014 Lockton Companies While exposure to medical malpractice remains a principal risk MIKE EGAN, CPCU Senior Vice President Unit
More informationHIPAA in an Omnibus World. Presented by
HIPAA in an Omnibus World Presented by HITECH COMPLIANCE ASSOCIATES IS NOT A LAW FIRM The information given is not intended to be a substitute for legal advice or consultation. As always in legal matters
More informationProofpoint HIPAA Breach Report:
Proofpoint HIPAA Breach Report: An Analysis of HITECH Breach Notifications and Settlements, Q1 2013 Healthcare Industry Update threat protection compliance archiving & governance secure communication Contents
More informationDisclaimer 8/8/2014. Current Developments in Privacy and Security Rule Enforcement
Office of the Secretary Office for Civil Rights () Current Developments in Privacy and Security Rule Enforcement Michigan Medical Billers Association Andrew C. Kruley, J.D. Equal Opportunity Specialist
More informationAn Independent Member of Baker Tilly International
Healthcare Security and Compliance July 23, 2015 Presenters Kelley Miller, CISA, CISM - Principal Kelley.Miller@mcmcpa.com Barbie Thomas, MBA, CHC Barbie.Thomas@mcmcpa.com 2 Agenda Introductions Cybersecurity
More informationStrategies for. Proactively Auditing. Compliance to Mitigate. Matt Jackson, Director Kevin Dunnahoo, Manager
Strategies for 1 Proactively Auditing HIPAA Security Compliance to Mitigate Risk Matt Jackson, Director Kevin Dunnahoo, Manager AHIA 32 nd Annual Conference August 25-28, 2013 Chicago, Illinois www.ahia.org
More informationComputer Security Incident Response Plan. Date of Approval: 23- FEB- 2015
Name of Approver: Mary Ann Blair Date of Approval: 23- FEB- 2015 Date of Review: 22- FEB- 2015 Effective Date: 23- FEB- 2015 Name of Reviewer: John Lerchey Table of Contents Table of Contents... 2 Introduction...
More informationCompliance Program and HIPAA Training For First Tier, Downstream and Related Entities
Compliance Program and HIPAA Training For First Tier, Downstream and Related Entities 09/2011 Training Goals In this training you will gain an understanding of: Our Compliance Program elements Pertinent
More informationHIPAA Overview. Darren Skyles, Partner McGinnis Lochridge. Darren S. Skyles dskyles@mcginnislaw.com
HIPAA Overview Darren Skyles, Partner McGinnis Lochridge HIPAA Health Insurance Portability and Accountability Act of 1996 Electronic transaction and code sets: Adopted standards for electronic transactions
More informationIsaac Willett April 5, 2011
Current Options for EHR Implementation: Cloud or No Cloud? Regina Sharrow Isaac Willett April 5, 2011 Introduction Health Information Technology for Economic and Clinical Health Act ( HITECH (HITECH Act
More informationPresented by: Leslie Bender, CIPP General Counsel/CPO The ROI Companies www.theroi.com
Healthcare Compliance: How HiTECH May Affect Relationships with Business Associates Presented by: Leslie Bender, CIPP General Counsel/CPO The ROI Companies www.theroi.com Legal Disclaimer This information
More informationBusiness Associates and HIPAA
Business Associates and HIPAA What BAs need to know to comply with HIPAA privacy and security rules by Dom Nicastro White paper The lax days of complying with privacy and security laws are over for business
More informationHow To Write A Report On The Health Care Privacy And Security Rules Of Health Care For A Patient
Annual Report to Congress on HIPAA Privacy, Security, and Breach Notification Rule Compliance For Calendar Years 2011 and 2012 As Required by the Health Information Technology for Economic and Clinical
More informationHIPAA Compliance Guide
HIPAA Compliance Guide Important Terms Covered Entities (CAs) The HIPAA Privacy Rule refers to three specific groups as covered entities, including health plans, healthcare clearinghouses, and health care
More informationHIPAA COMPLIANCE PLAN FOR 2013
HIPAA COMPLIANCE PLAN FOR 2013 Welcome! Presentor is Rebecca Morehead, Practice Manager Strategist www.practicemanagersolutions.com Meaningful Use? As a way to encourage hospitals and providers to adopt
More informationUnderstanding HIPAA Privacy and Security Helping Your Practice Select a HIPAA- Compliant IT Provider A White Paper by CMIT Solutions
Understanding HIPAA Privacy and Security Helping Your Practice Select a HIPAA- Compliant IT Provider A White Paper by CMIT Solutions Table of Contents Understanding HIPAA Privacy and Security... 1 What
More informationDe-Identification of Health Data under HIPAA: Regulations and Recent Guidance" " "
De-Identification of Health Data under HIPAA: Regulations and Recent Guidance" " " D even McGraw " Director, Health Privacy Project January 15, 201311 HIPAA Scope Does not cover all health data Applies
More informationHIPAA-G04 Limited Data Set and Data Use Agreement Guidance
HIPAA-G04 Limited Data Set and Data Use Agreement Guidance GUIDANCE CONTENTS Scope Reason for the Guidance Guidance Statement Definitions ADDITIONAL DETAILS Additional Contacts Web Address Forms Related
More informationHIPAA AND MEDICAID COMPLIANCE POLICIES AND PROCEDURES
SALISH BHO HIPAA AND MEDICAID COMPLIANCE POLICIES AND PROCEDURES Policy Name: HIPAA BREACH NOTIFICATION REQUIREMENTS Policy Number: 5.16 Reference: 45 CFR Parts 164 Effective Date: 03/2016 Revision Date(s):
More informationHOW TO REALLY IMPLEMENT HIPAA. Presented by: Melissa Skaggs Provider Resources Group
HOW TO REALLY IMPLEMENT HIPAA Presented by: Melissa Skaggs Provider Resources Group WHAT IS HIPAA The Health Insurance Portability and Accountability Act of 1996 (HIPAA; Pub.L. 104 191, 110 Stat. 1936,
More informationSomansa Data Security and Regulatory Compliance for Healthcare
Somansa White Paper Somansa Data Security and Regulatory Compliance for Healthcare How Somansa can protect ephi- electronic patient health information and meet the requirements for healthcare compliances,
More informationOCR Reports on the Enforcement. Learning Objectives 4/1/2013. HIPAA Compliance/Enforcement (As of December 31, 2012) HCCA Compliance Institute
OCR Reports on the Enforcement of the HIPAA Rules HCCA Compliance Institute April 22, 2013 David Holtzman Sr. Health IT & Privacy Specialist U.S. Department of Health and Human Services Office for Civil
More informationOCR Reports on the Enforcement. Learning Objectives
OCR Reports on the Enforcement of the HIPAA Rules HCCA Compliance Institute April 22, 2013 David Holtzman Sr. Health IT & Privacy Specialist U.S. Department of Health and Human Services Office for Civil
More informationSecurity Compliance, Vendor Questions, a Word on Encryption
Security Compliance, Vendor Questions, a Word on Encryption Alexis Parsons, RHIT, CPC, MA Director, Health Information Services Security/Privacy Officer Shasta Community Health Center aparsons@shastahealth.org
More informationHIPAA: Understanding The Omnibus Rule and Keeping Your Business Compliant
1 HIPAA: Understanding The Omnibus Rule and Keeping Your Business Compliant Introduction U.S. healthcare laws intended to protect patient information (Protected Health Information or PHI) and the myriad
More informationWelcome to the Privacy and Security PowerPoint presentation in the Data Analytics Toolkit. This presentation will provide introductory information
Welcome to the Privacy and Security PowerPoint presentation in the Data Analytics Toolkit. This presentation will provide introductory information about HIPAA, the HITECH-HIPAA Omnibus Privacy Act, how
More informationEthics, Privilege, and Practical Issues in Cloud Computing, Privacy, and Data Protection: HIPAA February 13, 2015
Ethics, Privilege, and Practical Issues in Cloud Computing, Privacy, and Data Protection: HIPAA February 13, 2015 Katherine M. Layman Cozen O Connor 1900 Market Street Philadelphia, PA 19103 (215) 665-2746
More informationHIPAA and Leadership. The Importance of Creating a More Compliance Focused Environment
HIPAA and Leadership The Importance of Creating a More Compliance Focused Environment 1 AGENDA HIPAA Basics The Importance of Leadership in RIM and IG Creating a More Compliance Focused Culture Potential
More informationTHE HIGH PRICE OF MEDICAL RECORD PRIVACY BREACHES
THE HIGH PRICE OF MEDICAL RECORD PRIVACY BREACHES Melissa D. Berry The views and opinions expressed in this paper are those of the author and do not necessarily reflect the official policy or position
More informationHIPAA Compliance Guide
HIPAA Compliance Guide Important Terms Covered Entities (CAs) The HIPAA Privacy Rule refers to three specific groups as covered entities, including health plans, healthcare clearinghouses, and health care
More informationGuidance on Risk Analysis Requirements under the HIPAA Security Rule
Guidance on Risk Analysis Requirements under the HIPAA Security Rule Introduction The Office for Civil Rights (OCR) is responsible for issuing annual guidance on the provisions in the HIPAA Security Rule.
More informationHIPAA Breaches, Security Risk Analysis, and Audits
HIPAA Breaches, Security Risk Analysis, and Audits Derrick Hill Senior Health IT Advisor Kentucky REC What cons?tutes PHI? HIPAA provides a list of 18 iden?fiers that cons?tute PHI. Any one of these iden?fiers
More informationStatement of Policy. Reason for Policy
Table of Contents Statement of Policy 2 Reason for Policy 2 HIPAA Liaison 2 Individuals and Entities Affected by Policy 2 Who Should Know Policy 3 Exclusions 3 Website Address for Policy 3 Definitions
More informationSCHOOL OF PUBLIC HEALTH. HIPAA Privacy Training
SCHOOL OF PUBLIC HEALTH HIPAA Privacy Training Public Health and HIPAA This presentation will address the HIPAA Privacy regulations as they effect the activities of the School of Public Health. It is imperative
More informationVirginia Commonwealth University Information Security Standard
Virginia Commonwealth University Information Security Standard Title: Scope: Data Classification Standard This document provides the classification requirements for all data generated, processed, stored,
More informationHIPAA Enforcement Training for State Attorneys General
: State Attorneys General Enforcement of Federal Health Privacy Law HIPAA Enforcement Training for State Attorneys General Module Introduction : Introduction This module of the HIPAA Enforcement Training
More informationLessons Learned from Recent HIPAA and Big Data Breaches. Briar Andresen Katie Ilten Ann Ladd
Lessons Learned from Recent HIPAA and Big Data Breaches Briar Andresen Katie Ilten Ann Ladd Recent health care breaches Breach reports to OCR as of February 2015 1,144 breaches involving 500 or more individual
More informationMCCP Online Orientation
Objectives At the conclusion of this presentation, students will be able to: Describe the federal requirements of the HIPAA/HITECH regulations that protect the privacy and security of confidential data.
More informationHIPAA Audits Are Happening. eroi
HIPAA Audits Are Happening. eroi Are You at Risk? efiling Advanced efile Form Completion Charting Host: Kathryn Ayers Wickenhauser Meaningful Use / HIPAA Compliance Consultant Kathryn.Wickenhauser@DatafileTechnologies.com
More informationSection C: Data Use Agreement. Illinois Department of Healthcare and Family Services. And DATA USE AGREEMENT
Section C: Data Use Agreement Illinois Department of Healthcare and Family Services And DATA USE AGREEMENT This Data Use Agreement (the Agreement ) is effective as of (the Agreement Effective Date ) by
More informationUnderstanding Health Insurance Portability Accountability Act AND HITECH. HIPAA s Privacy Rule
Understanding Health Insurance Portability Accountability Act AND HITECH HIPAA s Privacy Rule 1 What Is HIPAA s Privacy Rule The privacy rule is a component of the Health Insurance Portability and Accountability
More informationName of Other Party: Address of Other Party: Effective Date: Reference Number as applicable:
PLEASE NOTE: THIS DOCUMENT IS SUBMITTED AS A SAMPLE, FOR INFORMATIONAL PURPOSES ONLY TO ABC ORGANIZATION. HIPAA SOLUTIONS LC IS NOT ENGAGED IN THE PRACTICE OF LAW IN ANY STATE, JURISDICTION, OR VENUE OF
More information3/13/2015 HIPAA/HITECH WHAT S YOUR COMPLIANCE STATUS? Daniel B. Mills Pretzel & Stouffer, Chartered WHAT IS HIPAA?
HIPAA/HITECH WHAT S YOUR COMPLIANCE STATUS? Daniel B. Mills Pretzel & Stouffer, Chartered WHAT IS HIPAA? 1 DEFINITIONS HIPAA Health Insurance Portability and Accountability Act of 1996 Primarily designed
More informationHIPAA COMPLIANCE INFORMATION. HIPAA Policy
HIPAA COMPLIANCE INFORMATION HIPAA Policy Use of Protected Health Information for Research Policy University of North Texas Health Science Center at Fort Worth Applicability: All University of North Texas
More informationData Security Considerations for Research
Data Security Considerations for Research Institutional Review Board Annual Education May 8, 2012 1 PRIVACY vs. SECURITY What s the Difference?: PRIVACY Refers to WHAT is protected Health information about
More informationHIPAA Orientation. Health Insurance Portability and Accountability Act
HIPAA Orientation Health Insurance Portability and Accountability Act HIPAA Federal legislation enacted in 1996 to improve the efficiency and effectiveness of electronic information transfers used in the
More information