HIPAA Requirements for Data Security

Transcription

1 HIPAA Requirements for Data Security Dennis Schmidt, HIPAA Security Officer UNC School of Medicine March, 2012

2 What does HIPAA Compliant Mean? It depends! The HIPAA Security Rule does not give many specific technical requirements. The Security Rule is designed to be flexible and scalable so a covered entity can implement policies, procedures, and technologies that are appropriate for the entity s particular size, organizational structure, and risks to consumers e-phi. Due diligence and industry standards apply.

3 What does HHS Say? The Security Rule requires covered entities to maintain reasonable and appropriate administrative, technical, and physical safeguards for protecting e-phi. Specifically, covered entities must: Ensure the confidentiality, integrity, and availability of all e- PHI they create, receive, maintain or transmit; Identify and protect against reasonably anticipated threats to the security or integrity of the information; Protect against reasonably anticipated, impermissible uses or disclosures; and Ensure compliance by their workforce.

4 Administrative Safeguards Security Management Process Assigned Security Responsibility Workforce Security Information Access Management Security Awareness and Training Security Incident Procedures Contingency Plan Evaluation Business Associate Contracts

5 Physical Safeguards Facility Access Controls Workstation Use Workstation Security Device and Media Controls

6 Technical Safeguards Access Control Audit Controls Integrity Person or Entity Authentication Transmission Security

7 Required vs Addressable Required means it must be implemented. Addressable means that it must be done unless the entity can document that it is not reasonable and can implement and alternative reasonable and appropriate method. Example: Encryption is Addressable

8 Size Matters When a covered entity is deciding which security measures to use, the Rule does not dictate those measures but requires the covered entity to consider: Its size, complexity, and capabilities, Its technical, hardware, and software infrastructure, The costs of security measures, and The likelihood and possible impact of potential risks to e- PHI. Covered entities must review and modify their security measures to continue protecting e-phi in a changing environment.

9 Risk Analysis and Management Administrative Safeguards provisions in Security Rule require covered entities to perform risk analysis as part of their security management processes. Risk analysis process includes following activities: Evaluate the likelihood and impact of potential risks to e- PHI; Implement appropriate security measures to address the risks identified in the risk analysis; Document the chosen security measures and, where required, the rationale for adopting those measures; Maintain continuous, reasonable, and appropriate security protections.

10 An Ongoing Process Risk analysis should be an ongoing process, in which a covered entity regularly reviews its records to track access to e-phi and detect security incidents, periodically evaluates the effectiveness of security measures put in place, and regularly reevaluates potential risks to e- PHI.

11 The Fine Line Between HIPAA Data and Research Data The data elements may be the same or similar, however different laws regulate each. Breach reporting requirements are different. However, both types of data should be given the same levels of protection.

12 Enough Legal Jibberish, How Should I Secure My Data? Follow Campus Security Policies Conduct/update risk assessment of your systems/data Document, document, document!! Store data on a centrally managed server Physical Security, Access Controls, Backups, etc. Encrypt your laptops/workstations that process sensitive data Put server behind SOM or ITS firewall Use encryption technology on your data PGP Netshare, TrueCrypt, MS SQL TDE, etc.

13 Cloud Computing Public Clouds (Google Docs, Drop Box, Carbonite, Mozy, icloud, etc.) Okay to use for non-sensitive data Prohibited for sensitive data unless Signed Business Associates Agreement (BAA) approved by Office of University Counsel in place. Iron Mountain is currently only company that has signed one. Private Cloud (UNC NAS) Not currently approved for sensitive data

14 Questions?