HIPAA Compliance and the Protection of Patient Health Information

Size: px
Start display at page:

Download "HIPAA Compliance and the Protection of Patient Health Information"

Transcription

1 HIPAA Compliance and the Protection of Patient Health Information WHITE PAPER By Swift Systems Inc. April 2015 Swift Systems Inc Executive Way, Ste M Frederick MD

2 Contents HIPAA Compliance and the Protection of Patient Health Information... 1 Introduction... 3 Risks... 3 HIPAA Objectives... 3 Covered Entities... 4 Business Associates... 4 Penalties for Non-Compliance... 4 Criminal Penalties... 5 Civil Penalties... 5 Impact on Business... 5 The HIPAA Security Rule... 6 Security Rule Requirements... 6 Security Measures... 6 The Contingency Plan... 7 The HIPAA Omnibus Rule... 8 Definition of Business Associates... 8 The Conduit Exception... 9 Business Associate Agreement & Mandatory Provisions Swift Systems Solution for HIPAA Compliance Legal Disclosure

3 Introduction As technology moves forward at an ever faster pace, patient privacy has taken center stage and especially the concerns surrounding Digital security. Increasingly, digital record keeping has become the de facto norm for medical practices, and with Digital record keeping, healthcare organizations must be aware of the associated risks. Risk mitigation is crucial to protect both patients and healthcare organizations alike. Risks Risks associated with Digital record keeping include: The risk of a disaster resulting in physical damage to the integrity of patient data or outright loss. Corruption or loss of patient data by viruses or malware. Theft or corruption of patient data by hackers or physical intruders. Theft or corruption of patient data by internal staff. Accidental loss or theft of Mobile devices, such as laptops and tablets, containing patient data. HIPAA Objectives The Health Insurance Portability and Accountability Act ( HIPAA ) was enacted by Congress in 1996, and with the advent of this legislation, a set of universal standards was introduced to hold healthcare providers accountable for the safety of patient data. HIPAA s core objectives were to mandate patient confidentiality while promoting the portability of their records, with appropriate access to patient records amongst authorized healthcare providers and ancillary persons. Consistency was also a goal of HIPAA, not only across the healthcare industry, but also within individual provider s operations. 3

4 The ultimate objective of HIPAA is the protection of healthcare systems containing patient data, and promoting patient confidence in the integrity and security of their private information. Covered Entities A Covered Entity defines who must comply with HIPAA provisions: typically, any health care provider, health plan or clearinghouse who captures, stores or transmits patient records by Digital means. A Covered Entity must institute appropriate measures to protect patient data privacy, including physical, technical and administrative safeguards. Specifically, a Covered Entity must, amongst other things, establish: A Data Backup Plan. A Disaster Recovery Plan. An Emergency Mode Operation Plan. HIPAA provided for a compliance regime, together with penalties for violators. Penalties were increased and broadened in 2009 with the enactment of the Health Information Technology for Economic and Clinical Health Act ( HITECH ), which also broadened the range of violations and entities covered by HIPAA, e.g. business associates of medical practices. Business Associates Business Associates are defined to include vendors and providers of Electronic Health Records (EHR), and there is also the possibility for other parties to be held accountable under HIPAA. Compliance with HIPAA demonstrates your commitment to patient privacy and confidentiality, as well as your direct commitment to prevention of patient information by security breach and ensuing financial loss. Penalties for Non-Compliance Penalties for non-compliance with HIPAA are severe, and are divided into Criminal and Civil penalties: 4

5 Criminal Penalties Fines ranging from $50,000 to $250,000. Jail terms ranging from one year to 10 years in prison. Civil Penalties Where willful neglect is demonstrated, penalties include fines up to $250,000 through to $1.5 million for repeat violations (including where a prior violation has not been corrected). Impact on Business Aside from the civil and criminal penalties which may be levied for violations, there is the considerable risk of losing patient business, commercial partnerships, and the attendant negative publicity. 5

6 The HIPAA Security Rule The HIPAA Security Rule covers all patient health data transmitted or stored in an electronic format or managed on electronic media. Security Rule Requirements 45 CFR requires Covered Entities to: Protect patient data and electronic systems handling patient data from any reasonably anticipated threats which may affect the security of patient data. Protect the confidentiality, integrity and the availability of patient data stored or transmitted electronically, including when patient data is created or received by the Covered Entity as well as when stored or transmitted. Protect against unauthorized disclosure or misuse where such acts can be reasonably anticipated. Subpart E also stipulates what patient data is REQUIRED to be protected, irrespective of the reasonable anticipation language. Establish and enforce staff compliance with this subpart. Security Measures HIPAA provides a degree of flexibility for Covered Entities in how they implement these requirements. The language is clear in this through the use of phrases such as reasonably anticipated, which means specific security measures and procedures are left to the Covered Entity to determine. This naturally requires the Covered Entity to understand what security measures and protocols are available, and more particularly, what threats can be reasonably anticipated. The decision as to which security measures are to be implemented by the Covered Entity must consider the following: Existing infrastructure, including hardware and software and attendant security protections already afforded. 6

7 The size and complexity of the Covered Entity s operations, including their capabilities. Potential risks to patient data, together with an intentional assessment of the probability and criticality of any potential risk which can be reasonably anticipated. The Contingency Plan Covered Entities must also comply with the Security Rule s requirement to back up and protect electronic data. This includes the formulation and implementation of a Contingency Plan to be invoked in the event of a disaster or breach which may result in major loss of data. The Contingency Plan requirements are contained in Administrative Safeguards (a)(7)(i): Establish (and implement as needed) policies and procedures for responding to an emergency or other occurrence (for example, fire, vandalism, system failure, and natural disaster) that damages systems that contain electronic protected health information The Contingency Plan MUST be implemented using the following: REQUIRED Data Backup Plan the Covered Entity MUST establish and implement a Data Backup Plan to include the creation and maintenance of retrievable and exact copies of protected health data stored, transmitted or maintained in an electronic format. REQUIRED Disaster Recovery Plan the Covered Entity MUST establish and implement a Disaster Recovery Plan to recover any loss of protected information or data. REQUIRED Emergency Mode Operation Plan the Covered Entity MUST create and implement an Emergency Mode Operation Plan to ensure business continuation for critical business processes to ensure continuing security of protected health information and data during operations in emergency mode. Physical Requirements which MUST be complied with include: 7

8 o Physical Safeguards (a)(1) physical access to electronic systems MUST be limited by policies and procedures, and also includes restriction of access to the facilities within which electronic systems are situated such that only authorized access is permitted. o Facility Access during a Disaster or Emergency (a)(2)(i) procedures shall be created and implemented to facilitate access to any facility where such electronic systems are situated when executing either the Disaster Recovery Plan or Emergency Mode Operations Plan. Technical Safeguards Covered Entities must also adopt specified technical safeguards to cover the following (refer to for a full list): o Encryption and decryption of protected data. o Limitation of access to protected data. o Audit controls to record and monitor system activity containing or using protected data. o Technical security measures to protect against unauthorized access to protected data during transmission over an electronic communications network. Covered Entities should therefore assess and evaluate their electronic systems and secure electronic protected health information. This includes the deployment of a secure backup, archiving and retrieval solution to ensure full compliance with HIPAA. The HIPAA Omnibus Rule New privacy rules were introduced and became effective January 17, 2013 and are collectively known as the HIPAA Omnibus Rule. The HIPAA Omnibus Rule extends some of the rules to Business Associates of Covered Entities. Definition of Business Associates The Department of Health and Human Services (HHS) defines Business Associates, and some examples are: 8

9 A firm of IT consultants who manage IT infrastructure or provide network management services, and who may have access to patient health information in the performance of their duties under the contract. A firm of accountants who provide services to healthcare providers and which involves access to protected patient information. Healthcare clearinghouses who convert non-standard formatting of a claim into a standardized version for onward transmission to the payer. A consultant (person or organization) who conducts utilization reviews for a healthcare provider. Third party medical transcription service providers performing work for a medical practitioner. A benefits manager or administrator who manages a pharmacist network on behalf of a health plan provider. A lawyer acting for a healthcare provider and who has access to protected patient information. Third party claims processors. Click this link for detailed information on the HHS website. The Conduit Exception The Conduit Exception allows for an exemption for Business Associates who are providing a courier service, such as the U.S. Postal Service, FedEx or UPS. Incidentally, the Conduit Exception also applies to Internet Service Providers (ISPs) where they are only providing data transmission services. The underlying principle is that a conduit simply carries data or information, but does not have access to it except only as required to perform transmission or transport to the intended destination (unless otherwise required by law.) The Conduit Exception forms part of the Omnibus Rule, and an important amendment was to remove the old exemption for Business Associates who are providing cloud backup or data storage services. These providers are now specifically classified as Business Associates and are caught by HIPAA provisions. 9

10 Business Associate Agreement & Mandatory Provisions These provisions include the mandatory requirement they sign a Business Associate Agreement with the Covered Entity they provide services to. HHS REQUIRES the following contractual provisions: A provision the Business Associate will NOT use or disclose protected health data for any other purpose except as proscribed by law or for the purposes of carrying contractual provisions. A provision that the Business Associate will also adopt and take suitable precautions and safeguards to prevent unauthorized use or disclosure of protected health information, except as laid out in the contract. Swift Systems Solution for HIPAA Compliance Swift Systems has over 15 years of experience working with healthcare providers, and their Business Associates, in implementing and maintaining state-of-the-art IT systems to ensure compliance with HIPAA. We are the leading regional provider of HIPAA Some of our clients include: INSERT SUITABLE CLIENT LIST HERE Specifically, we offer: Managed IT Services & Network Security. Cloud Backup and Storage. Disaster Recovery. Backing Up & Recovery of protected health information. Emergency Mode Operation planning. Security & Encryption of protected health data. Logging & Archiving with full audit trail functionality using JobTraQ. 10

11 We are partnered with the leading manufacturers and vendors in the technology field, including: INSERT PARTNER LIST Ensure you fully comply with HIPAA and start with a free consultation from Swift Systems: Legal Disclosure Nothing in this White Paper is intended to constitute legal advice. For more information about HIPAA and compliance with HIPAA requirements please consult your legal counsel. 11

HIPAA COMPLIANCE AND DATA PROTECTION. sales@eaglenetworks.it +39 030 201.08.25 Page 1

HIPAA COMPLIANCE AND DATA PROTECTION. sales@eaglenetworks.it +39 030 201.08.25 Page 1 HIPAA COMPLIANCE AND DATA PROTECTION sales@eaglenetworks.it +39 030 201.08.25 Page 1 CONTENTS Introduction..... 3 The HIPAA Security Rule... 4 The HIPAA Omnibus Rule... 6 HIPAA Compliance and EagleHeaps

More information

HIPAA COMPLIANCE AND

HIPAA COMPLIANCE AND INTRONIS CLOUD BACKUP & RECOVERY HIPAA COMPLIANCE AND DATA PROTECTION CONTENTS Introduction 3 The HIPAA Security Rule 4 The HIPAA Omnibus Rule 6 HIPAA Compliance and Intronis Cloud Backup and Recovery

More information

Ensuring HIPAA Compliance with eztechdirect Online Backup and Archiving Services

Ensuring HIPAA Compliance with eztechdirect Online Backup and Archiving Services Ensuring HIPAA Compliance with eztechdirect Online Backup and Archiving Services Introduction Patient privacy continues to be a chief topic of concern as technology continues to evolve. Now that the majority

More information

Ensuring HIPAA Compliance with Pros 4 Technology Online Backup and Archiving Services

Ensuring HIPAA Compliance with Pros 4 Technology Online Backup and Archiving Services Ensuring HIPAA Compliance with Pros 4 Technology Online Backup and Archiving Services Introduction Patient privacy has become a major topic of concern over the past several years. With the majority of

More information

Ensuring HIPAA Compliance with Computer BYTES Online Backup and Archiving Services

Ensuring HIPAA Compliance with Computer BYTES Online Backup and Archiving Services Ensuring HIPAA Compliance with Computer BYTES Online Backup and Archiving Services Page 2 of 8 Introduction Patient privacy has become a major topic of concern over the past several years. With the majority

More information

Ensuring HIPAA Compliance with AcclaimVault Online Backup and Archiving Services

Ensuring HIPAA Compliance with AcclaimVault Online Backup and Archiving Services Ensuring HIPAA Compliance with AcclaimVault Online Backup and Archiving Services 1 Contents 3 Introduction 5 The HIPAA Security Rule 7 HIPAA Compliance & AcclaimVault Backup 8 AcclaimVault Security and

More information

WHITE PAPER. HIPPA Compliance and Secure Online Data Backup and Disaster Recovery

WHITE PAPER. HIPPA Compliance and Secure Online Data Backup and Disaster Recovery WHITE PAPER HIPPA Compliance and Secure Online Data Backup and Disaster Recovery January 2006 HIPAA Compliance and the IT Portfolio Online Backup Service Introduction October 2004 In 1996, Congress passed

More information

Heather L. Hughes, J.D. HIPAA Privacy Officer U.S. Legal Support, Inc. hhughes@uslegalsupport.com www.uslegalsupport.com

Heather L. Hughes, J.D. HIPAA Privacy Officer U.S. Legal Support, Inc. hhughes@uslegalsupport.com www.uslegalsupport.com Heather L. Hughes, J.D. HIPAA Privacy Officer U.S. Legal Support, Inc. hhughes@uslegalsupport.com www.uslegalsupport.com HIPAA Privacy Rule Sets standards for confidentiality and privacy of individually

More information

HIPAA PRIVACY AND SECURITY AWARENESS

HIPAA PRIVACY AND SECURITY AWARENESS HIPAA PRIVACY AND SECURITY AWARENESS Introduction The Health Insurance Portability and Accountability Act (known as HIPAA) was enacted by Congress in 1996. HIPAA serves three main purposes: To protect

More information

HIPAA Security Rule Compliance

HIPAA 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 information

HIPAA Compliance Guide

HIPAA 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 information

HIPAA Compliance Guide

HIPAA 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 information

HIPAA Security. 2 Security Standards: Administrative Safeguards. Security Topics

HIPAA Security. 2 Security Standards: Administrative Safeguards. Security Topics HIPAA Security SERIES Security Topics 1. Security 101 for Covered Entities 5. 2. Security Standards - Organizational, Security Policies Standards & Procedures, - Administrative and Documentation Safeguards

More information

Health Insurance Portability and Accountability Act (HIPAA) and Health Information Technology for Economic and Clinical Health Act (HITECH)

Health Insurance Portability and Accountability Act (HIPAA) and Health Information Technology for Economic and Clinical Health Act (HITECH) Health Insurance Portability and Accountability Act (HIPAA) and Health Information Technology for Economic and Clinical Health Act (HITECH) Table of Contents Introduction... 1 1. Administrative Safeguards...

More information

OCTOBER 2013 PART 1. Keeping Data in Motion: How HIPAA affects electronic transfer of protected health information

OCTOBER 2013 PART 1. Keeping Data in Motion: How HIPAA affects electronic transfer of protected health information OCTOBER 2013 PART 1 Keeping Data in Motion: How HIPAA affects electronic transfer of protected health information Part 1: How HIPAA affects electronic transfer of protected health information It is difficult

More information

Preparing for the HIPAA Security Rule

Preparing for the HIPAA Security Rule A White Paper for Health Care Professionals Preparing for the HIPAA Security Rule Introduction The Health Insurance Portability and Accountability Act (HIPAA) comprises three sets of standards transactions

More information

WHITE PAPER. HIPAA-Compliant Data Backup and Disaster Recovery

WHITE PAPER. HIPAA-Compliant Data Backup and Disaster Recovery WHITE PAPER HIPAA-Compliant Data Backup and Disaster Recovery DOCUMENT INFORMATION HIPAA-Compliant Data Backup and Disaster Recovery PRINTED March 2011 COPYRIGHT Copyright 2011 VaultLogix, LLC. All Rights

More information

HIPAA: Understanding The Omnibus Rule and Keeping Your Business Compliant

HIPAA: 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 information

What Virginia s Free Clinics Need to Know About HIPAA and HITECH

What Virginia s Free Clinics Need to Know About HIPAA and HITECH What Virginia s Free Clinics Need to Know About HIPAA and HITECH This document is one in a series of tools and white papers produced by the Virginia Health Care Foundation to help Virginia s free clinics

More information

COMPLIANCE ALERT 10-12

COMPLIANCE ALERT 10-12 HAWAII HEALTH SYSTEMS C O R P O R A T I O N "Touching Lives Every Day COMPLIANCE ALERT 10-12 HIPAA Expansion under the American Recovery and Reinvestment Act of 2009 The American Recovery and Reinvestment

More information

HIPAA/HITECH PRIVACY & SECURITY CHECKLIST SELF ASSESSMENT INSTRUCTIONS

HIPAA/HITECH PRIVACY & SECURITY CHECKLIST SELF ASSESSMENT INSTRUCTIONS 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

More information

Datto Compliance 101 1

Datto Compliance 101 1 Datto Compliance 101 1 Overview Overview This document provides a general overview of the Health Insurance Portability and Accounting Act (HIPAA) compliance requirements for Managed Service Providers (MSPs)

More information

The Case For HIPAA Risk Assessment. Leader s Guide

The Case For HIPAA Risk Assessment. Leader s Guide 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 information

HIPAA Information Security Overview

HIPAA Information Security Overview HIPAA Information Security Overview Security Overview HIPAA Security Regulations establish safeguards for protected health information (PHI) in electronic format. The security rules apply to PHI that is

More information

Understanding 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 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 information

BUSINESS ASSOCIATES AND BUSINESS ASSOCIATE AGREEMENTS

BUSINESS ASSOCIATES AND BUSINESS ASSOCIATE AGREEMENTS PRIVACY 27.0 BUSINESS ASSOCIATES AND BUSINESS ASSOCIATE AGREEMENTS Scope: Purpose: All subsidiaries of Universal Health Services, Inc., including facilities and UHS of Delaware Inc. (collectively, UHS

More information

Health Care Information Privacy The HIPAA Regulations What Has Changed and What You Need to Know

Health Care Information Privacy The HIPAA Regulations What Has Changed and What You Need to Know Health Care Information Privacy The HIPAA Regulations What Has Changed and What You Need to Know Note: Information provided to NCRA by Melodi Gates, Associate with Patton Boggs, LLC Privacy and data protection

More information

Building Trust and Confidence in Healthcare Information. How TrustNet Helps

Building Trust and Confidence in Healthcare Information. How TrustNet Helps Building Trust and Confidence in Healthcare Information The management of healthcare information in the United States is regulated under the HIPAA (Health Insurance Portability and Accountability Act)

More information

Ethics, 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 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 information

Bridging the HIPAA/HITECH Compliance Gap

Bridging the HIPAA/HITECH Compliance Gap 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

More information

Meaningful Use and Security Risk Analysis

Meaningful Use and Security Risk Analysis Meaningful Use and Security Risk Analysis Meeting the Measure Security in Transition Executive Summary Is your organization adopting Meaningful Use, either to gain incentive payouts or to avoid penalties?

More information

What 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 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 information

Sunday March 30, 2014, 9am noon HCCA Conference, San Diego

Sunday 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 information

HIPAA Omnibus Compliance How A Data Loss Prevention Solution Can Help

HIPAA Omnibus Compliance How A Data Loss Prevention Solution Can Help HIPAA Omnibus Compliance How A Data Loss Prevention Solution Can Help The Health Information Portability and Accountability Act (HIPAA) Omnibus Rule which will begin to be enforced September 23, 2013,

More information

HIPAA Audit Processes HIPAA Audit Processes. Erik Hafkey Rainer Waedlich

HIPAA Audit Processes HIPAA Audit Processes. Erik Hafkey Rainer Waedlich HIPAA Audit Processes Erik Hafkey Rainer Waedlich 1 Policies for all HIPAA relevant Requirements and Regulations Checklist for an internal Audit Process Documentation of the compliance as Preparation for

More information

Healthcare Compliance Solutions

Healthcare Compliance Solutions Privacy Compliance Healthcare Compliance Solutions Trust and privacy are essential for building meaningful human relationships. Let Protected Trust be your Safe Harbor The U.S. Department of Health and

More information

efolder White Paper: HIPAA Compliance

efolder White Paper: HIPAA Compliance efolder White Paper: HIPAA Compliance October 2014 Copyright 2014, efolder, Inc. Abstract This paper outlines how companies can use certain efolder services to facilitate HIPAA and HITECH compliance within

More information

Business Associate Management Methodology

Business Associate Management Methodology Methodology auxilioinc.com 844.874.0684 Table of Contents Methodology Overview 3 Use Case 1: Upstream of s I manage business associates 4 System 5 Use Case 2: Eco System of s I manage business associates

More information

2/9/2012. 2012 HIPAA Privacy and Security Audit Readiness. Table of contents

2/9/2012. 2012 HIPAA Privacy and Security Audit Readiness. Table of contents 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)

More information

Appendix 4-2: Sample HIPAA Security Risk Assessment For a Small Physician Practice

Appendix 4-2: Sample HIPAA Security Risk Assessment For a Small Physician Practice Appendix 4-2: Administrative, Physical, and Technical Safeguards Breach Notification Rule How Use this Assessment The following sample risk assessment provides you with a series of sample questions help

More information

HIPAA Compliance: Are you prepared for the new regulatory changes?

HIPAA 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 information

HIPAA Security Series

HIPAA Security Series 7 Security Standards: Implementation for the Small Provider What is the Security Series? The security series of papers provides guidance from the Centers for Medicare & Medicaid Services (CMS) on the rule

More information

OCRA Spring Convention ~ 2014 Phyllis Craver Lykken, RPR, CLR, CCR 2463. Court Reporters and HIPAA

OCRA Spring Convention ~ 2014 Phyllis Craver Lykken, RPR, CLR, CCR 2463. Court Reporters and HIPAA Court Reporters and HIPAA OCRA Spring Convention ~ 2014 Phyllis Craver Lykken, RPR, CLR, CCR 2463 1 What Exactly is HIPAA? HIPAA is an acronym for the Health Insurance Portability and Accountability Act

More information

Why Lawyers? Why Now?

Why 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 information

Double-Take in a HIPAA Regulated Health Care Industry

Double-Take in a HIPAA Regulated Health Care Industry Double-Take in a HIPAA Regulated Health Care Industry Abstract: This document addresses the contingency plan and physical access control requirements of the Administrative Simplification security provision

More information

HIPAA and Mental Health Privacy:

HIPAA and Mental Health Privacy: HIPAA and Mental Health Privacy: What Social Workers Need to Know Presenter: Sherri Morgan, JD, MSW Associate Counsel, NASW Legal Defense Fund and Office of Ethics & Professional Review 2010 National Association

More information

HIPAA Security Checklist

HIPAA Security Checklist HIPAA Security Checklist The following checklist summarizes HIPAA Security Rule requirements that should be implemented by covered entities and business associates. The citations are to 45 CFR 164.300

More information

SECURITY RISK ASSESSMENT SUMMARY

SECURITY RISK ASSESSMENT SUMMARY 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

More information

3/13/2015 HIPAA/HITECH WHAT S YOUR COMPLIANCE STATUS? Daniel B. Mills Pretzel & Stouffer, Chartered WHAT IS HIPAA?

3/13/2015 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 information

Trust 9/10/2015. Why Does Privacy and Security Matter? Who Must Comply with HIPAA Rules? HIPAA Breaches, Security Risk Analysis, and Audits

Trust 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 information

HIPAA: In Plain English

HIPAA: In Plain English HIPAA: In Plain English Material derived from a presentation by Kris K. Hughes, Esq. Posted with permission from the author. The Health Insurance Portability and Accountability Act of 1996 (HIPAA), Pub.

More information

HIPAA Omnibus Rule Overview. Presented by: Crystal Stanton MicroMD Marketing Communication Specialist

HIPAA Omnibus Rule Overview. Presented by: Crystal Stanton MicroMD Marketing Communication Specialist HIPAA Omnibus Rule Overview Presented by: Crystal Stanton MicroMD Marketing Communication Specialist 1 HIPAA Omnibus Rule - Agenda History of the Omnibus Rule What is the HIPAA Omnibus Rule and its various

More information

Meaningful Use and Core Requirement 15

Meaningful Use and Core Requirement 15 Meaningful Use and Core Requirement 15 How can I comply the lack of time and staff... www.compliancygroup.com 1 Meaningful Use and Core Requirement 15 Meaningful Use Protection of Protected Health Information

More information

VMware vcloud Air HIPAA Matrix

VMware vcloud Air HIPAA Matrix goes to great lengths to ensure the security and availability of vcloud Air services. In this effort VMware has completed an independent third party examination of vcloud Air against applicable regulatory

More information

Preparing for the HIPAA Security Rule Again; now, with Teeth from the HITECH Act!

Preparing for the HIPAA Security Rule Again; now, with Teeth from the HITECH Act! A White Paper for Health Care Professionals Preparing for the HIPAA Security Rule Again; now, with Teeth from the HITECH Act! Introduction Several years ago we first published A White Paper for Health

More information

ü Ensuring the privacy and security of personally identifiable health information (the Privacy and Security Rules); and

ü Ensuring the privacy and security of personally identifiable health information (the Privacy and Security Rules); and Provided by Benefits By Choice HIPAA Rules: Privacy, Security and Electronic Data Interchange The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a broad federal law regarding health

More information

Healthcare Insurance Portability & Accountability Act (HIPAA)

Healthcare Insurance Portability & Accountability Act (HIPAA) O C T O B E R 2 0 1 3 Healthcare Insurance Portability & Accountability Act (HIPAA) Secure Messaging White Paper This white paper briefly details how HIPAA affects email security for healthcare organizations,

More information

New HIPAA regulations require action. Are you in compliance?

New HIPAA regulations require action. Are you in compliance? New HIPAA regulations require action. Are you in compliance? Mary Harrison, JD Tami Simon, JD May 22, 2013 Discussion topics Introduction Remembering the HIPAA Basics HIPAA Privacy Rules HIPAA Security

More information

HOW TO REALLY IMPLEMENT HIPAA. Presented by: Melissa Skaggs Provider Resources Group

HOW 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 information

This is the third and final presentation on HIPAA Security Administrative Safeguards. This presentation focuses on the last 2 standards under the

This is the third and final presentation on HIPAA Security Administrative Safeguards. This presentation focuses on the last 2 standards under the 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.

More information

HIPAA 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 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 information

Data Security and Integrity of e-phi. MLCHC Annual Clinical Conference Worcester, MA Wednesday, November 12, 2014 2:15pm 3:30pm

Data 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 information

HIPAA SECURITY RISK ASSESSMENT SMALL PHYSICIAN PRACTICE

HIPAA SECURITY RISK ASSESSMENT SMALL PHYSICIAN PRACTICE HIPAA SECURITY RISK ASSESSMENT SMALL PHYSICIAN PRACTICE How to Use this Assessment The following risk assessment provides you with a series of questions to help you prioritize the development and implementation

More information

HIPAA Secure Now! How MSPs Can Profit From Selling HIPAA security services

HIPAA Secure Now! How MSPs Can Profit From Selling HIPAA security services HIPAA Secure Now! How MSPs Can Profit From Selling HIPAA security services How MSPs can profit from selling HIPAA security services Managed Service Providers (MSP) can use the Health Insurance Portability

More information

HIPAA and HITECH Compliance for Cloud Applications

HIPAA and HITECH Compliance for Cloud Applications What Is HIPAA? The healthcare industry is rapidly moving towards increasing use of electronic information systems - including public and private cloud services - to provide electronic protected health

More information

The Impact of HIPAA and HITECH

The Impact of HIPAA and HITECH The Health Insurance Portability & Accountability Act (HIPAA), enacted 8/21/96, was created to protect the use, storage and transmission of patients healthcare information. This protects all forms of patients

More information

HIPAA/HITECH: A Guide for IT Service Providers

HIPAA/HITECH: A Guide for IT Service Providers HIPAA/HITECH: A Guide for IT Service Providers Much like Arthur Dent in the opening scene of The Hitchhiker s Guide to the Galaxy (HHGTTG), you re experiencing the impact of new legislation that s infringing

More information

BUSINESS ASSOCIATE AGREEMENT

BUSINESS ASSOCIATE AGREEMENT BUSINESS ASSOCIATE AGREEMENT THIS BUSINESS ASSOCIATE AGREEMENT (this Agreement ), effective as of May 1, 2014 (the Effective Date ), by and between ( Covered Entity ) and Orchard Software Corporation,

More information

C.T. Hellmuth & Associates, Inc.

C.T. Hellmuth & Associates, Inc. Technical Monograph C.T. Hellmuth & Associates, Inc. Technical Monographs usually are limited to only one subject which is treated in considerably more depth than is possible in our Executive Newsletter.

More information

Guide: Meeting HIPAA Security Rules

Guide: Meeting HIPAA Security Rules Networks Guide: Meeting HIPAA Security Rules Intelligent Network Security 100 West Harrison North Tower, Suite 300 Seattle, WA 98119 T 206. 285. 8080 F 206. 285. 8081 w w w. l ockdow nnet w o r k s. com

More information

12/19/2014. HIPAA More Important Than You Realize. Administrative Simplification Privacy Rule Security Rule

12/19/2014. 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 information

Somansa Data Security and Regulatory Compliance for Healthcare

Somansa 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 information

The HIPAA Security Rule Primer A Guide For Mental Health Practitioners

The HIPAA Security Rule Primer A Guide For Mental Health Practitioners The HIPAA Security Rule Primer A Guide For Mental Health Practitioners Distributed by NASW Printer-friendly PDF 2006 APAPO 1 Contents Click on any title below to jump to that page. 1 What is HIPAA? 3 2

More information

By Ross C. D Emanuele, John T. Soshnik, and Kari Bomash, Dorsey & Whitney LLP Minneapolis, MN

By Ross C. D Emanuele, John T. Soshnik, and Kari Bomash, Dorsey & Whitney LLP Minneapolis, MN Major Changes to HIPAA Security and Privacy Rules Enacted in Economic Stimulus Package By Ross C. D Emanuele, John T. Soshnik, and Kari Bomash, Dorsey & Whitney LLP Minneapolis, MN The HITECH Act is the

More information

Presented by: Leslie Bender, CIPP General Counsel/CPO The ROI Companies www.theroi.com

Presented 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 information

Healthcare Compliance Solutions

Healthcare Compliance Solutions Healthcare Compliance Solutions Let Protected Trust be your Safe Harbor In the Health Information Technology for Economic and Clinical Health Act of 2009 (HITECH), the U.S. Department of Health and Human

More information

HIPAA Email Compliance & Privacy. What You Need to Know Now

HIPAA Email Compliance & Privacy. What You Need to Know Now HIPAA Email Compliance & Privacy What You Need to Know Now Introduction The Health Insurance Portability and Accountability Act of 1996 (HIPAA) places a number of requirements on the healthcare industry

More information

Top Ten Technology Risks Facing Colleges and Universities

Top Ten Technology Risks Facing Colleges and Universities Top Ten Technology Risks Facing Colleges and Universities Chris Watson, MBA, CISA, CRISC Manager, Internal Audit and Risk Advisory Services cwatson@schneiderdowns.com April 23, 2012 Overview Technology

More information

Nationwide 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 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 information

Disclaimer: Template Business Associate Agreement (45 C.F.R. 164.308)

Disclaimer: Template Business Associate Agreement (45 C.F.R. 164.308) HIPAA Business Associate Agreement Sample Notice Disclaimer: Template Business Associate Agreement (45 C.F.R. 164.308) The information provided in this document does not constitute, and is no substitute

More information

HIPAA Security Overview of the Regulations

HIPAA Security Overview of the Regulations HIPAA Security Overview of the Regulations Presenter: Anna Drachenberg Anna Drachenberg has been assisting healthcare providers and hospitals comply with HIPAA and other federal regulations since 2008.

More information

HIPAA Omnibus Rule Practice Impact. Kristen Heffernan MicroMD Director of Prod Mgt and Marketing

HIPAA Omnibus Rule Practice Impact. Kristen Heffernan MicroMD Director of Prod Mgt and Marketing HIPAA Omnibus Rule Practice Impact Kristen Heffernan MicroMD Director of Prod Mgt and Marketing 1 HIPAA Omnibus Rule Agenda History of the Rule HIPAA Stats Rule Overview Use of Personal Health Information

More information

Texas House Bill 300 & HIPAA. A MainNerve Whitepaper

Texas House Bill 300 & HIPAA. A MainNerve Whitepaper A MainNerve Whitepaper Overview If you do business in Texas and your organization handles, creates, stores, transmits or has access to electronic patient healthcare information, you need to be mindful

More information

6/17/2013 PRESENTED BY: Updates on HIPAA, Data, IT and Security Technology. June 25, 2013

6/17/2013 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 information

Use & Disclosure of Protected Health Information by Business Associates

Use & Disclosure of Protected Health Information by Business Associates Applicability: Policy Title: Policy Number: Use & Disclosure of Protected Health Information by Business Associates PP-12 Superseded Policy(ies) or Entity Policy: N/A Date Established: January 31, 2003

More information

HIPAA Security. 1 Security 101 for Covered Entities. Security Topics

HIPAA Security. 1 Security 101 for Covered Entities. Security Topics HIPAA SERIES Topics 1. 101 for Covered Entities 2. Standards - Administrative Safeguards 3. Standards - Physical Safeguards 4. Standards - Technical Safeguards 5. Standards - Organizational, Policies &

More information

BUSINESS ASSOCIATE AGREEMENT. Recitals

BUSINESS ASSOCIATE AGREEMENT. Recitals BUSINESS ASSOCIATE AGREEMENT This Agreement is executed this 8 th day of February, 2013, by BETA Healthcare Group. Recitals BETA Healthcare Group consists of BETA Risk Management Authority (BETARMA) and

More information

HIPAA Security Alert

HIPAA Security Alert Shipman & Goodwin LLP HIPAA Security Alert July 2008 EXECUTIVE GUIDANCE HIPAA SECURITY COMPLIANCE How would your organization s senior management respond to CMS or OIG inquiries about health information

More information

White Paper #6. Privacy and Security

White Paper #6. Privacy and Security The Complexity of America s Health Care Industry White Paper #6 Privacy and Security www.nextwavehealthadvisors.com 2015 Next Wave Health Advisors and Lynn Harold Vogel, Ph.D. The Complexity of America

More information

HIPAA and the HITECH Act Privacy and Security of Health Information in 2009

HIPAA and the HITECH Act Privacy and Security of Health Information in 2009 HIPAA and the HITECH Act Privacy and Security of Health Information in 2009 What is HIPAA? Health Insurance Portability & Accountability Act of 1996 Effective April 13, 2003 Federal Law HIPAA Purpose:

More information

Information Security Handbook

Information Security Handbook Information Security Handbook Adopted 6/4/14 Page 0 Page 1 1. Introduction... 5 1.1. Executive Summary... 5 1.2. Governance... 5 1.3. Scope and Application... 5 1.4. Biennial Review... 5 2. Definitions...

More information

Vermont Information Technology Leaders

Vermont Information Technology Leaders Vermont Information Technology Leaders HIPAA COMPLIANCE POLICIES AND PROCEDURES Policy Number: InfoSec 1 Policy Title: Information Privacy and Security Management Process IDENT INFOSEC1 Type of Document:

More information

Texas Medical Records Privacy Act (a.k.a. Texas House Bill 300)

Texas Medical Records Privacy Act (a.k.a. Texas House Bill 300) Texas Medical Records Privacy Act (a.k.a. Texas House Bill 300) Ricky Link, Coalfire ISACA North Texas and IIA Fort Worth Chapters The Petroleum Club of Fort Worth March 4, 2014 1 About Coalfire Coalfire

More information

HIPAA Security. 2 Security Standards: Administrative Safeguards. Security. Topics

HIPAA Security. 2 Security Standards: Administrative Safeguards. Security. Topics HIPAA Security SERIES Security Topics 1. Security 101 for Covered Entities 5. 2. Security Standards - Organizational, Security Policies Standards & Proc - A edures, dministrativ and e Documentation Safeguards

More information

Tools 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 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 information

White Paper THE HIPAA FINAL OMNIBUS RULE: NEW CHANGES IMPACTING BUSINESS ASSOCIATES

White Paper THE HIPAA FINAL OMNIBUS RULE: NEW CHANGES IMPACTING BUSINESS ASSOCIATES White Paper THE HIPAA FINAL OMNIBUS RULE: NEW CHANGES IMPACTING BUSINESS ASSOCIATES CONTENTS Introduction 3 Brief Overview of HIPPA Final Omnibus Rule 3 Changes to the Definition of Business Associate

More information

BUSINESS ASSOCIATE AGREEMENT. Business Associate. Business Associate shall mean.

BUSINESS ASSOCIATE AGREEMENT. Business Associate. Business Associate shall mean. BUSINESS ASSOCIATE AGREEMENT This Business Associate Agreement is made as of the day of, 2010, by and between Methodist Lebonheur Healthcare, on behalf of itself and all of its affiliates ( Covered Entity

More information

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 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 information

Montclair State University. HIPAA Security Policy

Montclair State University. HIPAA Security Policy Montclair State University HIPAA Security Policy Effective: June 25, 2015 HIPAA Security Policy and Procedures Montclair State University is a hybrid entity and has designated Healthcare Components that

More information