Decrypting the Security Risk Assessment (SRA) Requirement for Meaningful Use

Size: px
Start display at page:

Download "Decrypting the Security Risk Assessment (SRA) Requirement for Meaningful Use"

Transcription

1 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, /8/

2 Who is M-CEITA? Michigan Center for Effective Information Technology Adoption (M-CEITA) One of 62 ONC Regional Extension Centers (REC) providing education & technical assistance to primary care providers across the country Founded as part of the HITECH Act to accelerate the adoption, implementation, and effective use of electronic health records (EHR), e.g. 90-days of MU Funded by ARRA of 2009 (Stimulus Plan) Purpose: support the Triple Aim by achieving 5 overall performance goals THE TRIPLE AIM Improve patient experience Improve population health 3Reduce costs Improve Quality, Safety & Efficiency Engage Patients & Families Performance Measurement Improve Care Coordination Improve Population And Public Health Meaningful Use Ensure Privacy And Security Protections Certified Technology Infrastructure 2

3 M-CEITA's Performance 5,700+ providers enrolled for M-CEITA support, impacting 1.6 million patients 4,500+ providers are live on EHR 3,800+ have achieved Meaningful Use standards Latest survey shows 99% of M-CEITA customers are satisfied with services 3

4 M-CEITA s Services Our services are highly subsidized for qualified physicians. These Health IT services include: Meaningful Use Support Security Risk Assessment Targeted Process Optimization (Lean) Attestation/Audit Preparation 4

5 Security Risk Assessment 5

6 Risk People want to get value from the world The world can be dangerous People want to be secure from dangers How do we get security in an insecure world? 6

7 HIPAA Security Rule Title II Administrative Simplification Security Rule Security Standards Administrative Safeguards Physical Safeguards Technical Safeguards Organizational Requirements Policies and Procedures Documentation Requirements 7

8 Security Rule Requirements Security Components Example Variables Example Security Measures Physical Safeguards Facility structure Data storage center Computer hardware Building alarm system Locked doors Monitors shielded from view Administrative Safeguards Designated security officer Staff training and oversight Information security control Security Risk Assessment / review Technical Safeguards Controls on access to EHR Audit log monitoring Secure electronic exchanges Policies and Procedures Written P&P addressing HIPAA Security requirements Documentation of security measures Staff training Monthly review of user activity Policy enforcement New hire background checks Secure passwords Data backup Virus scans Encryption Written protocols on safeguards Record retention Periodic policy and procedure review Organizational Requirements Breach notification and other policies Business Associate agreements Periodic Business Associate Agreement review and updates 8

9 Why Complete a Security Risk Assessment? Consider three reasons to complete an SRA: Patient Safety Public Perception Compliance All good reasons, but which is the top priority for your practice? 9

10 Patient Safety First, do no harm. Breached medical records of over 90 million people have been reported in March, 2015 alone Average of 11.5 million identities stolen every year (this will increase in 2015) Average cost: $4,930 per household 10

11 Public Perception Patients want access to their information and they want it to be safe 81% of patients have concerns about privacy and security of EHR 60% of patients believe that EHR use will result in more information being lost or stolen Patients, like any consumer, vote with their feet 11

12 Risk is on the Rise Protected Health Information breaches expected to increase 25%* in 2014 The majority of PHI breaches now involve hacking attacks Healthcare is the leading US industry for data breaches This is despite increased awareness of the HIPAA Security Rule due to Meaningful Use programs Factors resulting in increased risk: Lax security practices in health care Increased interconnectivity Changing landscape (ACO, HIE) 12

13 Recent Major Breaches Anthem Premera Community Health Systems Sony Pictures Entertainment 80 million patient records March, million patient records March, million patient records August, ,000 unique SSN s November,

14 Security Risk Assessment HIPAA Security Rule 45 CFR (a)(1) Risk Assessment Risk Management Sanction Policy Information System Activity Review Risk Assessment (or Analysis) Conduct an accurate and thorough assessment of the potential risks and vulnerabilities to the confidentiality, integrity, and availability of electronic protected health information held by the covered entity. 14

15 SRA as a Meaningful Use requirement: Core Objective Protect electronic health information created or maintained by the certified EHR technology through the implementation of appropriate technical capabilities Measure Conduct or review a security risk analysis in accordance with the requirements under 45 CFR (a)(1) and implement security updates as necessary and correct identified security deficiencies as part of its risk management process. 15

16 HHS Office for Civil Rights (OCR) Final Guidance Scope must include all ephi in organization Data collection and methods must be documented Identify and document anticipated threats and vulnerabilities Assess current security measures in place Establish likelihood of threat occurrence Establish potential impact of threat occurrence Determine level of risk Document complete risk analysis Periodic review and update There is no one way to do an SRA, but every method must meet these objectives 16

17 Risk Defined Risk is the potential (likelihood) of a negative outcome (impact) toward an asset, due to a vulnerability being exploited by a threat that would reduce the value of the asset to the organization. (NIST SP ) 17

18 What is at risk? Confidentiality Integrity Availability 18

19 Vulnerabilities and Controls For valuable assets, we need access to utilize the value Systems are designed to permit access, but all have vulnerabilities Controls reduce or eliminate unauthorized access 19

20 Threats and Threat Sources Hostile outsiders Theft / Sabotage Malicious insider Poorly trained staff External Business Associates Internal Infrastructure failures Natural disasters Shadow IT Lax enforcement of P&P 20

21 Business Associates All vendors who process, store, or transmit PHI need to sign a Business Associate Agreement Disputes between vendors and providers have serious implications: Maine small clinic dispute with EHR vendor Malicious Outsider/Insider: Think Edward Snowden Getting the Business Associate Agreement in place is the first step Equally important is ongoing vendor management, including security Would your vendors pass a HIPAA audit? They might have to. 21

22 Encryption Addressable Specification found at CFR (a)(2)(iv)...but not optional! ephi must be encrypted when at rest (stored) and in transmission 22

23 Good Faith Effort Compliance isn t enough You can be compliant and still suffer a breach Risk can never be eliminated Reduce risk to a reasonable and appropriate level The expectation is for organizations to put forth a good faith effort 23

24 HIPAA Audit Program OCR has been enforcing HIPAA since 2003 OCR random audit program set to begin in 2015 Provider compliance with Security, Privacy, and Breach Rules will be audited Most common Security deficiencies from pilot audits: Lack of or incomplete SRA Unaware of Security Rule requirements On-site and remote audits to be performed Covered Entities and Business Associates 24

25 Meaningful Use Audits vs HIPAA Audits Meaningful Use Audits Performed by Figliozzi and Co. under contract with CMS 1 / 10 MU attesting providers audited Random and based on prior audit results, if applicable Focus on timing and scope of SRA, key remediation activities (audit logs, compare previous results to current) HIPAA Audits Performed by OCR Comprehensive examination of organization s risk management program Only a few hundred random audits Most OCR investigations occur following a breach 25

26 Best Practices Security is an investment in your business. Your stakeholders benefit. Educate employees, managers, and ownership on security threats and protocols. Build a culture of security awareness from top to bottom. Involve everyone! Establish, refine, and enhance security policies and practices. Treat your business associates like insiders. Be confident you can trust them by getting the right information. 26

27 Security Risk Assessment Process Step 1: Identify and Classify Assets Step 2: Identify and Classify Threats and Vulnerabilities Step 3: Assess Current Controls Step 4: Determine Likelihood of Threat Occurrence Step 5: Analyze Impact to Organization Step 6: Determine Level of Risk Step 7: Implement Security Controls Step 8: Ongoing Risk Management Program and Recurring SRA Review All Steps: Documentation! 27

28 Attesting to Meaningful Use Risk assessment requirements Must take place no earlier than the start of the EHR reporting year and no later than the provider attestation date. Must assess certified EHR technology (CEHRT). Repeat for each reporting period (see: CMS FAQ #10754) Attest after you have conducted your Security Risk Assessment You do not have to correct deficiencies identified in the SRA before you attest to Meaningful Use 28

29 How frequently do I need to do a Risk Assessment? For practices participating in Meaningful Use, a Security Risk Assessment needs to be completed for every year of attestation. Also, after major changes or upgrades to practice, technology, or environment For HIPAA compliance, recommendation is at least annually 29

30 SRA Service and Tools M-CEITA Security Risk Assessment Toolkit Follows NIST guidance ( & ) Work on-site with practice leaders Guide through every step of SRA process Deliver analysis and recommended plan of action to improve compliance 30

31 Risk Assessment Tool Sample Page 31

32 Sample Policy Breach Notification and Reporting Customizable to your practice 32

33 Conclusion Security Risk Assessments required for compliance with HIPAA and Meaningful Use Risk and regulatory oversight increasing Practices are expected to take security seriously and put forth a good faith effort Required: Hard work, diligence, integrity An SRA is the first step of a continuous, comprehensive Risk Management Program that will benefit your patients and your practice 33

34 Resources NIST SP NIST SP NIST SP ONC Guide to Privacy and Security of Health Information OCR Wall of Shame HHS Final Guidance on Risk Analysis HIPAA Administrative Simplification 34

35 Questions? Upcoming webinars: April 15, 2015, 12-1pm April 17, am April 21, pm April 23, pm Managing Hypertension and Diabetes by Mastering IT ADDITIONAL CONTACT INFO: MEANINGFUL USE 888-MICH-EHR SRA Security Risk Assessment Andy Petrovich

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

Privacy & Security: Fundamentals of a Security Risk Analysis. Preparing for Meaningful Use Measure 15

Privacy & Security: Fundamentals of a Security Risk Analysis. Preparing for Meaningful Use Measure 15 Privacy & Security: Fundamentals of a Security Risk Analysis Preparing for Meaningful Use Measure 15 1/18/2012 Why Are We Here? Privacy and Security is a priority for ONC Consistency among Regional Extension

More information

HIPAA Security Risk Analysis for Meaningful Use

HIPAA 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 information

Meaningful Use Audits. NextGen Physician Consulting Services

Meaningful Use Audits. NextGen Physician Consulting Services Meaningful Use Audits NextGen Physician Consulting Services Agenda Audit Overview Documentation for measures requiring numerator and denominator data Documentation for attestation only measures Security

More information

HIPAA: Compliance Essentials

HIPAA: Compliance Essentials HIPAA: Compliance Essentials Presented by: Health Security Solutions August 15, 2014 What is HIPAA?? HIPAA is Law that governs a person s ability to qualify immediately for health coverage when they change

More information

2/27/2014. Meaningful Use as it Relates to HIPAA Compliance. Objectives and Agenda. Understand the statutory and regulatory background and purpose

2/27/2014. Meaningful Use as it Relates to HIPAA Compliance. Objectives and Agenda. Understand the statutory and regulatory background and purpose 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 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 COMPLIANCE PLAN FOR 2013

HIPAA 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 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

Overview of the HIPAA Security Rule

Overview 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 information

Cybersecurity for Meaningful Use. 2013 FRHA Annual Summit "Setting the Health Care Table: Politics, Economics, Health" November 20-22, 2013

Cybersecurity for Meaningful Use. 2013 FRHA Annual Summit Setting the Health Care Table: Politics, Economics, Health November 20-22, 2013 Cybersecurity for Meaningful Use 2013 FRHA Annual Summit "Setting the Health Care Table: Politics, Economics, Health" November 20-22, 2013 Healthcare Sector Vulnerable to Hackers By Robert O Harrow Jr.,

More information

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 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

InfoGard Healthcare Services. 2015 InfoGard Laboratories Inc.

InfoGard Healthcare Services. 2015 InfoGard Laboratories Inc. InfoGard Healthcare Services 10 Steps To Protect My Covered Entity From Breach Your Presenters Alan Martin Account Manger Marvin Byrd Security Engineer Test and Certification Laboratory Healthcare Payment

More information

How to Use the NYeC Privacy and Security Toolkit V 1.1

How to Use the NYeC Privacy and Security Toolkit V 1.1 How to Use the NYeC Privacy and Security Toolkit V 1.1 Scope of the Privacy and Security Toolkit The tools included in the Privacy and Security Toolkit serve as guidance for educating stakeholders about

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

Ensuring Privacy & Security of Patient Information

Ensuring Privacy & Security of Patient Information Ensuring Privacy & Security of Patient Information Danika Brinda, Assistant Professor and REACH P&S Subject Matter Expert Jane McGrath, Program Manager REACH/Stratis Health Session 12, Thursday, June 12,

More information

Privacy and Security Meaningful Use Requirement HIPAA Readiness Review

Privacy and Security Meaningful Use Requirement HIPAA Readiness Review Privacy and Security Meaningful Use Requirement HIPAA Readiness Review REACH - Achieving - Achieving meaningful meaningful use of your use EHR of your EHR Patti Kritzberger, RHIT, CHPS ND e-health Summit

More information

Information Protection Framework: Data Security Compliance and Today s Healthcare Industry

Information Protection Framework: Data Security Compliance and Today s Healthcare Industry Information Protection Framework: Data Security Compliance and Today s Healthcare Industry Executive Summary Today s Healthcare industry is facing complex privacy and data security requirements. The movement

More information

Guidance on Risk Analysis Requirements under the HIPAA Security Rule

Guidance 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 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

Security Is Everyone s Concern:

Security Is Everyone s Concern: Security Is Everyone s Concern: What a Practice Needs to Know About ephi Security Mert Gambito Hawaii HIE Compliance and Privacy Officer July 26, 2014 E Komo Mai! This session s presenter is Mert Gambito

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

The HIPAA Audit Program

The HIPAA Audit Program The HIPAA Audit Program Anna C. Watterson Davis Wright Tremaine LLP The U.S. Department of Health and Human Services (HHS) was given authority, and a mandate, to conduct periodic audits of HIPAA 1 compliance

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

Sustainable Compliance: A System for Ongoing Audit Readiness

Sustainable Compliance: A System for Ongoing Audit Readiness View the Replay on YouTube Sustainable Compliance: A System for Ongoing Audit Readiness FairWarning Executive Webinar Series November 14, 2013 Agenda Sustainable Compliance at St. Charles Health System

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

View the Replay on YouTube. Sustainable HIPAA Compliance: Enhancing Your Epic Reporting. FairWarning Executive Webinar Series October 17, 2013

View the Replay on YouTube. Sustainable HIPAA Compliance: Enhancing Your Epic Reporting. FairWarning Executive Webinar Series October 17, 2013 View the Replay on YouTube Sustainable HIPAA Compliance: Enhancing Your Epic Reporting FairWarning Executive Webinar Series October 17, 2013 Today s Panel Chris Arnold FairWarning VP of Product Management

More information

8/3/2015. Integrating Behavioral Health and HIV Into Electronic Health Records Communities of Practice

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 information

Lessons 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 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 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

Meaningful Use Security Risk Analysis: Do It Right and Retain Your Incentive

Meaningful Use Security Risk Analysis: Do It Right and Retain Your Incentive Meaningful Use Security Risk Analysis: Do It Right and Retain Your Incentive Introduction Adam Kehler, CISSP Privacy and Security Specialist PA REACH East & West akehler@wvmi.org Goals 1. Understand what

More information

Art 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 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 information

2016 OCR AUDIT E-BOOK

2016 OCR AUDIT E-BOOK !! 2016 OCR AUDIT E-BOOK About BlueOrange Compliance: We specialize in healthcare information privacy and security solutions. We understand that each organization is busy running its business and that

More information

2011 2012 Aug. Sept. Oct. Nov. Dec. Jan. Feb. March April May-Dec.

2011 2012 Aug. Sept. Oct. Nov. Dec. Jan. Feb. March April May-Dec. The OCR Auditors are coming - Are you next? What to Expect and How to Prepare On June 10, 2011, the U.S. Department of Health and Human Services Office for Civil Rights ( OCR ) awarded KPMG a $9.2 million

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

Health Homes Implementation Series: NYeC Privacy and Security Toolkit. 16 February 2012

Health Homes Implementation Series: NYeC Privacy and Security Toolkit. 16 February 2012 Health Homes Implementation Series: NYeC Privacy and Security Toolkit 16 February 2012 1 Agenda What are the New York ehealth Collaborative (NYeC) and the Regional Extension Center? What are Health Homes?

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

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

HIPAA Secure Now! HIPAA Security and Omnibus Rules Overview

HIPAA Secure Now! HIPAA Security and Omnibus Rules Overview HIPAA Secure Now! HIPAA Security and Omnibus Rules Overview HIPAA Risk Assessment The HIPAA Security Rule requires that a Risk Assessment be completed. The purpose of a Risk Assessment is to: identify

More information

Our Commitment to Information Security

Our Commitment to Information Security Our Commitment to Information Security What is HIPPA? Health Insurance Portability and Accountability Act 1996 The HIPAA Privacy regulations require health care providers and organizations, as well as

More information

Developing HIPAA Security Compliance. Trish Lugtu CPHIMS, CHP, CHSS Health IT Consultant

Developing HIPAA Security Compliance. Trish Lugtu CPHIMS, CHP, CHSS Health IT Consultant Developing HIPAA Security Compliance Trish Lugtu CPHIMS, CHP, CHSS Health IT Consultant Learning Objectives Identify elements of a HIPAA Security compliance program Learn the HIPAA Security Rule basics

More information

HITRUST CSF Assurance Program You Need a HITRUST CSF Assessment Now What?

HITRUST CSF Assurance Program You Need a HITRUST CSF Assessment Now What? HITRUST CSF Assurance Program You Need a HITRUST CSF Assessment Now What? Introduction This material is designed to answer some of the commonly asked questions by business associates and other organizations

More information

HIT Audit Workshop. Jeffrey W. Short. jshort@hallrender.com

HIT Audit Workshop. Jeffrey W. Short. jshort@hallrender.com HIT Audit Workshop Jeffrey W. Short jshort@hallrender.com 1 Audits and Investigations to be Discussed Meaningful Use Audits HIPAA Audits Data Breach Investigations Software Vendor Audits FTC Investigations

More information

HIPAA Compliance Review Analysis and Summary of Results

HIPAA Compliance Review Analysis and Summary of Results HIPAA Compliance Review Analysis and Summary of Results Centers for Medicare & Medicaid Services (CMS) Office of E-Health Standards and Services (OESS) Reviews 2008 Table of Contents Introduction 1 Risk

More information

HIPAA Privacy and Security Requirements

HIPAA Privacy and Security Requirements 600 East Superior Street, Suite 404 I Duluth, MN 55802 I Ph. 800.997.6685 or 218.727.9390 I www.ruralcenter.org HIPAA Privacy and Security Requirements Joe Wivoda CIO and HIT Consultant June 19, 2013 Purpose

More information

Agenda. OCR Audits of HIPAA Privacy, Security and Breach Notification, Phase 2. Linda Sanches, MPH Senior Advisor, Health Information Privacy 4/1/2014

Agenda. OCR Audits of HIPAA Privacy, Security and Breach Notification, Phase 2. Linda Sanches, MPH Senior Advisor, Health Information Privacy 4/1/2014 OCR Audits of HIPAA Privacy, Security and Breach Notification, Phase 2 Linda Sanches, MPH Senior Advisor, Health Information Privacy HCCA Compliance Institute March 31, 2014 Agenda Background Audit Phase

More information

Essentials of the Security Risk Analysis 2016

Essentials of the Security Risk Analysis 2016 Essentials of the Security Risk Analysis 2016 Brett Paepke, OD Director of ECP Services, Rev360 Jeff Wussow Business Development Manager, MetaStar Brad Trudell, JD HIPAA Privacy & Security Lead, MetaStar

More information

HIPAA Security. 6 Basics of Risk Analysis and Risk Management. Security Topics

HIPAA Security. 6 Basics of Risk Analysis and Risk Management. Security Topics HIPAA Security SERIES Security Topics 1. Security 101 for Covered Entities 2. Security Standards - Administrative Safeguards 3. Security Standards - Physical Safeguards 4. Security Standards - Technical

More information

MEANINGFUL USE DESK AUDIT

MEANINGFUL USE DESK AUDIT MEANINGFUL USE DESK AUDIT October 2015 Protect Electronic Health Information HIPAA Risk Management 1680 E. Joyce Blvd Fayetteville, AR 72704 (800) 501-8973 www.hipaarisk.com Copyright 2015 by HRM Services,

More information

Straight from the Source: HHS Tools for Avoiding Some of the Biggest HIPAA Mistakes

Straight from the Source: HHS Tools for Avoiding Some of the Biggest HIPAA Mistakes Watch the Replay Straight from the Source: HHS Tools for Avoiding Some of the Biggest HIPAA Mistakes FairWarning Executive Webinar Series May 20, 2014 #AnytimeAudit Today s Panel Laura E. Rosas, JD, MPH

More information

Privacy Officer Job Description 4/28/2014. HIPAA Privacy Officer Orientation. Cathy Montgomery, RN. Presented by:

Privacy Officer Job Description 4/28/2014. HIPAA Privacy Officer Orientation. Cathy Montgomery, RN. Presented by: HIPAA Privacy Officer Orientation Presented by: Cathy Montgomery, RN Privacy Officer Job Description Serve as leader Develop Policies and Procedures Train staff Monitor activities Manage Business Associates

More information

HIPAA Security Rule Changes and Impacts

HIPAA Security Rule Changes and Impacts HIPAA Security Rule Changes and Impacts Susan A. Miller, JD Tony Brooks, CISA, CRISC HIPAA in a HITECH WORLD American Health Lawyers Association March 22, 2013 Baltimore, MD Agenda I. Introduction II.

More information

HIPAA Audits Are Happening. eroi

HIPAA 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 information

Who are we? *Founded in 2005 by Purdue University, the Regenstrief Center for Healthcare Engineering, and the Indiana Hospital Association.

Who are we? *Founded in 2005 by Purdue University, the Regenstrief Center for Healthcare Engineering, and the Indiana Hospital Association. Who are we? Purdue Healthcare Advisors (PHA)*, a business unit of Purdue University, specializes in affordable assistance to organizations that share our passion for healthcare transformation. We bring

More information

The HIPAA Omnibus Final Rule

The HIPAA Omnibus Final Rule WHITE PAPER The HIPAA Omnibus Final Rule Four risk exposure events that can uncover compliance issues leading to investigations, potential fines, and damage to your organization s reputation. By Virginia

More information

HIPAA Audits: How to Be Prepared. Lindsey Wiley, MHA, CHTS-IM, CHTS-TS HIT Manager Oklahoma Foundation for Medical Quality

HIPAA Audits: How to Be Prepared. Lindsey Wiley, MHA, CHTS-IM, CHTS-TS HIT Manager Oklahoma Foundation for Medical Quality HIPAA Audits: How to Be Prepared Lindsey Wiley, MHA, CHTS-IM, CHTS-TS HIT Manager Oklahoma Foundation for Medical Quality An Important Reminder For audio, you must use your phone: Step 1: Call (866) 906-0123.

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

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

How to Leverage HIPAA for Meaningful Use

How to Leverage HIPAA for Meaningful Use How to Leverage HIPAA for Meaningful Use The overlap between HIPAA and Meaningful Use requirements 2015 SecurityMetrics How to Leverage HIPAA for Meaningful Use 2 About this ebook Who should read this

More information

Conducting a HIPAA Security Risk Analysis For MEANINGFUL USE, HIPAA Compliance and Good Business Practice. Presented for ICAHN by David A.

Conducting a HIPAA Security Risk Analysis For MEANINGFUL USE, HIPAA Compliance and Good Business Practice. Presented for ICAHN by David A. Conducting a HIPAA Security Risk Analysis For MEANINGFUL USE, HIPAA Compliance and Good Business Practice Presented for ICAHN by David A. Ginsberg Agenda Deep Dive into the 15 th Core Objective Conducting

More information

RSA SECURE WEB ACCESS FOR HEALTHCARE ENVIRONMENTS

RSA SECURE WEB ACCESS FOR HEALTHCARE ENVIRONMENTS RSA SECURE WEB ACCESS FOR HEALTHCARE ENVIRONMENTS Security solutions for patient and provider access AT A GLANCE Healthcare organizations of all sizes are responding to the demands of patients, physicians,

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

Preparing for HIPAA and Meaningful Use Compliance Audits

Preparing for HIPAA and Meaningful Use Compliance Audits Preparing for HIPAA and Meaningful Use Compliance Audits Presented by: David Holtzman VP of Compliance, CynergisTek CynergisTek, Inc. 11410 Jollyville Road, Suite 2201, Austin TX 78759 512.402.8550 info@cynergistek.com

More information

CHIS, Inc. Privacy General Guidelines

CHIS, Inc. Privacy General Guidelines CHIS, Inc. and HIPAA CHIS, Inc. provides services to healthcare facilities and uses certain protected health information (PHI) in connection with performing these services. Therefore, CHIS, Inc. is classified

More information

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

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 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 information

OIG Security Audit: What You Need To Know

OIG Security Audit: What You Need To Know Watch the Replay on YouTube OIG Security Audit: What You Need To Know Executive Series Webinar July 23rd, 2015 Today s Speakers Elana R. Zana Attorney & Author Ogden Murphy Wallace P.L.L.C. ezana@omwlaw.com

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

Nine Network Considerations in the New HIPAA Landscape

Nine Network Considerations in the New HIPAA Landscape Guide Nine Network Considerations in the New HIPAA Landscape The Health Insurance Portability and Accountability Act of 1996 (HIPAA) Omnibus Final Rule, released January 2013, introduced some significant

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

HIPAA Workshop Ensuring PHI: Creating a Comprehensive Office Policy

HIPAA Workshop Ensuring PHI: Creating a Comprehensive Office Policy HIPAA Workshop Ensuring PHI: Creating a Comprehensive Office Policy 2014 OP User Conference Presented by: Sue Kressly, MD, FAAP and Leann DiDomenico, MBA Goal: Develop your Strategy to Ensure the Safety

More information

Securing the FOSS VistA Stack HIPAA Baseline Discussion. Jack L. Shaffer, Jr. Chief Operations Officer

Securing the FOSS VistA Stack HIPAA Baseline Discussion. Jack L. Shaffer, Jr. Chief Operations Officer Securing the FOSS VistA Stack HIPAA Baseline Discussion Jack L. Shaffer, Jr. Chief Operations Officer HIPAA as Baseline of security: To secure any stack which contains ephi (electonic Protected Health

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

HIPAA Privacy, Security, Breach, and Meaningful Use. CHUG October 2012

HIPAA 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 information

CIBHS Small Counties Training January 29, 2016

CIBHS Small Counties Training January 29, 2016 CIBHS Small Counties Training January 29, 2016 Training content accurate as of 1/28/2016 and will not reflect any regulation changes that are published after that date. Copyright by Xpio Health. All rights

More information

Electronically Communicating in Compliance with HIPAA Privacy and Security Requirements. Adam H. Greene, JD, MPH Partner, Davis Wright Tremaine LLP

Electronically Communicating in Compliance with HIPAA Privacy and Security Requirements. Adam H. Greene, JD, MPH Partner, Davis Wright Tremaine LLP Electronically Communicating in Compliance with HIPAA Privacy and Security Requirements Adam H. Greene, JD, MPH Partner, Davis Wright Tremaine LLP Agenda Communicating with Patients Security Rule compliance

More information

HIPAA: Protecting Your. Ericka L. Adler. Practice and Your Patients

HIPAA: Protecting Your. Ericka L. Adler. Practice and Your Patients HIPAA: Protecting Your Ericka L. Adler Practice and Your Patients Rachel V. Rose Fallout from the Omnibus Rule Compliance strategies for medical practices 1. Know / manage your business associates and

More information

FACT SHEET: Ransomware and HIPAA

FACT SHEET: Ransomware and HIPAA FACT SHEET: Ransomware and HIPAA A recent U.S. Government interagency report indicates that, on average, there have been 4,000 daily ransomware attacks since early 2016 (a 300% increase over the 1,000

More information

Strategies for. Proactively Auditing. Compliance to Mitigate. Matt Jackson, Director Kevin Dunnahoo, Manager

Strategies 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 information

Joe Dylewski President, ATMP Solutions

Joe Dylewski President, ATMP Solutions Joe Dylewski President, ATMP Solutions Joe Dylewski President, ATMP Solutions Assistant Professor, Madonna University 20 Years, Technology and Application Implementation Experience Served as Michigan Healthcare

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

U.S. Department of Health and Human Services (HHS) The Office of the National Coordinator for Health Information Technology (ONC)

U.S. Department of Health and Human Services (HHS) The Office of the National Coordinator for Health Information Technology (ONC) U.S. Department of Health and Human Services (HHS) The Office of the National Coordinator for Health Information Technology (ONC) Security Risk Assessment (SRA) Tool User Guide Version Date: March 2014

More information

HIPAA Compliance and the Protection of Patient Health Information

HIPAA Compliance and the Protection of Patient Health Information HIPAA Compliance and the Protection of Patient Health Information WHITE PAPER By Swift Systems Inc. April 2015 Swift Systems Inc. 7340 Executive Way, Ste M Frederick MD 21704 1 Contents HIPAA Compliance

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

What is required of a compliant Risk Assessment?

What is required of a compliant Risk Assessment? What is required of a compliant Risk Assessment? ACR 2 Solutions President Jack Kolk discusses the nine elements that the Office of Civil Rights requires Covered Entities perform when conducting a HIPAA

More information

Assessing Your HIPAA Compliance Risk

Assessing Your HIPAA Compliance Risk Assessing Your HIPAA Compliance Risk Jennifer Kennedy, MA, BSN, RN, CHC National Hospice and Palliative Care Organization HIPAA Security Rule All electronic protected health information (PHI and EPHI)

More information

The HIPAA Security Rule Primer Compliance Date: April 20, 2005

The HIPAA Security Rule Primer Compliance Date: April 20, 2005 AMERICAN PSYCHOLOGICAL ASSOCIATION PRACTICE ORGANIZATION Practice Working for You The HIPAA Security Rule Primer Compliance Date: April 20, 2005 Printer-friendly PDF 1 Contents Click on any title below

More information

HIPAA Compliance Audits: Your Newest Risk: Are You Prepared?

HIPAA Compliance Audits: Your Newest Risk: Are You Prepared? HIPAA Compliance Audits: Your Newest Risk: Are You Prepared? Presented by: Melissa (Lisa) Thompson, JD, MPH and Elizabeth Lamkin, MHA Slide 1 Speakers Melissa (Lisa) Thompson, JD, MPH Partner Adelman,

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

HIPAA Security & Compliance

HIPAA Security & Compliance Creative Mind. Creative Heart. Creative Care. 2014 WALA Spring Conference HIPAA Security & Compliance Jeff Grady Thursday, March 27 10:30 am HIPAA Security & Compliance A TIME FOR ACTION Jeff Grady, Senior

More information

Healthcare IT (HIT) Strategic Planning & Budgeting MARCH 26, 2014

Healthcare IT (HIT) Strategic Planning & Budgeting MARCH 26, 2014 Healthcare IT (HIT) Strategic Planning & Budgeting MARCH 26, 2014 Agenda Introduction / Session Overview HIT Budgeting 101 Security and Compliance EHR budgeting HIT Where Are We Going Q & A 2 Copyright

More information

What s New with HIPAA? Policy and Enforcement Update

What 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 information

My Docs Online HIPAA Compliance

My Docs Online HIPAA Compliance My Docs Online HIPAA Compliance Updated 10/02/2013 Using My Docs Online in a HIPAA compliant fashion depends on following proper usage guidelines, which can vary based on a particular use, but have several

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 Security Rule Toolkit

HIPAA Security Rule Toolkit California Office of Health Information Integrity (CalOHII) HIPAA Security Rule Toolkit User Guide Version 1.0 2/1/2012 Table of Contents 1.0 - HIPAA Security Rule Background... 0 2.0 Purpose... 1 3.0

More information

HIPAA 203: Security. An Introduction to the Draft HIPAA Security Regulations

HIPAA 203: Security. An Introduction to the Draft HIPAA Security Regulations HIPAA 203: Security An Introduction to the Draft HIPAA Security Regulations Presentation Agenda Security Introduction Security Component Requirements and Impacts Administrative Procedures Physical Safeguards

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

Guided HIPAA Compliance

Guided HIPAA Compliance Guided HIPAA Compliance HIPAA Solutions for Office Managers and Practitioners SecurityMetrics We protect business Since its founding in 2000, privately-held SecurityMetrics has grown from a small security

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

Are You Ready for an OCR Audit? Tom Walsh, CISSP Tom Walsh Consulting, LLC Overland Park, KS. What would you do? Session Objectives

Are You Ready for an OCR Audit? Tom Walsh, CISSP Tom Walsh Consulting, LLC Overland Park, KS. What would you do? Session Objectives Are You Ready for an OCR Audit? Tom Walsh, CISSP Tom Walsh Consulting, LLC Overland Park, KS What would you do? Your organization received a certified letter sent from the Office for Civil Rights (OCR)

More information