Privacy and Security Meaningful Use Requirement HIPAA Readiness Review

Size: px
Start display at page:

Download "Privacy and Security Meaningful Use Requirement HIPAA Readiness Review"

Transcription

1 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 Wednesday, November 20, , ext. 222

2 Objectives EHR Incentive Program Meaningful Use Core Measure OCR Audit Protocol Privacy and Security Meaningful Use Requirement HIPAA Readiness Review Purpose, Content, Process Resources Q & A 2

3 EHR Incentive Program Meaningful Use Core Measure Eligible Hospitals/CAH Core Measure #13 Eligible Professionals Core Measure #14 Eligible hospitals and CAHs /Eligible professionals must attest YES to having conducted or reviewed a security risk analysis in accordance with the requirements under 45 CFR (a)(1) and implemented security updates as necessary and corrected identified security deficiencies prior to or during the EHR reporting period to meet this measure. 3

4 Objectives EHR Incentive Program Meaningful Use Core Measure OCR Audit Protocol Privacy and Security Meaningful Use Requirement HIPAA Readiness Review Purpose, Content, Process Resources Q & A 4

5 Audit Protocol The OCR HIPAA Audit program analyzes processes, controls, and policies of selected covered entities pursuant to the HITECH Act audit mandate. OCR established a comprehensive audit protocol that contains the requirements to be assessed through these performance audits. The entire audit protocol is organized around modules, representing separate elements of privacy, security, and breach notification. The combination of these multiple requirements may vary based on the type of covered entity selected for review. 5

6 What the Audit Protocol Covers Privacy Rule requirements for: (1) notice of privacy practices for PHI, (2) rights to request privacy protection for PHI, (3) access of individuals to PHI, (4) administrative requirements, (5) uses and disclosures of PHI, (6) amendment of PHI, and (7) accounting of disclosures. Security Rule requirements for administrative, physical, and technical safeguards Requirements for the Breach Notification Rule 6

7 Categories of Standards Addressable the CE must assess the reasonableness and appropriateness of the safeguard to protect the ephi: Size, complexity & capability of the CE CEs technical infrastructure, hardware and software security capabilities Cost of security measures Probability and criticality of potential risks to ephi Required the CE must comply with the standard & implement policies &/or procedures that meet the requirement 7

8 Four Distinct Parts of Security Rule Administrative Safeguards administrative actions, including the establishment of policies & procedures, to manage the activities needed to establish security measures that protect ephi. Security Management Process Risk Analysis (Required) Risk Management (Required) Sanction Policy (Required) IS Activity Review (Required) Assigned Security Responsibility Designate Security Officer (Required) Workforce Security Authorization and/or Supervision (Addressable) Workforce Clearance Procedure (Addressable) Termination Procedures (Addressable) 8

9 Distinct Parts, cont Physical Safeguards physical measures and policies & procedures, including policies & procedures to protect electronic information systems & related buildings & equipment from natural & environmental hazards & unauthorized intrusion Facility Access Controls Contingency Operations (Addressable) Facility Security Plan (Addressable) Access Control & Validation Procedures (Addressable) Workstation Use (Required) Workstation Security (Required) Device & Media Controls Disposal (Required) Media Reuse (Required) Accountability (Addressable) Data Backup & Storage (Addressable) 9

10 Distinct Parts, cont. Technical Safeguards the technology, including policies & procedures for its use, that protect ephi & control access to it. Access Control Unique User Identification (Required) Emergency Access Procedure (Required) Automated Logoff (Addressable) Encryption & Decryption (Addressable) Audit Controls (Required) Integrity Mechanism to Authenticate ephi (Addressable) Person or Entity Authentication (Required) Transmission Security Integrity Controls (Addressable) Encryption (Addressable) 10

11 Distinct Parts, cont. Organizational Safeguards arrangements made between organizations to protect ephi, including Business Associate Agreements Business Associate Contracts or Other Arrangements Business Associate Agreements (Required) Other Arrangments (Required) Requirements for Group Health Plans Implementation Specification (Required) Policies & Procedures (Required) Mechanism to Authenticate ephi (Addressable) Documentation Time Limit (Required) Availability (Required) Updates (Required) 11

12 Objectives EHR Incentive Program Meaningful Use Core Measure ONC Audit Protocol Privacy and Security Meaningful Use Requirement HIPAA Readiness Review Purpose, Content, Process Resources Q & A 12

13 REACH HIPAA Readiness Review Service Focus of the Service Eligibility Criteria REACH Clients: Active SLA Site has to be included on SLA Has not met MU or still has an RHC that has not met MU You must have completed your security risk assessment on the certified version of your EHR to be eligible for this service Non-REACH Clients: Fee-for-Service Offering amount to be determined by scope of work 13

14 REACH HIPAA Readiness Review Purpose OCR performing HIPAA Privacy & Security audits Figliozzi & Company performing meaningful use audits up to 20% pre- or post-payment audits This service has been designed to help clients make sure they have all elements for HIPAA Privacy & Security in place. REACH s assistance and guidance does not ensure you will pass an audit or that auditors will not ask for additional information unanticipated by REACH. 14

15 REACH HIPAA Readiness Review Content Tools, education, and assistance related to your organization s completion of the HIPAA security risk assessment Conduct a review and readiness assessment of your organization s security risk assessment required for HIPAA (since 2005). REACH s assessment includes a review of your: Most recent HIPAA security risk assessment HIPAA privacy and security policies and procedures Business continuity and disaster recovery plans Business associate agreements Privacy and security staff education program A report will be provided including suggestions for areas that would benefit from greater focus and attention from your organization. Privacy and security tools will be provided to assist you in your work. 15

16 REACH HIPAA Readiness Review Process Contact REACH or, if a current client, contact your REACH Consultant Complete an intake form A series of calls will be set up Initial Follow up Final (followed by final report) 16

17 Objectives EHR Incentive Program Meaningful Use Core Measure OCR Audit Protocol Privacy and Security Meaningful Use Requirement HIPAA Readiness Review Purpose, Content, Process Resources Q & A 17

18 OCR/CMS Resources securityruleguidance.html Administrative- Simplification/HIPAAGenInfo/index.html?redirect=/HIPAAGenInf o/04_privacystandards.asp 18

19 Other Resources a-security-requirements.php , ext

20 QUESTIONS? 20

21 Key Health Alliance Stratis Health, Rural Health Resource Center, and The College of St. Scholastica. REACH is a project federally funded through the Office of the National Coordinator, Department of Health and Human Services (grant number EP-HIT )

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

PRIVACY POLICIES AND FORMS FOR BUSINESS ASSOCIATES

PRIVACY POLICIES AND FORMS FOR BUSINESS ASSOCIATES PRIVACY POLICIES AND FORMS FOR BUSINESS ASSOCIATES TABLE OF CONTENTS A. Overview of HIPAA Compliance Program B. General Policies 1. Glossary of Defined Terms Used in HIPAA Policies and Procedures 2. Privacy

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

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

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

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

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

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

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 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 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

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

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

The OCR Audit Protocol a first look

The OCR Audit Protocol a first look The OCR Audit Protocol a first look On June 26, 2012, the Office for Civil Rights published its Audit Protocols for HIPAA Security, HIPAA Breach and Privacy at http://ocrnotifications.hhs.gov/hipaa.html.

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

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

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

Policies and Procedures Audit Checklist for HIPAA Privacy, Security, and Breach Notification

Policies and Procedures Audit Checklist for HIPAA Privacy, Security, and Breach Notification Policies and Procedures Audit Checklist for HIPAA Privacy, Security, and Breach Notification Type of Policy and Procedure Comments Completed Privacy Policy to Maintain and Update Notice of Privacy Practices

More information

HIPAA Security. 5 Security Standards: Organizational, Policies. Security Topics. and Procedures and Documentation Requirements

HIPAA Security. 5 Security Standards: Organizational, Policies. Security Topics. and Procedures and Documentation Requirements HIPAA Security S E R I E S Security Topics 1. Security 101 for Covered Entities 2. Security Standards - Administrative Safeguards 3. Security Standards - Physical Safeguards 4. Security Standards - Technical

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

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

HIPAA PRIVACY AND SECURITY FOR EMPLOYERS

HIPAA PRIVACY AND SECURITY FOR EMPLOYERS HIPAA PRIVACY AND SECURITY FOR EMPLOYERS Agenda Background and Enforcement HIPAA Privacy and Security Rules Breach Notification Rules HPID Number Why Does it Matter HIPAA History HIPAA Title II Administrative

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 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

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

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

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

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

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 Matrix

HIPAA Security Matrix HIPAA Matrix Hardware : 164.308(a)(1) Management Process =Required, =Addressable Risk Analysis The Covered Entity (CE) can store its Risk Analysis document encrypted and offsite using EVault managed software

More information

Empowering Nurses & Building Trust Through Health IT

Empowering Nurses & Building Trust Through Health IT Empowering Nurses & Building Trust Through Health IT Helen Caton-Peters, MSN, RN Health Information Privacy & Security Specialist Office of the National Coordinator for Health Information Technology 2

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

Interim Final Rule on Standards, Implementation Specifications, and Certification Criteria

Interim Final Rule on Standards, Implementation Specifications, and Certification Criteria Interim Final Rule on Standards, Implementation Specifications, and Certification Criteria NIST/OCR Conference Safeguarding Health Information: Building Assurance through HIPAA Security Steven Posnack,

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

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. Jeanne Smythe, UNC-CH Jack McCoy, ECU Chad Bebout, UNC-CH Doug Brown, UNC-CH

HIPAA Security. Jeanne Smythe, UNC-CH Jack McCoy, ECU Chad Bebout, UNC-CH Doug Brown, UNC-CH HIPAA Security Jeanne Smythe, UNC-CH Jack McCoy, ECU Chad Bebout, UNC-CH Doug Brown, UNC-CH What is this? Federal Regulations August 21, 1996 HIPAA Became Law October 16, 2003 Transaction Codes and Identifiers

More information

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

Decrypting the Security Risk Assessment (SRA) Requirement for Meaningful Use Click to edit Master title style Decrypting the Security Risk Assessment (SRA) Requirement for Meaningful Use Andy Petrovich, MHSA, MPH M-CEITA / Altarum Institute April 8, 2015 4/8/2015 1 1 Who is M-CEITA?

More information

Privacy for Healthcare Data in the Cloud - Challenges and Best Practices

Privacy for Healthcare Data in the Cloud - Challenges and Best Practices Privacy for Healthcare Data in the Cloud - Challenges and Best Practices Dr. Sarbari Gupta sarbari@electrosoft-inc.com 703-437-9451 ext 12 Cloud Standards Customer Council (CSCC) Cloud Privacy Summit Electrosoft

More information

Lessons Learned from OCR Privacy and Security Audits

Lessons Learned from OCR Privacy and Security Audits Lessons Learned from OCR Privacy and Security Audits Program Overview & Initial Analysis Linda Sanches, MPH Verne Rinker, JD MPH Presentation to IAPP Global Privacy Summit March 7, 2013 Program Mandate

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

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

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

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

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

Ready for an OCR Audit? Will you pass or fail an OCR security audit? Tom Walsh, CISSP

Ready for an OCR Audit? Will you pass or fail an OCR security audit? Tom Walsh, CISSP Ready for an OCR Audit? Will you pass or fail an OCR security audit? Tom Walsh, CISSP Tom Walsh Consulting, LLC Overland Park, KS What would you do? You receive a phone call from your CEO. They just received

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

Huseman Health Law Group 3733 University Blvd. West, Suite 305-A Jacksonville, Florida 32217 Telephone (904) 448-5552 Facsimile (904) 448-5653

Huseman Health Law Group 3733 University Blvd. West, Suite 305-A Jacksonville, Florida 32217 Telephone (904) 448-5552 Facsimile (904) 448-5653 Huseman Health Law Group 3733 University Blvd. West, Suite 305-A Jacksonville, Florida 32217 Telephone (904) 448-5552 Facsimile (904) 448-5653 rusty@husemanhealthlaw.com use e Health care law firm fighting

More information

Health Informa.on Technology Audits: "Meaningful Use" and HIPAA. January 23, 2015 Eli Poliakoff Gary Capps

Health Informa.on Technology Audits: Meaningful Use and HIPAA. January 23, 2015 Eli Poliakoff Gary Capps Health Informa.on Technology Audits: "Meaningful Use" and HIPAA January 23, 2015 Eli Poliakoff Gary Capps 1 HITECH - Related Audits Health Informa.on Technology for Economic and Clinical Health Act ("HITECH")

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

Objectives 5/5/2015. Quality Health Associates (QHA) of ND

Objectives 5/5/2015. Quality Health Associates (QHA) of ND Privacy and Security: HIPAA/HITECH/Meaningful Use Looking Back, Forging Ahead Patti Kritzberger, RHIT, CHPS Quality Health Associates of North Dakota HIT/Quality Improvement Specialist Quality Health Associates

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

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

Research and the HIPAA Security Rule Prepared for the Association of American Medical Colleges by Daniel Masys, M.D. Professor and Chairman,

Research and the HIPAA Security Rule Prepared for the Association of American Medical Colleges by Daniel Masys, M.D. Professor and Chairman, Research and the HIPAA Security Rule Prepared for the Association of American Medical Colleges by Daniel Masys, M.D. Professor and Chairman, Department of Biomedical Informatics Vanderbilt University School

More information

Welcome to the Privacy and Security PowerPoint presentation in the Data Analytics Toolkit. This presentation will provide introductory information

Welcome to the Privacy and Security PowerPoint presentation in the Data Analytics Toolkit. This presentation will provide introductory information Welcome to the Privacy and Security PowerPoint presentation in the Data Analytics Toolkit. This presentation will provide introductory information about HIPAA, the HITECH-HIPAA Omnibus Privacy Act, how

More 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

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

IBM Internet Security Systems. The IBM Internet Security Systems approach for Health Insurance Portability and Accountability Act compliance overview

IBM Internet Security Systems. The IBM Internet Security Systems approach for Health Insurance Portability and Accountability Act compliance overview IBM Internet Security Systems The IBM Internet Security Systems approach for Health Insurance Portability and Accountability Act compliance overview Health Insurance Portability and Accountability Act

More information

HIPAA Security. assistance with implementation of the. security standards. This series aims to

HIPAA Security. assistance with implementation of the. security standards. This series aims to 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

What is HIPAA? The Health Insurance Portability and Accountability Act of 1996

What is HIPAA? The Health Insurance Portability and Accountability Act of 1996 What is HIPAA? The Health Insurance Portability and Accountability Act of 1996 BASIC QUESTIONS AND ANSWERS What Does HIPAA do? Creates national standards to protect individuals' medical records and other

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

HIPAA Security. 4 Security Standards: Technical Safeguards. Security Topics

HIPAA Security. 4 Security Standards: Technical Safeguards. Security Topics HIPAA Security S E R I E S Security Topics 1. Security 101 for Covered Entities 2. Security Standards - Administrative Safeguards 3. Security Standards - Physical Safeguards 4. Security Standards - Technical

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 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

How to prepare your organization for an OCR HIPAA audit

How to prepare your organization for an OCR HIPAA audit How to prepare your organization for an OCR HIPAA audit Presented By: Mac McMillan, FHIMSS, CISM CEO, CynergisTek, Inc. Technical Assistance: 978-674-8121 or Amanda.Howell@iatric.com Audio Options: Telephone

More information

Protecting Patient Information in an Electronic Environment- New HIPAA Requirements

Protecting Patient Information in an Electronic Environment- New HIPAA Requirements Protecting Patient Information in an Electronic Environment- New HIPAA Requirements SD Dental Association Holly Arends, RHIT Clinical Program Manager Meet the Speaker TRUST OBJECTIVES Overview of HIPAA

More information

Preparing for and Responding to an OCR HIPAA Audit

Preparing for and Responding to an OCR HIPAA Audit Preparing for and Responding to Carole Klove Carole.Klove@ucsfmedctr.or g Gerry Hinkley gerry.hinkley@pillsburylaw.com SIXTH NATIONAL HIPAA SUMMIT WEST October 10-12, 2012 Overview Background What to expect

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

HIPAA Risk Assessments for Physician Practices

HIPAA Risk Assessments for Physician Practices HIPAA Risk Assessments for Physician Practices Eric Sandhusen Corporate Compliance Director and Privacy Officer Lloyd Torres Director of Ambulatory HIM DISCLAIMER The statements and opinions presented

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

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

Patient Privacy and Security. Presented by, Jeffery Daigrepont

Patient Privacy and Security. Presented by, Jeffery Daigrepont Patient Privacy and Security Presented by, Jeffery Daigrepont Jeffery Daigrepont, SVP No Financial Conflicts to Report Jeffery Daigrepont, Senior Vice President of The Coker Group, specializes in health

More information

HIPAA Audits Are Here!

HIPAA Audits Are Here! HIPAA Audits Are Here! How to prepare for and what to expect when OCR comes knocking May 12, 2016 James B. Wieland, Principal, Ober Kaler Emily H. Wein, Principal, Ober Kaler David Holtzman, VP of Compliance,

More information

Does Your Information Security Program Measure Up? Session #74

Does Your Information Security Program Measure Up? Session #74 Does Your Information Security Program Measure Up? Session #74 DISCLAIMER: The views and opinions expressed in this presentation are those of the author and do not necessarily represent official policy

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

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

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

BEFORE THE BOARD OF COUNTY COMMISSIONERS FOR MULTNOMAH COUNTY, OREGON RESOLUTION NO. 05-050

BEFORE THE BOARD OF COUNTY COMMISSIONERS FOR MULTNOMAH COUNTY, OREGON RESOLUTION NO. 05-050 BEFORE THE BOARD OF COUNTY COMMISSIONERS FOR MULTNOMAH COUNTY, OREGON RESOLUTION NO. 05-050 Adopting Multnomah County HIPAA Security Policies and Directing the Appointment of Information System Security

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

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

The second section of the HIPAA Security Rule is related to physical safeguards. Physical safeguards are physical measures, policies and procedures

The second section of the HIPAA Security Rule is related to physical safeguards. Physical safeguards are physical measures, policies and procedures The second section of the HIPAA Security Rule is related to physical safeguards. Physical safeguards are physical measures, policies and procedures to protect and secure a covered entity s electronic information

More information

AHLA. B. HIPAA Compliance Audits. Marti Arvin Chief Compliance Officer UCLA Health System and David Geffen School of Medicine Los Angeles, CA

AHLA. B. HIPAA Compliance Audits. Marti Arvin Chief Compliance Officer UCLA Health System and David Geffen School of Medicine Los Angeles, CA AHLA B. HIPAA Compliance Audits Marti Arvin Chief Compliance Officer UCLA Health System and David Geffen School of Medicine Los Angeles, CA Anna C. Watterson Davis Wright Tremaine LLP Washington, DC Fraud

More information

Can Your Diocese Afford to Fail a HIPAA Audit?

Can Your Diocese Afford to Fail a HIPAA Audit? Can Your Diocese Afford to Fail a HIPAA Audit? PETULA WORKMAN & PHIL BUSHNELL MAY 2016 2016 ARTHUR J. GALLAGHER & CO. BUSINESS WITHOUT BARRIERS Agenda Overview Privacy Security Breach Notification Miscellaneous

More information

RAYSAFE S1 SECURITY WHITEPAPER VERSION B. RaySafe S1 SECURITY WHITEPAPER

RAYSAFE S1 SECURITY WHITEPAPER VERSION B. RaySafe S1 SECURITY WHITEPAPER RaySafe S1 SECURITY WHITEPAPER Contents 1. INTRODUCTION 2 ARCHITECTURE OVERVIEW 2.1 Structure 3 SECURITY ASPECTS 3.1 Security Aspects for RaySafe S1 Data Collector 3.2 Security Aspects for RaySafe S1 cloud-based

More information

WHITE PAPER. Support for the HIPAA Security Rule RadWhere 3.0

WHITE PAPER. Support for the HIPAA Security Rule RadWhere 3.0 WHITE PAPER Support for the HIPAA Security Rule RadWhere 3.0 SUMMARY This white paper is intended to assist Nuance customers who are evaluating the security aspects of the RadWhere 3.0 system as part of

More information

Surviving a HIPAA Audit: What you need to know NOW So you can cope THEN. Jonathan Krasner www.beinetworks.com www.hipaasecurenow.

Surviving a HIPAA Audit: What you need to know NOW So you can cope THEN. Jonathan Krasner www.beinetworks.com www.hipaasecurenow. Surviving a HIPAA Audit: What you need to know NOW So you can cope THEN Jonathan Krasner www.beinetworks.com www.hipaasecurenow.com Healthcare IT Landscape Meaningful Use Incentives Technology Advances

More information

Unified Security Anywhere HIPAA COMPLIANCE ACHIEVING HIPAA COMPLIANCE WITH MASERGY PROFESSIONAL SERVICES

Unified Security Anywhere HIPAA COMPLIANCE ACHIEVING HIPAA COMPLIANCE WITH MASERGY PROFESSIONAL SERVICES Unified Security Anywhere HIPAA COMPLIANCE ACHIEVING HIPAA COMPLIANCE WITH MASERGY PROFESSIONAL SERVICES HIPAA COMPLIANCE Achieving HIPAA Compliance with Security Professional Services The Health Insurance

More information

Meaningful Use Crosswalk to the Security Rule

Meaningful Use Crosswalk to the Security Rule Meaningful Use Crosswalk to the Security Rule Safeguarding Health Information: Building Assurance through HIPAA Security June 7, 2012 Adam H. Greene, J.D., M.P.H. Partner, Davis Wright Tremaine EHR Certification

More information

2015 Minnesota e-health Summit Data Privacy and Security Prevailing Federal Laws for Local Public Health

2015 Minnesota e-health Summit Data Privacy and Security Prevailing Federal Laws for Local Public Health 2015 Minnesota e-health Summit Data Privacy and Security Prevailing Federal Laws for Local Public Health Adam Stone, MBA, CISSP, CIPP/US, ISSMP, HCISPP, CHPS Secure Digital Solutions, LLC 952-544-0234

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

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

White Paper. Support for the HIPAA Security Rule PowerScribe 360

White Paper. Support for the HIPAA Security Rule PowerScribe 360 White Paper Support for the HIPAA Security Rule PowerScribe 360 2 Summary This white paper is intended to assist Nuance customers who are evaluating the security aspects of the PowerScribe 360 system as

More information

HIPAA BUSINESS ASSOCIATE AGREEMENT

HIPAA BUSINESS ASSOCIATE AGREEMENT HIPAA BUSINESS ASSOCIATE AGREEMENT This Business Associate Agreement ( BAA ) is effective ( Effective Date ) by and between ( Covered Entity ) and Egnyte, Inc. ( Egnyte or Business Associate ). RECITALS

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

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

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

Lessons Learned from HIPAA Audits

Lessons Learned from HIPAA Audits Lessons Learned from HIPAA Audits October 29, 2012 Tony Brooks, CISA, CRISC Partner - IT Assurance and Risk Services HORNE LLP AGENDA HIPAA/HITECH Regulations Breaches and Fines OCR HIPAA/HITECH Compliance

More information

Support for the HIPAA Security Rule

Support for the HIPAA Security Rule WHITE PAPER Support for the HIPAA Security Rule PowerScribe 360 Reporting v2.0 HEALTHCARE 2 SUMMARY This white paper is intended to assist Nuance customers who are evaluating the security aspects of PowerScribe

More information

HIPAA and 42 CFR Part 2: What does it have to do with you? Carolyn Heyman-Layne, Esq.

HIPAA and 42 CFR Part 2: What does it have to do with you? Carolyn Heyman-Layne, Esq. HIPAA and 42 CFR Part 2: What does it have to do with you? Carolyn Heyman-Layne, Esq. 1 HIPAA 42 CFR Part 2 Other potential privacy laws: Privacy Act, FERPA, AK PIPA, other State laws Other healthcare

More information

HIPAA SECURITY RULES FOR IT: WHAT ARE THEY?

HIPAA SECURITY RULES FOR IT: WHAT ARE THEY? HIPAA SECURITY RULES FOR IT: WHAT ARE THEY? HIPAA is a huge piece of legislation. Only a small portion of it applies to IT providers in healthcare; mostly the Security Rule. The HIPAA Security Rule outlines

More information

OCR HIPAA Security Audit Protocol a second look

OCR HIPAA Security Audit Protocol a second look OCR HIPAA Security Audit Protocol a second look On June 26, 2012, the Office for Civil Rights published its Audit Protocols for HIPAA Security, HIPAA Breach and Privacy at http://ocrnotifications.hhs.gov/hipaa.html.

More information