HIPAA compliance toolkit by HHS for Healthcare providers

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A new security risk assessment (SRA) tool to help guide health care providers in small to medium sized offices conduct risk assessments of their organizations is now available from HHS. The SRA tool is the result of a collaborative effort by the HHS Office of the National Coordinator for Health Information Technology (ONC) and Office for Civil Rights (OCR). The tool is designed to help practices conduct and document a risk assessment in a thorough, organized fashion at their own pace by allowing them to assess the information security risks in their organizations under the Health Insurance Portability and Accountability Act (HIPAA) Security Rule. The application, available for downloading at www.HealthIT.gov/security-risk-assessment also produces a report that can be provided to auditors.

HIPAA requires organizations that handle protected health information to regularly review the administrative, physical and technical safeguards they have in place to protect the security of the information. By conducting these risk assessments, health care providers can uncover potential weaknesses in their security policies, processes and systems.  Risk assessments also help providers address vulnerabilities, potentially preventing health data breaches or other adverse security events. A vigorous risk assessment process supports improved security of patient health data.

Conducting a security risk assessment is a key requirement of the HIPAA Security Rule and a core requirement for providers seeking payment through the Medicare and Medicaid EHR Incentive Program, commonly known as the Meaningful Use Program.

“Protecting patients’ protected health information is important to all health care providers and the new tool we are releasing today will help them assess the security of their organizations,” said Karen DeSalvo, M.D., national coordinator for health information technology. “The SRA tool and its additional resources have been designed to help health care providers conduct a risk assessment to support better security for patient health data.”

“We are pleased to have collaborated with the ONC on this project,” said Susan McAndrew, deputy director of OCR’s Division of Health Information Privacy. “We believe this tool will greatly assist providers in performing a risk assessment to meet their obligations under the HIPAA Security Rule.”

The SRA tool’s website contains a User Guide and Tutorial video to help providers begin using the tool. Videos on risk analysis and contingency planning are available at the website to provide further context.

The tool is available for both Windows operating systems and iOS iPads. Download the Windows version athttp://www.HealthIT.gov/security-risk-assessment. The iOS iPad version is available from the Apple App Store (search under “HHS SRA tool”).

The ONC is committed to improving the SRA tool in future update cycles, and is requesting that users provide feedback.  Public comments on the SRA tool will be accepted at http://www.HealthIT.gov/security-risk-assessment until June 2, 2014.

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  • 10 Myths and Facts about HIPAA and Meaningful Security Risk Analysis

    Conducting  a security risk analysis to meet the standards of Health Insurance Portability and Accountability Act of 1996 (HIPAA) Security Rule is included in the meaningful use requirements of the Medicare and Medicaid EHR Incentive Programs. The following areas addresses some of the common myths about conducting a risk analysis, and provides facts and tips that can help you structure your risk analysis process.

     

    Myth 1: The security risk analysis is optional for small providers

    Fact: False. All providers who are “covered entities” under HIPAA are required to perform a risk analysis. In addition, all providers who want to receive EHR incentive payments must conduct a risk analysis.

    Myth 2:  Simply installing a certified EHR fulfills the security risk analysis MU requirement

    Fact: 

    False. Even with a certified EHR, you must perform a full security risk analysis. Security requirements address all electronic protected health information you maintain, not just what is in your EHR.

    Myth 3: My EHR vendor took care of everything I need to do about privacy and security

    Fact:  False. Your EHR vendor may be able to provide information, assistance, and training on the privacy and security aspects of the EHR product. However, EHR vendors are not responsible for making their products compliant with HIPAA Privacy and Security Rules. It is solely your responsibility to have a complete risk analysis conducted.

    Myth 4:  I have to outsource the security risk analysis

    Fact: False. It is possible for small practices to do risk analysis themselves using self-help tools. However, doing a thorough and professional risk analysis that will stand up to a compliance review will require expert knowledge that could be obtained through services of an experienced outside professional.

    Myth 5:  A checklist will suffice for the risk analysis requirement

    Fact: False. Checklists can be useful tools, especially when starting a risk analysis, but they fall short of performing a systematic security risk analysis or documenting that one has been performed.

    Myth 6:  There is a specific risk analysis method that I must follow

    Fact:  False. A risk analysis can be performed in countless ways. OCR has issued Guidance on Risk Analysis Requirements of the Security Rule. This guidance assists organizations in identifying and implementing the most effective and appropriate safeguards to secure e-PHI.

    Myth 7:  My security risk analysis only needs to look at my EHR

    Fact:  False. Review all electronic devices that store, capture, or modify electronic protected health information. Include your EHR hardware and software and devices that can access your EHR data (e.g., your tablet computer, your practice manager’s mobile phone). Remember that copiers also store data.  Please see U.S. Department of Health and Human Services (HHS) guidance on remote use.

    Myth 8:  I only need to do a risk analysis once

    Fact:  False. To comply with HIPAA, you must continue to review, correct or modify, and update security protections.

    Myth 9:  Before I attest for an EHR incentive program, I must fully mitigate all risks

    Fact: False. The EHR incentive program requires correcting any deficiencies (identified during the risk analysis) according to the timeline established in the provider’s risk management process, not the date the provider chooses to submit meaningful use attestation. The timeline needs to meet the requirements under 45 CFR 164.308(a)(1), including the requirement to “Implement security measures sufficient to reduce risks and vulnerabilities to a reasonable and appropriate level to comply with [45 CFR ]§164.306(a).”

    Myth 10:  Each year, I’ll have to completely redo my security risk analysis

    Fact:  False. Perform the full security risk analysis as you adopt an EHR. Each year or when changes to your practice or electronic systems occur, review and update the prior analysis for changes in risks. Under meaningful use, reviews are required for each EHR reporting period. For EPs, the EHR reporting period will be 90 days or a full calendar year, depending on the EP’s year of  participation in the program.

    Source: CMS

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