Meaningful Use Risk Analysis Webinar


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One of the Meaningful Use(MU) core objectives for eligible professionals, eligible hospitals and critical access hospitals is to conduct through technical risk analysis of EHR and ePHI systems. The primary objective of the risk analysis is to identify the key vulnerabilities in the ePHI and EHR systems and plan on mitigating the risks by fixing, transferring or accepting risks. Attestation of the risk analysis is required every year to CMS for incentive payments. EHR 2.0 risk analysis services ensures you identify the key technical risks in your areas.

Why risk analysis?
HIPAA and meaningful risk analysis is the first step in healthcare practice’s security rule compliance efforts. Risk analysis is an ongoing process that should provide the practice with a detailed understanding of the risks to the confidentiality, integrity, and availability of e-PHI. The key questions asked during a risk analysis are:
Have you identified the e-PHI within your organization? This includes e-PHI that you create, receive, maintain or transmit.
What are the external sources of e-PHI? For example, do vendors or consultants create, receive, maintain or transmit e-PHI?
What are the human, natural, and environmental threats to information systems that contain e-PHI?

What is the scope of the risk analysis?
The scope of risk analysis that the HIPAA security rule encompasses includes the potential risks and vulnerabilities to the confidentiality, availability and integrity of all e-PHI that an organization creates, receives, maintains, or transmits. This includes e-PHI in all forms of electronic media, such as hard drives, floppy disks, CDs,
DVDs, smart cards or other storage devices, personal digital assistants, transmission media, or portable electronic media. Electronic media includes a single workstation as well as complex networks connected between multiple locations. Thus, an organization’s risk analysis should take into account all of its e-PHI, regardless of the particular electronic medium in which it is created, received, maintained or transmitted or the source or location of its e-PHI.
How to inventory ePHI systems?
An healthcare organization must identify where the e-PHI is stored, received, maintained or transmitted. An organization could gather relevant data by: reviewing past and/or existing projects; performing interviews; reviewing documentation; or using other data gathering
techniques. The data on e-PHI gathered using these methods must be documented.

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Meaningful Use Risk Analysis Webinar

  1. 1. Meaningful Use RiskAnalysis
  2. 2. Who are we EHR 2.0 Mission: To assist healthcare organizations develop and implement practices to secure IT systems and comply with HIPAA/HITECH regulations.  Education  Consulting  Toolkit(Tools, Best Practices & Checklist)Goal: To make compliance an enjoyable and painless experience
  3. 3. Webinar ObjectiveUnderstand and Perform Meaningful UseRisk Analysis that satisfies CMSincentive and attestation requirement. 3
  4. 4. Glossary1. HHS, CMS:2. NIST:3. Threats and Vulnerabilities:4. Findings:5. Risk Analysis: 4
  5. 5. The American Recovery andReinvestment Act of 2009 and HITECH 5
  6. 6. HITECH ActThe Health Information Technology for Economic andClinical Health (“HITECH”) provisions of theAmerican Recovery and Reinvestment Act of 2009(“ARRA”, also referred to as the “Stimulus Bill”) codify andexpand on many of the requirements contained in theHealth Insurance Portability and Accountability Act of 1996(“HIPAA”) and its regulations to protect the privacy andsecurity of protected health information (“PHI”). 6
  7. 7. HITECHHITECH modifications to HIPAA including: Creating incentives for developing a meaningful use of electronic health records Changing the liability and responsibilities of Business Associates Redefining what a breach is Creating stricter notification standards Tightening enforcement Raising the penalties for a violation Creating new code and transaction sets (HIPAA 5010, ICD10) 7
  8. 8. CMS Meaningful Use IncentivesFor Eligible Professionals 8
  9. 9. For Eligible Professionals 9
  10. 10. For Eligible Hospital & CAH 10
  11. 11. HIPAA Titles - Overview 11
  12. 12. HIPAA Security Rule 12
  13. 13. Information Security Model Confidentiality Limiting information access and disclosure to authorized users (the right people) Integrity Trustworthiness of information resources (no inappropriate changes) Availability Availability of information resources (at the right time) 13
  14. 14. PHI Health Information Individually Identifiable Health Information PHI 14
  15. 15. ePHI – 18 Elements Elements ExamplesName Max Bialystock 1355 Seasonal LaneAddress (all geographic subdivisions smaller than state, including street address, city, county, or ZIP code)Dates related to an individual Birth, death, admission, discharge 212 555 1234, home, office, mobile etc.,Telephone numbers 212 555 1234Fax numberEmail address, personal, officialSocial Security number 239-68-9807Medical record number 189-88876Health plan beneficiary number 123-ir-2222-98Account number 333389Certificate/license number 3908763 NYAny vehicle or other device serial number SZV4016Device identifiers or serial numbers Unique Medical DevicesWeb URL www.rickymartin.comInternet Protocol (IP) address numbers or voice prints finger.jpgPhotographic images mypicture.jpgAny other characteristic that could uniquely 15identify the individual
  16. 16. HIPAA Security –Administrativesafeguard (§164.308) (A) Risk analysis (Required) Conduct an accurate and thorough assessment of the potential risks and vulnerabilities to the confidentiality, integrity, and availability of electronic protected healtha(1) Security information held by the covered entity. (B) Risk management (Required)Management Implement security measures sufficient to reduce risks and vulnerabilities to a reasonable and appropriate levelProcess to comply with §164.306(a). Implement policies and (C) Sanction policy (Required) procedures to prevent, detect, contain, and Apply appropriate sanctions against workforce members correct security who fail to comply with the security policies and violations. procedures of the covered entity. (D) Information system activity review (Required) Implement procedures to regularly review records of information system activity, such as audit logs, access reports, and security incident tracking reports.
  17. 17. Infrastructure  Computers  Storage Devices  Networking devices (Routers, Switches & Wireless)  Medical Devices  Scanners, fax andAny device that photocopierselectronically stores or  VoIPtransmits information  Smart-phones, Tablets (ipad,using a software PDAs)program 17  Cloud-based services
  18. 18. Trends in Healthcare IT Informatics Collaboration Mobile EHR Computing HIE 18
  19. 19. Handheld Usage in Healthcare• 25% usage with providers• Another 21% expected to use• 38% physicians use medical apps• 70% think it is a high priority• 1/3 use hand-held for accessing EMR/EHR 19compTIA 2011 Survey
  20. 20. EMR and EHR systems 20
  21. 21. Health Information Exchange (HIE) 21
  22. 22. Social Media How does your practice use it? How do your employees use it? Do you have policies? 22
  23. 23. Cloud-based services  Public Cloud  EHR Applications HIPAA regulations  Private-label e-mail remain barriers to full cloud adoption  Private Cloud  Archiving of Images  File SharingCloud Computing is takingall batch processing, and  On-line Backupsfarming it out to a hugecentral or virtualized  Hybrid 23computers.
  24. 24. Informatics 24
  25. 25. Risk Assessment Methodology Flowchart(NIST) Step 3: Step 5: Step 7: Step 8:Step 1: System Step 2: Threat Step 4: Step 6: Vulnerability Likelihood Risk ControlCharacterization Identification Control Analysis Impact Analysis Identification determination Determination Recommendation Current controls Mission impact Recommended Reports from and planned Likelihood of Hardware, analysis, asset controls previous risk controls Threat source threat Software, criticality assessments, motivation, assessment, exploitation, System any audit threat capacity, data criticality, magnitude of Interfaces, Data History of comments, Nature of data sensitivity impact, and Information, system attack, security List of current vulnerability, adequacy of People and Data from requirements, and planned current controls planned or System mission intelligence security test controls current controls agencies results Impact rating Risk and List of potential Likelihood rating Associated risk System vulnerabilities levels boundary, functions, criticality and sensitivity Threat Statement
  26. 26. Risk Analysis - Example Risk Description Risk Description /Threat and Probability Conse- Risk Risk Potential Loss of Loss quence Score ValueePHI located on Desk top in an 4 4 16 Highemployees office is not routinelybacked up.Risk = Loss of PHI(Identified in Gap Analysis)
  27. 27. Sample Risk Analysis Template Likelihood High Medium Low High Unencrypted Lack of auditing on Missing security laptop ePHI EHR systems patches on web server hosting patient informationImpact Medium Unsecured Outdated anti-virus External hard drives wireless network software not being backed up in doctor’s office Sales presentation Web server backup Weak password on Low on USB thumb tape not stored in a internal document drive secured location server 27
  28. 28. Risk Management- Steps Develop and implement a risk management plan Implement security measures Evaluate and maintain security measures Risk transfer, reduction, acceptance
  29. 29. Sanction PolicyAcceptable Use of PHI - Minimum Necessary - Sanction ExemptionsDisciplinary ActionsSample sanction policy:
  30. 30. Information System Security Review -Example Review of Security Incidents Response reports System user privileges grants and changes logs User-level system access logs, if available User level system activity logs, if available User level transaction log reports, if available Exception reports The required level of system activity logging and reporting capabilities, and the actual scope
  31. 31. Top 5 Recommendations 1. Ensure encryption on all protected health information in storage and transit.(at least de-identification) 2. Implement a mobile device security program. 3. Strengthen information security user awareness and training programs. 4. Ensure that business associate due diligence includes clearly written contract, a periodic review of implemented controls. 5. Minimize sensitive data capture, storage and sharing. 31
  32. 32. Meaningful Use Stage 2 and Stage 3Security Requirements Security Risk Analysis with encryption assessment Secure Messaging for ambulatory practices 32
  33. 33. Effective Management of Security andCompliance Find out where your business is weak Determine the Re-evaluate on a compliance and periodic and security needs & consistent basis gaps Implement the right Put reasonable technologies & policies and processes to help business processes 33 with enforcement in place
  34. 34. HIPAA Security ChecklistOverview 34
  35. 35. Key Takeaways Risk Analysis is foundation for an effective security program ePHI elements drives risk analysis scope There is no silver bullet for risk management. It is a journey of continuous assessment and improvement 35
  36. 36. Additional Resources NIST - Risk Management Guide for Information Technology Systems SP800-30 Small Practice Security Guide 36
  37. 37. How can you help us? Follow-us on social media (Like) (Follow us)!/EHR_20 (Follow) Next Webinar on Business Associate Assessment( 3/21) We sincerely appreciate your referrals! 37
  38. 38. Thank you!! 38