HIPAA Breach Notification - How to Know What to Do and Avoid Penalties
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The HIPAA Breach Notification Rule has new standards for determining what qualifies as a reportable breach.
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CHAPTER
3 Maintaining Compliance
MANY LAWS AND REGULATIONS ARE IN PLACE regarding the protection of
information technology (IT) systems. Companies have a requirement to comply with the laws that
apply to them. The first step is to understand the laws. You’re not expected to be a lawyer, but you
should understand the basics of relevant laws.
Once you have an idea of which laws and regulations apply, you can then dig in deeper to
ensure your organization is in compliance. The cost of not complying can sometimes be
expensive. Fines can be in the hundreds of thousands of dollars. Some offenses can result in jail
time.
Chapter 3 Topics
This chapter covers the following topics and concepts:
• What U.S. compliance laws exist
• What some relevant regulations related to compliance are
• What organizational policies for compliance should be considered
• What standards and guidelines for compliance exist
Chapter 3 Goals
When you complete this chapter, you will be able to:
• Define compliance
• Describe the purpose of FISMA
• Identify the purpose and scope of HIPAA
• Describe GLBA and SOX, and the impact for IT
• Describe the purpose of FERPA
• Identify the purpose and scope of CIPA
• List some federal entities that control regulations related to IT
• Describe the purpose of PCI DSS
• Describe the contents of SP 800-30
• Describe the purpose of COBIT
• Describe the purpose of ISO and identify some relevant security standards
• Identify the purpose of ITIL
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U.S. Compliance Laws
Many laws exist in the United States related to information technology (IT). Companies affected
by the laws are expected to comply with the laws. This is commonly referred to as compliance.
Many organizations have internal programs in place to ensure they remain in compliance with
relevant laws and regulations. These programs commonly use internal audits. They can also use
certification and accreditation programs. When compliance is mandated by law, external audits are
often done. These external audits provide third-party verification that the requirements are being
met.
An old legal saying is “ignorance is no excuse.” In other words, you can’t break the law and
then say “I didn’t know.” The same goes for laws that apply to any organization. It’s important for
any organization to know what the relevant laws and regulations are.
You aren’t expected to be an expert on any of these laws. However, as a manager or executive,
you should be aware of them. You can roll any of the relevant laws and regulations into a
compliance program for more detailed checks.
This section covers the following U.S. laws:
• Federal Information Security Management Act (FISMA) 2002
• Health Insurance Portability and Accountability Act (HIPAA) 1996
• Gramm-Leach-Bliley Act (GLBA) 1999
• Sarbanes-Oxley Act (SOX) 2002
• Family Educational Rights and Privacy Act (FERPA) 1974
• Children’s Internet Protection Act (CIPA) 2000
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HIPAA week1
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This document provides an overview of the Health Insurance Portability and Accountability Act (HIPAA). It discusses the background and objectives of HIPAA in ensuring privacy of health information. It describes the key aspects of HIPAA including the Privacy Rule, Security Rule, and definitions of protected health information. It also outlines enforcement measures for non-compliance and additional regulations like HITECH that have expanded HIPAA's requirements. Challenges of ensuring HIPAA compliance are discussed as well.
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Before embarking on a research project, especially one aimed at scoping and defining parameters like the one described for health tech IT, several crucial considerations should be addressed. Here’s a comprehensive guide covering key aspects to ensure a well-structured and successful research initiative:
1. Define Research Objectives and Scope
Clear Objectives: Define specific goals such as understanding market needs, identifying new opportunities, assessing risks, or refining pricing strategies.
Scope Definition: Clearly outline the boundaries of the research in terms of geographical focus, target demographics (e.g., age, socio-economic status), and industry sectors (e.g., healthcare IT).
3. Review Existing Literature and Resources
Literature Review: Conduct a thorough review of existing research, market reports, and relevant literature to build foundational knowledge.
Gap Analysis: Identify gaps in existing knowledge or areas where further exploration is needed.
4. Select Research Methodology and Tools
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Tonsils act as filters, trapping germs that could otherwise enter the airways and cause infection.
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- 2. Agenda • State and Federal Breach Notification Laws • HIPAA Breach Notification Requirements • Preventing and Preparing for Breaches Using an Information Security Management Process • The Most Common Types of Breaches • Health Information Breach Notification Policies • The Importance of Documentation • New HIPAA Violation Categories and Penalties • Preparing for HIPAA Audits • Q&A session © Copyright 2014 Lewis Creek Systems, LLC All Rights Reserved jim@lewiscreeksystems.com www.lewiscreeksystems.com 802-425-3839 2
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