Presentations that briefly covers HIPAA and concentrates of the Risk Assessment portion which is a requirement for overall compliance and meaningful use.
GDPR and ISO 27001 - how to be compliantIlesh Dattani
being GDPR Compliant using a long-standing international standing and getting accreditation. Demonstrate GDPR Compliance. accreditation provides a means to demonstrate that you are in line with standard procedures and processes
8 Reasons You Need an Electronic Document Management SystemHelpSystems
Want to go paperless in the office and boost employee productivity? View this slideshow to learn how you can with an electronic document management system.
GDPR and ISO 27001 - how to be compliantIlesh Dattani
being GDPR Compliant using a long-standing international standing and getting accreditation. Demonstrate GDPR Compliance. accreditation provides a means to demonstrate that you are in line with standard procedures and processes
8 Reasons You Need an Electronic Document Management SystemHelpSystems
Want to go paperless in the office and boost employee productivity? View this slideshow to learn how you can with an electronic document management system.
With GDPR coming into effect, we can see a lot of changes in the privacy policies of companies doing business online. The presentation is a description of GDPR and its implications in India and worldwide. The main aim of the presentation is to identify the key issues of data privacy and the rights available to the consumer who's data is to be shared.
A presentation on document management system presented by Converse Solutions during the Global Executive Event in Colombo, Sri Lanka, 22nd August 2010.
General Data Protection Regulation (GDPR) and ISO 27001Owako Rodah
The General Data Protection Regulation (GDPR) came into effect on May 25th 2018 and organisations and data subjects alike are mostly in the dark about what it means and how it affects them This is a summary of the regulation and how businesses can leverage the implementation of international standards such as ISO 27001 to meet the requirements of the regulation.
Organizational Benefits Of Document Management SystemClare White
There are several benefits of document management system(DMS). Sometimes it seems that DMS becoming a necessity for organizations. I'd say future belongs to DMS.
Information Security between Best Practices and ISO StandardsPECB
Main points covered:
• Information Security best practices (ESA, COBIT, ITIL, Resilia)
• NIST security publications (NIST 800-53)
• ISO standards for information security (ISO 20000 and ISO 27000 series)
- Information Security Management in ISO 20000
- ISO 27001, ISO 27002 and ISO 27005
• What is best for me: Information Security Best Practices or ISO standards?
Presenter:
This webinar was presented by Mohamed Gohar. Mr.Gohar has more than 10 years of experience in ISM/ITSM Training and Consultation. He is one of the expert reviewers of CISA RM 26th edition (2016), ISM Senior Trainer/Consultant at EGYBYTE.
Link of the recorded session published on YouTube: https://youtu.be/eKYR2BG_MYU
What is ISO 27005? How is an ISO 27005 Risk Assessment done effectively? Find out in this presentation delivered at the ISACA Bangalore Chapter Office by Dharshan Shanthamurthy.
Design and validate assessment and test strategies, Conduct security control testing, Collect security process data (e.g., management and operational controls),
My presentation at 7th Business Security Conference in Warsaw. Describes ON Semiconductor approach to implement Physical Security Management system globally.
The HIPAA Security Rule establishes national standards to protect individuals’ electronic personal health information that is created, received, used, or maintained by a covered entity. The Security Rule requires appropriate administrative, physical and technical safeguards to ensure the confidentiality, integrity, and security of electronic protected health information. The Security Rule is located at 45 CFR Part 160 and Subparts A and C of Part 164.
HIPAA Security Rule list 28 adminstrative safeguards, 12 Physical safeguards, 12 technical safeguards along with specific organization and policies and procedures requirements. EHR 2.0 HIPAA security assessment services help covered entities to discover the gap areas based on the required and addressable requirements.
There are two main rules for HIPAA. One is a rule on privacy and the other on Security.
The HIPAA Privacy Rule establishes national standards to protect individuals’ medical records and other personal health information and applies to health plans, health care clearinghouses, and those health care providers that conduct certain health care transactions electronically. The Rule requires appropriate safeguards to protect the privacy of personal health information, and sets limits and conditions on the uses and disclosures that may be made of such information without patient authorization. The Rule also gives patients rights over their health information, including rights to examine and obtain a copy of their health records, and to request corrections. The Privacy Rule is located at 45 CFR Part 160 and Subparts A and E of Part 164.
How often the security should be reviewed?
Security standard mentioned under HIPAA should be reviewed and modified as needed to continue provision of reasonable and appropriate protection of electronic protected health information.
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)
http://ehr20.com/services/hipaa-security-assessment/
Redspin HIPAA Security Risk Analysis RFP TemplateRedspin, Inc.
RFP Template for healthcare organizations to use when looking for a qualified information security assessment firm to perform a HIPAA Security Risk Analysis as defined in the HIPAA Security Rule 45 CFR 164.308(a)(1)(A).
With GDPR coming into effect, we can see a lot of changes in the privacy policies of companies doing business online. The presentation is a description of GDPR and its implications in India and worldwide. The main aim of the presentation is to identify the key issues of data privacy and the rights available to the consumer who's data is to be shared.
A presentation on document management system presented by Converse Solutions during the Global Executive Event in Colombo, Sri Lanka, 22nd August 2010.
General Data Protection Regulation (GDPR) and ISO 27001Owako Rodah
The General Data Protection Regulation (GDPR) came into effect on May 25th 2018 and organisations and data subjects alike are mostly in the dark about what it means and how it affects them This is a summary of the regulation and how businesses can leverage the implementation of international standards such as ISO 27001 to meet the requirements of the regulation.
Organizational Benefits Of Document Management SystemClare White
There are several benefits of document management system(DMS). Sometimes it seems that DMS becoming a necessity for organizations. I'd say future belongs to DMS.
Information Security between Best Practices and ISO StandardsPECB
Main points covered:
• Information Security best practices (ESA, COBIT, ITIL, Resilia)
• NIST security publications (NIST 800-53)
• ISO standards for information security (ISO 20000 and ISO 27000 series)
- Information Security Management in ISO 20000
- ISO 27001, ISO 27002 and ISO 27005
• What is best for me: Information Security Best Practices or ISO standards?
Presenter:
This webinar was presented by Mohamed Gohar. Mr.Gohar has more than 10 years of experience in ISM/ITSM Training and Consultation. He is one of the expert reviewers of CISA RM 26th edition (2016), ISM Senior Trainer/Consultant at EGYBYTE.
Link of the recorded session published on YouTube: https://youtu.be/eKYR2BG_MYU
What is ISO 27005? How is an ISO 27005 Risk Assessment done effectively? Find out in this presentation delivered at the ISACA Bangalore Chapter Office by Dharshan Shanthamurthy.
Design and validate assessment and test strategies, Conduct security control testing, Collect security process data (e.g., management and operational controls),
My presentation at 7th Business Security Conference in Warsaw. Describes ON Semiconductor approach to implement Physical Security Management system globally.
The HIPAA Security Rule establishes national standards to protect individuals’ electronic personal health information that is created, received, used, or maintained by a covered entity. The Security Rule requires appropriate administrative, physical and technical safeguards to ensure the confidentiality, integrity, and security of electronic protected health information. The Security Rule is located at 45 CFR Part 160 and Subparts A and C of Part 164.
HIPAA Security Rule list 28 adminstrative safeguards, 12 Physical safeguards, 12 technical safeguards along with specific organization and policies and procedures requirements. EHR 2.0 HIPAA security assessment services help covered entities to discover the gap areas based on the required and addressable requirements.
There are two main rules for HIPAA. One is a rule on privacy and the other on Security.
The HIPAA Privacy Rule establishes national standards to protect individuals’ medical records and other personal health information and applies to health plans, health care clearinghouses, and those health care providers that conduct certain health care transactions electronically. The Rule requires appropriate safeguards to protect the privacy of personal health information, and sets limits and conditions on the uses and disclosures that may be made of such information without patient authorization. The Rule also gives patients rights over their health information, including rights to examine and obtain a copy of their health records, and to request corrections. The Privacy Rule is located at 45 CFR Part 160 and Subparts A and E of Part 164.
How often the security should be reviewed?
Security standard mentioned under HIPAA should be reviewed and modified as needed to continue provision of reasonable and appropriate protection of electronic protected health information.
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)
http://ehr20.com/services/hipaa-security-assessment/
Redspin HIPAA Security Risk Analysis RFP TemplateRedspin, Inc.
RFP Template for healthcare organizations to use when looking for a qualified information security assessment firm to perform a HIPAA Security Risk Analysis as defined in the HIPAA Security Rule 45 CFR 164.308(a)(1)(A).
EHR meaningful use security risk assessment sample documentdata brackets
Under the HIPAA Privacy and Security Rule, business associates are required to perform active risk prevention and safeguarding of patient information that are very important to patient privacy. The HITECH act allows only minimum necessary to be disclosed when handling protected health information (PHI).
This security risk assessment exercise has been performed to support the requirements of the Department of Health and Human Services (HHS), Office for the Civil Rights (OCR) and other applicable state data privacy laws and regulations. Upon completion of this risk assessment, a detail risk management plan need to be developed based on the gaps identified from the risk analysis. The gaps identified and recommendations provided are based on the input provided by the staff, budget, scope and other practical considerations
The HITECH Act authorizes Health and Human Services(HHS) to conduct periodic audits to ensure that covered entities and business associates are complying with the HIPAA/HITECH Privacy, Security and Breach rules. As a result, Office for Civil Rights(OCR), through the use of KPMG audit services, has begun to develop a pilot audit program.
HIPAA Security Assessment Intro & OverviewBob Chaput
Covered Entities and Business Associates – take control of your HIPAA Security – HITECH Act compliance program starting today! Our HIPAA Security Assessment Tool™ is the easiest, fastest and most popular way to establish a baseline scorecard and track compliance progress.
Meaningful Use and Security Risk AnalysisEvan Francen
Presentation delivered by FRSecure president, Evan Francen to the 100+ Iowa CPSI User Group attendees on October 18th, 2011.
Meaningful Use Core Requirement "Security Risk Analysis"
When thinking about cybersecurity, you have to move past the lone thought of data breaches. Cybersecurity should include preparing for the slew of additional threats that are out there. Take a peek at this review of today’s most prevalent cybersecurity risks and see the steps to identifying, preventing, detecting, responding to and recovering from attacks.
Get information on the HIPAA Omnibus rule and how the revised regulations will impact not only healthcare organization but also covered entities and other IT providers - OConnor Davies - NYC CPA Firm.
Securing Healthcare Data on AWS for HIPAAAlert Logic
Get the scoop on addressing HIPAA compliance requirements and using DevOps and a Security Operations Center (SOC) to assist with compliance.
Slides from AWS Healthcare Meetup in NYC with Logicworks and Alert Logic on May 4, 2016.
Security Audits of Electronic Health I.docxkenjordan97598
Security Audits of Electronic Health Information (Updated)
Editor's note: This update supplants the November 2003 practice brief "Security Audits (Updated)."
Introducing the AHIMA Compendium http://compendium.ahima.org
Throughout this brief, sentences marked with the † symbol indicate AHIMA best practices in health information management. These practices are collected in the new AHIMA Compendium, offering health information management professionals "just in time" guidance as they research and address practice challenges.
In a perfect world, access controls alone would ensure the privacy of electronic protected health information (ePHI). However, the complexities of the healthcare environment today make it extremely challenging to limit worker access to the minimum information necessary to do their jobs.
For example, many jobs in smaller organizations and community-based hospitals require workers perform multiple functions. Without access to at least select portions of every patient's health record, some employees' effectiveness could be significantly inhibited and patient care could be compromised.
Organizations must develop security audits and related policies and procedures to hold workers accountable for their actions while utilizing ePHI and an electronic health record (EHR).
Security audits are conducted using audit trails and audit logs that offer a back-end view of system use. Audit trails and logs record key activities, showing system threads of access, changes, and transactions. Periodic reviews of audit logs may be useful for:
· Detecting unauthorized access to patient information
· Establishing a culture of responsibility and accountability
· Reducing the risk associated with inappropriate accesses (behavior may be altered when individuals know they are being monitored)
· Providing forensic evidence during investigations of suspected and known security incidents and breaches to patient privacy, especially if sanctions against a workforce member, business associate, or other contracted agent will be applied
· Tracking disclosures of PHI
· Responding to patient privacy concerns regarding unauthorized access by family members, friends, or others
· Evaluating the overall effectiveness of policy and user education regarding appropriate access and use of patient information (comparing actual worker activity to expected activity and discovering where additional training or education may be necessary to reduce errors)
· Detecting new threats and intrusion attempts
· Identifying potential problems
· Addressing compliance with regulatory and accreditation requirements
This practice brief identifies and defines the components necessary for a successful security audit strategy. It also outlines considerations for legal and regulatory requirements, how to evaluate and retain audit logs, and the overall audit process.
Legal and Regulatory Requirements
Many regulatory requirements drive how and why security audits are conducted. .
Security Audits of Electronic Health I.docxbagotjesusa
Security Audits of Electronic Health Information (Updated)
Editor's note: This update supplants the November 2003 practice brief "Security Audits (Updated)."
Introducing the AHIMA Compendium http://compendium.ahima.org
Throughout this brief, sentences marked with the † symbol indicate AHIMA best practices in health information management. These practices are collected in the new AHIMA Compendium, offering health information management professionals "just in time" guidance as they research and address practice challenges.
In a perfect world, access controls alone would ensure the privacy of electronic protected health information (ePHI). However, the complexities of the healthcare environment today make it extremely challenging to limit worker access to the minimum information necessary to do their jobs.
For example, many jobs in smaller organizations and community-based hospitals require workers perform multiple functions. Without access to at least select portions of every patient's health record, some employees' effectiveness could be significantly inhibited and patient care could be compromised.
Organizations must develop security audits and related policies and procedures to hold workers accountable for their actions while utilizing ePHI and an electronic health record (EHR).
Security audits are conducted using audit trails and audit logs that offer a back-end view of system use. Audit trails and logs record key activities, showing system threads of access, changes, and transactions. Periodic reviews of audit logs may be useful for:
· Detecting unauthorized access to patient information
· Establishing a culture of responsibility and accountability
· Reducing the risk associated with inappropriate accesses (behavior may be altered when individuals know they are being monitored)
· Providing forensic evidence during investigations of suspected and known security incidents and breaches to patient privacy, especially if sanctions against a workforce member, business associate, or other contracted agent will be applied
· Tracking disclosures of PHI
· Responding to patient privacy concerns regarding unauthorized access by family members, friends, or others
· Evaluating the overall effectiveness of policy and user education regarding appropriate access and use of patient information (comparing actual worker activity to expected activity and discovering where additional training or education may be necessary to reduce errors)
· Detecting new threats and intrusion attempts
· Identifying potential problems
· Addressing compliance with regulatory and accreditation requirements
This practice brief identifies and defines the components necessary for a successful security audit strategy. It also outlines considerations for legal and regulatory requirements, how to evaluate and retain audit logs, and the overall audit process.
Legal and Regulatory Requirements
Many regulatory requirements drive how and why security audits are conducted. .
Get your Ducks in a Row - The OCR Audit Season is About to BeginID Experts
The HHS Office for Civil Rights has unveiled information about Phase 2 of its HIPAA audits. These audits will be conducted by OCR itself and will focus on high-risk areas and enforcement. Organizations may be hearing from OCR over this summer, with audits to begin in the fall. This webinar will overview some lessons learned from the first round of audits and highlight the changes and process for the next round. Phase 2’s additional focus on compliance with breach notification rule will be discussed. We also will provide some tips to prepare for the audits, which also will be helpful to prepare for any OCR investigation or compliance review.
To view the Webinar Recording, click here: https://www2.idexpertscorp.com/resources/single/get-your-ducks-in-a-row-the-ocr-audit-season-is-about-to-begin/r-general
The increase level of awareness and training is also very important as is the culture impact of the CE’s environment. How you proceed to successfully train and change the culture depends on the choice of an external HIPAA-HITECH privacy and security auditor. Simply stated, your external auditor should possess the skills and knowledge to comprehensively evaluate all aspect of the HIPAA-HITECH impact on your practice. Upon completion of an audit each area should address its findings, impact and corrective action plan. The action plan should incorporate the training requirements and a training plan to address the specific requirements of each staff member’s relevance to their job function within the practice.
In today's rapidly advancing technological landscape, the intersection of privacy and innovation has become a paramount concern. One area that has sparked considerable debate and regulatory scrutiny is the use of tracking technologies in the healthcare sector. As healthcare providers strive to improve patient care and streamline operations, they have turned to various tracking technologies to enhance efficiency and data collection. However, the implementation of these technologies raises significant questions about patient privacy and compliance with the Health Insurance Portability and Accountability Act (HIPAA).
HIPAA, enacted in 1996, was designed to safeguard the privacy and security of individuals' medical information. It sets strict guidelines and standards for the handling, storage, and transmission of protected health information (PHI). The law not only applies to healthcare providers but also to their business associates, such as technology vendors and service providers. HIPAA's primary objective is to strike a balance between the need for healthcare organizations to collect and share patient data for treatment and administrative purposes while ensuring the confidentiality and privacy of individuals' sensitive medical information.
Tracking technologies, such as electronic health records (EHRs), wearable devices, and location tracking systems, have shown immense potential in revolutionizing healthcare delivery. EHRs enable healthcare providers to access patient information instantaneously, leading to quicker diagnoses and improved treatment outcomes. Wearable devices, such as fitness trackers and smartwatches, provide real-time health data that can help individuals monitor their well-being and make informed decisions about their lifestyle. Location tracking systems are utilized in hospitals and nursing homes to ensure patient safety and streamline workflows.
While these tracking technologies offer undeniable benefits, they also raise concerns about patient privacy. The vast amount of data generated by these technologies, ranging from personal identifiers to sensitive medical records, demands robust safeguards and strict adherence to HIPAA regulations. Unauthorized access, data breaches, and misuse of patient information can result in severe consequences, including legal repercussions, reputational damage, and loss of patient trust.
In this context, it becomes crucial for healthcare organizations to strike a delicate balance between leveraging tracking technologies to improve patient care and compliance with HIPAA regulations. Robust security measures, such as encryption, access controls, and regular audits, must be implemented to protect patient information from unauthorized access or breaches. Additionally, transparent communication and patient consent are vital to ensure individuals are aware of how their data is being collected, stored, and used.
Presentation designed to explain Business Associates the basics of HIPAA and real-life examples of cases that failed to implement and follow HIPAA requirements on a timely basis.
The current healthcare system in the United States is heavily influenced by HIPAA Security. This translates into a need to understand technology and cybersecurity beyond the use of anti-malware applications. This presentation presents some of the basics Covered Entities and Business Associates must be aware of as it relates to HIPAA Security.
Medicare Access and Chip Reauthorization Act (MACRA) is the law that changes how Providers are to be reimbursed. One of the key characteristics is that it rewards Providers based on value and not volume.
Monthly series covering key subjects regarding healthcare business in the USA. This seminar covers: Affordable Care Act section 1557, HIPAA Security, Medicare Payment models and Chronic conditions.
Brief presentation regarding key topics in the USA healthcare industry. Some of the basic topics include: MACRA, ICD 10, Meaningful Use and a very brief comment about diabetes as a chronic condition.
Interesting codes found in ICD-10 and a quick way to code using ICD 9 as a basis. Codes presented are real but presented to simply relax health professionals as they tackle this subject.
Meaningful Use Audits and healthcare compliance course offered to Physicians and healthcare professionals to explain the basics of Meaningful Use and HITECH audits. Course is general in nature as many Physicians and organizations are in different stages of meaningful use.
Basic explanation of the physician quality reporting system. Some of the due dates and actions that could be taken before Dec 31st to prevent losing money in the future.
Based on misconceptions regarding the exchanges and healthcare reform I created a presentation that covers some of the basic issues and actions to consider.
Review of the health business status in the United States as of July 2013. Brief description of ICD 10 implementation status and potential repercussions and HIPAA Title 2 requirements.
Steps to consider when moving from paper to digital in any business. Solutions presented have been developed by TC Inc. and or Networking team. Steps provided should work on just about any environment and allows for expansion while minimizing growing pains.
This document is designed as an introductory to medical students,nursing students,midwives or other healthcare trainees to improve their understanding about how health system in Sri Lanka cares children health.
Health Education on prevention of hypertensionRadhika kulvi
Hypertension is a chronic condition of concern due to its role in the causation of coronary heart diseases. Hypertension is a worldwide epidemic and important risk factor for coronary artery disease, stroke and renal diseases. Blood pressure is the force exerted by the blood against the walls of the blood vessels and is sufficient to maintain tissue perfusion during activity and rest. Hypertension is sustained elevation of BP. In adults, HTN exists when systolic blood pressure is equal to or greater than 140mmHg or diastolic BP is equal to or greater than 90mmHg. The
Letter to MREC - application to conduct studyAzreen Aj
Application to conduct study on research title 'Awareness and knowledge of oral cancer and precancer among dental outpatient in Klinik Pergigian Merlimau, Melaka'
Navigating Challenges: Mental Health, Legislation, and the Prison System in B...Guillermo Rivera
This conference will delve into the intricate intersections between mental health, legal frameworks, and the prison system in Bolivia. It aims to provide a comprehensive overview of the current challenges faced by mental health professionals working within the legislative and correctional landscapes. Topics of discussion will include the prevalence and impact of mental health issues among the incarcerated population, the effectiveness of existing mental health policies and legislation, and potential reforms to enhance the mental health support system within prisons.
Deep Leg Vein Thrombosis (DVT): Meaning, Causes, Symptoms, Treatment, and Mor...The Lifesciences Magazine
Deep Leg Vein Thrombosis occurs when a blood clot forms in one or more of the deep veins in the legs. These clots can impede blood flow, leading to severe complications.
TEST BANK For Accounting Information Systems, 3rd Edition by Vernon Richardso...rightmanforbloodline
TEST BANK For Accounting Information Systems, 3rd Edition by Vernon Richardson, Verified Chapters 1 - 18, Complete Newest Version
TEST BANK For Accounting Information Systems, 3rd Edition by Vernon Richardson, Verified Chapters 1 - 18, Complete Newest Version
TEST BANK For Accounting Information Systems, 3rd Edition by Vernon Richardson, Verified Chapters 1 - 18, Complete Newest Version
Rate Controlled Drug Delivery Systems, Activation Modulated Drug Delivery Systems, Mechanically activated, pH activated, Enzyme activated, Osmotic activated Drug Delivery Systems, Feedback regulated Drug Delivery Systems systems are discussed here.
KEY Points of Leicester travel clinic In London doc.docxNX Healthcare
In order to protect visitors' safety and wellbeing, Travel Clinic Leicester offers a wide range of travel-related health treatments, including individualized counseling and vaccines. Our team of medical experts specializes in getting people ready for international travel, with a particular emphasis on vaccines and health consultations to prevent travel-related illnesses. We provide a range of travel-related services, such as health concerns unique to a trip, prevention of malaria, and travel-related medical supplies. Our clinic is dedicated to providing top-notch care, keeping abreast of the most recent recommendations for vaccinations and travel health precautions. The goal of Travel Clinic Leicester is to keep you safe and well-rested no matter what kind of travel you choose—business, pleasure, or adventure.
ICH Guidelines for Pharmacovigilance.pdfNEHA GUPTA
The "ICH Guidelines for Pharmacovigilance" PDF provides a comprehensive overview of the International Council for Harmonisation of Technical Requirements for Pharmaceuticals for Human Use (ICH) guidelines related to pharmacovigilance. These guidelines aim to ensure that drugs are safe and effective for patients by monitoring and assessing adverse effects, ensuring proper reporting systems, and improving risk management practices. The document is essential for professionals in the pharmaceutical industry, regulatory authorities, and healthcare providers, offering detailed procedures and standards for pharmacovigilance activities to enhance drug safety and protect public health.
DECODING THE RISKS - ALCOHOL, TOBACCO & DRUGS.pdfDr Rachana Gujar
Introduction: Substance use education is crucial due to its prevalence and societal impact.
Alcohol Use: Immediate and long-term risks include impaired judgment, health issues, and social consequences.
Tobacco Use: Immediate effects include increased heart rate, while long-term risks encompass cancer and heart disease.
Drug Use: Risks vary depending on the drug type, including health and psychological implications.
Prevention Strategies: Education, healthy coping mechanisms, community support, and policies are vital in preventing substance use.
Harm Reduction Strategies: Safe use practices, medication-assisted treatment, and naloxone availability aim to reduce harm.
Seeking Help for Addiction: Recognizing signs, available treatments, support systems, and resources are essential for recovery.
Personal Stories: Real stories of recovery emphasize hope and resilience.
Interactive Q&A: Engage the audience and encourage discussion.
Conclusion: Recap key points and emphasize the importance of awareness, prevention, and seeking help.
Resources: Provide contact information and links for further support.
About this webinar: This talk will introduce what cancer rehabilitation is, where it fits into the cancer trajectory, and who can benefit from it. In addition, the current landscape of cancer rehabilitation in Canada will be discussed and the need for advocacy to increase access to this essential component of cancer care.
Stem Cell Solutions: Dr. David Greene's Path to Non-Surgical Cardiac CareDr. David Greene Arizona
Explore the groundbreaking work of Dr. David Greene, a pioneer in regenerative medicine, who is revolutionizing the field of cardiology through stem cell therapy in Arizona. This ppt delves into how Dr. Greene's innovative approach is providing non-surgical, effective treatments for heart disease, using the body's own cells to repair heart damage and improve patient outcomes. Learn about the science behind stem cell therapy, its benefits over traditional cardiac surgeries, and the promising future it holds for modern medicine. Join us as we uncover how Dr. Greene's commitment to stem cell research and therapy is setting new standards in healthcare and offering new hope to cardiac patients.
3. Must Know
• Every Covered Entity (CE) must identify a
HIPAA Security Officer
• Every CE entity must be in compliance with
the final HIPAA Omnibus Rule
• Every CE must have a Risk Assessment
Completed with all components covered
• A covered entity can be fined $1,000 to
$50,000 per patient record up to $1,500,000 if
patient records are breached
4. HIPAA Audits
• Audits will be conducted by Office for Civil Rights
instead of contractor
• Number of audits to increase
• Monies collected to be used to fund further audits
• Audits to include Covered Entities and Business
Associates
• 2014 first time a Government Entity was fined
5. Meaningful Use
• Ties HIPAA Security to Attestation
• Fraud charges possibility based on answers
• Part of Meaningful Use and Records Review
Audits
9. Basic Concepts
Scalability – flexibility to adopt implementing measures
appropriate to their situation.
“Required” and “Addressable”
Under no conditions should any covered entity considered
addressable specifications as optional requirements.
10. Risk Analysis
CFR 164.308(a)(1)
"Conduct accurate and thorough assessment of the potential risks and
vulnerabilities to the confidentiality, integrity, and availability of electronic
protected health information (ePHI) held by the covered entity."
• Perform Risk Assessment
• Formalized/Document Risk Assessment Process
• Update Risk Assessment Process
• Address all potential areas of risk
11. Risk Analysis
• Gap/risk assessment
– Audit of security based on HIPAA Security
Components
– Document findings on all areas
– Use initial analysis as baseline
– Base Security Management on findings
13. Security Risk Assessment
HIPAA
Meets
Requirem
ent
Not
Review of Current Procedure Citation Guidelines for Policy Yes No Reqd
.
Person Responsible
Task 1
Identify
Relevant
Information
System
- Has all hardware and software
for which the organization is
responsible been identified?
- Is the current information
system configuration
documented, including
connections to other systems?
- Have the types of information
and uses of that information
been identified and the
sensitivity of each type of
information been evaluated?
§164.30
8
(a)(1)
- Identify all information systems
that house individually
identifiable health information.
- Include all hardware and
software that are used to collect,
store, process, or transmit
protected health information.
- Analyze business functions and
verify ownership and control of
information system elements as
necessary.
15. Risk Management
§ 164.308(a)(1)(ii)(B)
"“[i]mplement security measures sufficient to reduce risks and vulnerabilities to
a reasonable and appropriate level to comply with 164.306(a) [(the General
Requirements of the Security Rule)].”
• Develop and implement a risk management plan.
• Implement security measures.
• Evaluate and maintain security measures.
16. Policies
• Live Documents
• Review as needed
• Document reviews and updates
• Having policies alone will not suffice
17. Forms/Documentation
• Not Required
• Useful to document actions
• Prevents adding too much information
“Anything you say can be used against you”
20. Administrative Safeguards
• Security management process (CFR §164.308(a)(1)): Prevent, detect,
contain, and correct security violations
• Assigned security responsibility (CFR §164.308(a)(2))
• Workforce security (CFR §164.308(a)(3)): Employees and access to EPHI.
• Information access management (CFR §164.308(a)(4)): ePHI access.
• Security awareness and training (CFR §164.308(a)(5))
• Security incident procedures (CFR §164.308(a)(6))
• Contingency plan (CFR §164.308(a)(7))
• Evaluation (CFR §164.308(a)(8)): Periodic evaluations.
• Business associate contracts and other arrangements (CFR
§164.308(b)(1))
21. Administrative Safeguards
Security Management Process 164.308(a)(
1)
Risk Analysis (R)
Risk Management
(R)
Sanction Policy (R)
Information System
Activity Review (R)
Assigned Security Responsibility 164.308(a)(
2)
[None]
Workforce Security 164.308(a)(
3)
Authorization and/or Supervision (A)
Workforce Clearance Procedure (A)
Termination Procedures (A)
Information Access Management 164.308(A)
(4)
Isolating Health Care Clearinghouse
Function (R)
Access Authorization (A)
Access Establishment and Modification (A)
Security Awareness and Training 164.308(a)(
5)
Security Reminders (A)
Protection from Malicious Software (A)
Log-in Monitoring (A)
Password Management (A)
22. Administrative Safeguards
Continuation
Security Incident Procedures 164.308(a)(6) Response and Reporting (R)
Contingency Plan 164.308(a)(7) Data Backup Plan (R)
Disaster Recovery Plan (R)
Emergency Mode Operation Plan (R)
Testing and Revision Procedure (A)
Applications and Data Criticality Analysis A)
Evaluation 164.308(a)(8) [None]
Business Associate Contracts and
Other Arrangements
164.308(b)(1) Written Contract or Other Arrangement (R)
23. Sanction Policy
CFR 164.308(a)(1)
• Every covered entity must
"have and apply appropriate
sanctions against members
of its workforce who fail to
comply”.
• Any system of penalties
should be reasonable in
relation to the violations to
which they apply, particularly
with regard to deterrence.
24. System Activity Review
“Implement procedures to regularly review records of information system
activity, such as audit logs, access reports, and security incident tracking
reports.”
• What are the audit and activity review functions of the current
information systems?
• Are the information systems functions adequately used and monitored
to promote continual awareness of information system activity?
• What logs or reports are generated by the information systems?
• Is there a policy that establishes what reviews will be conducted?
• Is there a procedure that describes specifics of the reviews?
25. Assigned Security Responsibility
The HIPAA Security Officer is responsible for:
• Understanding the HIPAA Security Rule and how it applies.
• Developing appropriate policies and procedures.
• Overseeing the security of EPHI.
• Monitoring each Covered Component for compliance.
• Identifying and evaluating threats.
• Responding to actual or suspected breaches.
26. AUTHORIZATION AND/OR SUPERVISION
§164.308(a)(3)(ii)(A)
“Implement procedures for the authorization and/or supervision of
workforce members who work with electronic protected health
information or in locations where it might be accessed.”
• Detailed job descriptions with level of access to EPHI?
• Policy that identifies the authority to determine who can access EPHI
27. Security Reminders
CFR 164.308(a)(5)
Security reminders are just tidbits of information
given to employees of covered entities throughout
the year.
Recommendations:
Bulletin board in the break room or main office is a start.
“org chart” showing who is in charge of HIPAA
Emergency contact phone numbers
HIPAA Breach checklist
Changing HIPAA security reminders
Use e-mail to sent security reminders
28. Protection from Malicious Software
“Procedures for guarding against, detecting, and reporting
malicious software.”
• Policies covering antivirus protection
• Software used against malicious software
• Updates and logs
• Employee training
29. Log-in Monitoring
CFR 164.308(a)(5)
Procedures for monitoring log-in
attempts and reporting
discrepancies.
• Identify multiple unsuccessful
attempts to log-in.
• Record attempts in a log or audit
trail.
• Resetting of a password after a
specified number of unsuccessful log-
in attempts.
30. Contingency Plans
164.308(a)(7)
• Data Backup Plan
• Disaster recovery plan
• Emergency Mode Operation Plan
• Testing and Revision Procedure
• Applications and Data Criticality
Analysis: procedures for assessing
the criticality of applications and
systems.
31. Physical Safeguards
• Facility access controls: limit
physical access to systems.
• Workstation use: specify the
proper workstation functions.
• Workstation security: limit access
to only authorized users.
• Device and media controls:
receipt and removal of hardware
and electronic media.
32. Physical Safeguards
Facility Access Controls 164.310(a)(1) Contingency Operations (A)
Facility Security Plan (A)
Access Control and Validation Procedures (A)
Maintenance Records (A)
Workstation Use 164.310(b) [None]
Workstation Security 164.310(c) [None]
Device and Media Controls 164.310(D)(1) Disposal (R)
Media Re-use (R)
Accountability (A)
Data Backup and Storage (A)
33. Technical Safeguards
• Access control: Implementing policies and procedures for electronic
information systems that contain EPHI to only allow access to persons or
software programs that have appropriate access rights.
• Audit controls: Implementing hardware, software, and/or procedural
mechanisms to record and examine activity in information systems that
contain or use EPHI.
• Integrity: Implementing policies and procedures to protect EPHI from
improper modification or destruction.
• Person or entity authentication: Implementing procedures to verify that
persons or entities seeking access to EPHI are who or what they claim to
be.
• Transmission security: Implementing security measures to prevent
unauthorized access to EPHI that is being transmitted over an electronic
communications network.
34. Technical Safeguards
Access Control 164.312(a)
(1)
Unique User Identification
(R)
Emergency Access
Procedure (R)
Automatic Logoff (A)
Encryption and
Decryption (A)
Audit Controls 164.312(b) [None]
Integrity 164.312(c)
(1)
Mechanism to Authenticate Electronic Protected
Health Information (A)
Person or Entity
Authentication
164.312(d) [None]
Transmission Security 164.312(e)
(1)
Integrity Controls (A) Encryption (A)
35. Key Items to Remember
• Policies and Procedures not enough
• Documentation is key
– Evidence book
• Follow the steps
– Risk Assessment
– Risk Management
– Training
ACT NOW!!
36. Dr. Jose I Delgado
Tel 904-794-7830
DrDelgado@Tainoconsultants.com
www.tainoconsultants.com
Editor's Notes
Covered entity audits in 2015 will focus on issues including computing device and storage media security controls, transmission security, and HIPAA safeguards such as procedures and staff training. The focus in 2016 will include physical access, encryption, decryption and other issues, according to the article.
OCR recently levied its first fine against a local government for HIPAA non-compliance. Skagit County in Washington state was ordered to pay $215,000 for failing to act after a hospital's September 2011 self-reported breach compromised the electronic protected health information of close to 1,600 people served by the public health department.
The Health Insurance Portability and Accountability Act of 1996 (HIPAA; Pub.L. 104-191, 110 Stat. 1936, enacted August 21, 1996) was enacted by the United States Congress and signed by President Bill Clinton in 1996. It was sponsored by Sen. Nancy Kassebaum (R-Kan.). Title I of HIPAA protects health insurance coverage for workers and their families when they change or lose their jobs. Title II of HIPAA, known as the Administrative Simplification (AS) provisions, requires the establishment of national standards for electronic health care transactions and national identifiers for providers, health insurance plans, and employers
To improve the effectiveness and efficiency of the nation’s healthcare system, the Health Insurance Portability and Accountability Act (HIPAA) of 1996 includes a series of “administrative simplification” provisions requiring HHS to adopt national standards for electronic healthcare transactions. By ensuring consistency throughout the industry, the national standards will make it easier for health care organizations to process transactions electronically. The law also requires the adoption of privacy and security standards in order to protect individually identifiable health information. HIPAA requires that “covered entities” e.g. health plans, healthcare clearinghouses, and those healthcare providers conducting electronic financial and administrative transactions (such as eligibility, referral authorizations, and claims) comply with each set of standards. Other businesses may choose to comply with the standards, but the law does not mandate that they do so.
Administrative safeguards: Administrative functions that should be implemented to meet the security standards. These include assignment or delegation of security responsibility to an individual and security training requirements.
Physical safeguards: Mechanisms required to protect electronic systems, equipment and the data they hold, from threats, environmental hazards and unauthorized intrusion. They include restricting access to EPHI and retaining off site computer backups.
Technical safeguards: Automated processes used to protect data and control access to data. They include using authentication controls to verify that the person signing onto a computer is authorized to access that EPHI, or encrypting and decrypting data as it is being stored and/or transmitted.
CEs did not perform a risk assessment;
CEs did not have a formalized, documented risk assessment process;
CEs had outdated risk assessments; and,
CEs did not address all potential areas of risk.
Develop and Implement a Risk Management Plan
The first step in the risk management process should be to develop and implement a risk management plan. The purpose of a risk management plan is to provide structure for the covered entity’s evaluation, prioritization, and implementation of risk-reducing security measures.
For the risk management plan to be successful, key members of the covered entity’s workforce, including senior management and other key decision makers, must be involved. The outputs of the risk analysis process will provide these key workforce members with the information needed to make risk prioritization and mitigation decisions.
The risk prioritization and mitigation decisions will be determined by answering questions such as:
Should certain risks be addressed immediately or in the future?
Which security measures should be implemented?
Many of the answers to these questions will be determined using data gathered during the risk analysis. The entity has already identified, through that process, what vulnerabilities exist, when and how a vulnerability can be exploited by a threat, and what the impact of the risk could be to the organization. This data will allow the covered entity to make informed decisions on how to reduce risks to reasonable and appropriate levels.
An important component of the risk management plan is the plan for implementation of the selected security measures. The implementation component of the plan should address:
Risks (threat and vulnerability combinations) being addressed;
Security measures selected to reduce the risks;
Implementation project priorities, such as: required resources; assigned responsibilities; start and completion dates; and maintenance requirements.
The implementation component of the risk management plan may vary based on the circumstances of the covered entity. Compliance with the Security Rule requires financial resources, management commitment, and the workforce involvement. Cost is one of the factors a covered entity must consider when determining security measures to implement.
However, cost alone is not a valid reason for choosing not to implement security measures that are reasonable and appropriate.
The output of this step is a risk management plan that contains prioritized risks to the covered entity, options for mitigation of those risks, and a plan for implementation. The plan will guide the covered entity’s actual implementation of security measures to reduce risks to EPHI to reasonable and appropriate levels.
2. Implement Security Measures
Once the risk management plan is developed, the covered entity must begin implementation. This step will focus on the actual implementation of security measures (both technical and non-technical) within the covered entity. The projects or activities to implement security measures should be performed in a manner similar to other projects, i.e., these projects or activities should each have an identified scope, timeline and budget.
Covered entities may also want to consider the benefits, if any, of implementing security measures as part of another existing project, such as implementation of a new information system.
A covered entity may choose to use internal or external resources to perform these projects. The Security Rule does not require or prohibit either method. It is important to note that, even if it uses outside vendors to implement the security measures selected, the covered entity is responsible for its compliance with the Security Rule.
3. Evaluate and Maintain Security Measures
The final step in the risk management process is to continue evaluating and monitoring the risk mitigation measures implemented. Risk analysis and risk management are not one-time activities. Risk analysis and risk management are ongoing, dynamic processes that must be periodically reviewed and updated in response to changes in the environment. The risk analysis will identify new risks or update existing risk levels resulting from environmental or operational changes. The output of the updated risk analysis will be an input to the risk management processes to reduce newly identified or updated risk levels to reasonable and appropriate levels.
Security management process (CFR §164.308(a)(1)): Implementing policies and procedures to prevent, detect, contain, and correct security violations.
Assigned security responsibility (CFR §164.308(a)(2)): A single individual must be designated as having overall responsibility for the security of a Covered Entity's (CE) Electronic Patient Health Information (EPHI).
Workforce security (CFR §164.308(a)(3)): Implementing policies and procedures to ensure that employees have only appropriate access to EPHI.
Information access management (CFR §164.308(a)(4)): Implementing policies and procedures for authorizing access to EPHI.
Security awareness and training (CFR §164.308(a)(5)): Implementing a security awareness and training program for a CE's entire workforce.
Security incident procedures (CFR §164.308(a)(6)): Implementing policies and procedures to handle security incidents.
Contingency plan (CFR §164.308(a)(7)): Implementing policies and procedures for responding to an emergency or other occurrence that damages systems containing EPHI.
Evaluation (CFR §164.308(a)(8)): Performing periodic technical and non-technical evaluations that determine the extent to which a CE's security policies and procedures meet the ongoing requirements of the Security Rule.
Business associate contracts and other arrangements (CFR §164.308(b)(1)): A CE may permit a business associate to create, receive, maintain, or transmit EPHI on the CE's behalf only if the CE has satisfactory assurance that the business associate will appropriately safeguard the data.
The HIPAA Security Officer is responsible for:
Understanding the HIPAA Security Rule and how it applies within each Covered Component.
Developing appropriate policies and procedures to comply with the HIPAA Security Rule
Overseeing the security of EPHI within each Covered Component.
Monitoring each Covered Component for compliance with EPHI security policies and procedures.
Identifying and evaluating threats to the confidentiality and integrity of EPHI.
Responding to actual or suspected breaches in the confidentiality or integrity of EPHI.
Security reminders are just that, a refresh of the annual HIPAA awareness training