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Health information technology (IT) systems are essential to the healthcare industry. In order to develop, deploy, and maintain these systems in compliance with the Health Information Exchange (HIE) a proper certification and accreditation (C&A) process is needed. The researchers will provide a model for C&A in the state hospital systems. C&A implementation is needed in order to protect patient information and uphold the standards of the Health Insurance Portability and Accountability Act (HIPPA). Executing Health IT systems can significantly improve healthcare quality, prevent medical oversights, immensely reduce healthcare costs, improve administrative competency, and expand healthcare access exponentially. Creating a national standard for healthcare IT systems implementation will improve the healthcare system and improve the process of healthcare delivery.
Certification and Accreditation for Health IT SystemsMaurice Dawson
Health information technology (IT) systems are essential to the healthcare industry. In order to develop, deploy, and maintain these systems in compliance with the Health Information Exchange (HIE) a proper certification and accreditation (C&A) process is needed. The researchers will provide a model for C&A in the state hospital systems. C&A implementation is needed in order to protect patient information and uphold the standards of the Health Insurance Portability and Accountability Act (HIPPA). Executing Health IT systems can significantly improve healthcare quality, prevent medical oversights, immensely reduce healthcare costs, improve administrative competency, and expand healthcare access exponentially. Creating a national standard for healthcare IT systems implementation will improve the healthcare system and improve the process of healthcare delivery.
MeHI Privacy & Security Webinar 3.18.15MassEHealth
Top Reason Why Providers Fail Meaningful Use Audits: Inadequate Security Risk Analysis
Providers are losing incentive dollars by not meeting the Meaningful Use Privacy & Security Measure.
Get on track with your Security Risk Assessment and attest to Meaningful Use with MeHI’s support & solutions:
• Assess your practice’s privacy and security status
• Develop remediation plans to resolve gaps
• Communicate resolution steps to the providers involved
• Track progress in addressing outstanding issues
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(inter)national privacy regulations may have a negative impact on patient care, especially safety and efficiency. This presentation shows the measures taken by the Spaarne Hospital, Hoofddorp (NL)
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Explains about Health Record Standards, ICTs, Standards for Healthcare Sector, Ministry of Health and Family Welfare. For more information visit: http://www.transformhealth-it.org/
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Identify successes, challenges and lessons learned with implementation of cyber strategies
Identify success strategies for gaining the C Suite support and ways cyber security can be integrated into the organization's culture and work processes.
Identify best practices with anticipating new and emerging threats and ways to maintain a proactive position instead of reactive
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Top Reason Why Providers Fail Meaningful Use Audits: Inadequate Security Risk Analysis
Providers are losing incentive dollars by not meeting the Meaningful Use Privacy & Security Measure.
Get on track with your Security Risk Assessment and attest to Meaningful Use with MeHI’s support & solutions:
• Assess your practice’s privacy and security status
• Develop remediation plans to resolve gaps
• Communicate resolution steps to the providers involved
• Track progress in addressing outstanding issues
Let us help you conduct a security risk analysis and address deficiencies and potential threats and ensure that your practice is compliant and that patient data is safe-guarded.
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HIPAA consent is the state of being in alignment with guidelines et by Health Insurance Portability and Accountability Act of 1996 passed by the congress.
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CHIME LEAD Fourm Houston - "Case Studies from the Field: Putting Cyber Security Strategies into Action" - Hitchhikers Guide to IT Security
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Learn from those in the trenches who have deployed effective cyber strategies in their organizations, foiled attacks and managed breach situations. Learn approaches for success and pitfalls to avoid by exploring the experience of others with deployment and management of cyber security strategies and plans.
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Identify successes, challenges and lessons learned with implementation of cyber strategies
Identify success strategies for gaining the C Suite support and ways cyber security can be integrated into the organization's culture and work processes.
Identify best practices with anticipating new and emerging threats and ways to maintain a proactive position instead of reactive
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Presentations that briefly covers HIPAA and concentrates of the Risk Assessment portion which is a requirement for overall compliance and meaningful use.
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This includes tasks like:
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Administering medications and treatments.
Performing procedures as directed by doctors.
Assisting with daily living activities (bathing, feeding).
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Objective: Promote healthy behaviors and educate children, families, and communities about preventive healthcare.
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Administering vaccinations.
Providing education on nutrition, hygiene, and development.
Offering breastfeeding and childbirth support.
Counseling families on safety and injury prevention.
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Objective: Collaborate effectively with doctors, social workers, therapists, and other healthcare professionals to ensure coordinated care for children.
Objective: Advocate for the rights and best interests of their patients, especially when children cannot speak for themselves.
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Communicating effectively with healthcare teams.
Identifying and addressing potential risks to child welfare.
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Objective: Stay up-to-date on the latest advancements in pediatric healthcare through continuing education and research.
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Participating in clinical trials related to child health.
Implementing evidence-based practices into their daily routines.
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COVID-19 PCR tests remain a critical component of safe and responsible travel in 2024. They ensure compliance with international travel regulations, help detect and control the spread of new variants, protect vulnerable populations, and provide peace of mind. As we continue to navigate the complexities of global travel during the pandemic, PCR testing stands as a key measure to keep everyone safe and healthy. Whether you are planning a business trip, a family vacation, or an international adventure, incorporating PCR testing into your travel plans is a prudent and necessary step. Visit us at https://www.globaltravelclinics.com/
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Privacy, Confidentiality, and Security Lecture 3_slides
1.
2. The Culture of Health Care
Privacy, Confidentiality, and Security
Lecture d
This material (Comp 2 Unit 9) was developed by Oregon Health & Science University, funded by the Department
of Health and Human Services, Office of the National Coordinator for Health Information Technology under
Award Number IU24OC000015. This material was updated in 2016 by Bellevue College under Award
Number 90WT0002.
This work is licensed under the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International
License. To view a copy of this license, visit http://creativecommons.org/licenses/by-nc-sa/4.0/.
3. Privacy, Confidentiality, and Security
Learning Objectives
• Define and discern the differences between privacy,
confidentiality, and security (Lecture a).
• Discuss methods for using information technology to
protect privacy and confidentiality(Lecture b).
• Describe and apply privacy, confidentiality, and
security under the tenets of HIPAA Privacy and
Security rules (Lectures c and d).
• Discuss the intersection of a patient’s right to privacy
with the need to share and exchange patient
information (Lecture d).
3
4. HIPAA Security Rule
• Readable overview in Security 101 for Covered Entities
(CMS, 2007)
• Aligned with terminology of Privacy Rule
• Aims to minimize specificity to allow scalability, flexibility,
and changes in technology
• For covered entities, business associates, and
subcontractors, rules are either
– Required: Must be implemented
– Addressable: If reasonable and appropriate to implement
• As with HIPAA Privacy Rule, modifications under
HITECH and other legislative actions
• State laws are instrumental
4
5. General Provisions
• Covered entities, business associates, and their
subcontractors must
– Ensure confidentiality, integrity, and availability of electronic PHI
that they create, receive, transmit, and maintain
– Protect against reasonably anticipated threats and hazards to
such information
– Protect against reasonably anticipated uses or disclosures not
permitted or required by Privacy Rule
– Ensure compliance by workforce
• HHS (2010) provides guidance on conducting risk
assessments and helps determine whether an issue
that’s addressable should be addressed by the provider
5
6. Required Safeguards
• Grouped into three categories
– Administrative: Policies and procedures
designed to prevent, detect, contain, and
correct security violations
– Physical: Protecting facilities, equipment, and
media
– Technical: Implementing technological policies
and procedures
• Following slides from Security 101
6
8. Administrative Safeguards
Continued
• Security awareness and training
– Security reminders (A)
– Protection from malicious software (A)
– Log-in monitoring (A)
– Password management (A)
• Security incident procedures—response & reporting (R)
• Contingency plan
– Data back-up plan (R)
– Disaster recovery plan (R)
– Emergency mode operation plan (R)
– Testing and revision procedures (A)
– Application and data criticality analysis (A)
• Evaluation (R)
• Business association contracts, subcontractors, and other
arrangements (R)
8
9. Physical Safeguards
• Facility access controls
– Contingency operations (A)
– Facility security plan (A)
– Access control and validation procedures (A)
– Maintenance records (A)
• Workstation use (R)
• Workstation security (R)
• Device and media controls
– Disposal (R)
– Media re-use (R)
– Accountability (A)
– Data backup and storage (A)
9
10. Technical Safeguards
• Access control
– Unique user identification (R)
– Emergency access procedure (R)
– Automatic logoff (A)
– Encryption and decryption (A)
• Audit controls (R)
• Integrity—mechanism to authenticate electronic PHI (A)
• Person or entity authentication (R)
• Transmission security
– Integrity controls (A)
– Encryption (A)
10
11. Other Regulations
• Business associates and subcontractors are required to
– Implement safeguards to protect covered entity’s PHI
– Ensure its agents meet same standards
– Report to covered entity any security incident
• Documentation of covered entity must be
– Maintained for six years
– Available to those responsible for implementing
– Reviewed and updated periodically
• HITECH meaningful use criteria specify use of various
encryption standards (e.g., AES, TLS, IPsec, SHA-2)
11
12. In the End…
• Ongoing breaches of data are worsening, but
– Complete security of all health information is
impossible
– Security is a trade-off with ease of use; a happy
medium must be found
– Will concerns be tempered when society sees more
benefits of health IT?
– Would other societal changes lessen the impact of
this problem (changes in legal system, health care
financing, etc.)?
12
13. Privacy, Confidentiality, and Security
Summary – Lecture d
• HIPAA Security Rule aims to be actionable
but flexible
• Rules are either required or addressable
• Rules fall into three categories:
– Administrative
– Physical
– Technical
13
14. Privacy, Confidentiality, and Security
Summary
• Privacy is the right to keep information to
yourself
• Confidentiality is the right to keep information
about yourself from being disclosed to others
• Security in this context is the protection of
sensitive health information
• There are many technologies to maintain
security, but human vigilance is also required
• The HIPAA Privacy and Security Rules spell out
the requirements for the United States
14
15. Privacy, Confidentiality, and Security
References – Lecture d
References
CMS (Centers for Medicare and Medicaid Services). (2007). Security 101 for covered entities.
Baltimore, MD: Centers for Medicare and Medicaid Services. Retrieved from
http://www.hhs.gov/sites/default/files/ocr/privacy/hipaa/administrative/securityrule/security101.pdf
HealthIT.gov. (2014). Security risk assessment. Retrieved from https://www.healthit.gov/providers-
professionals/security-risk-assessment
HHS (U.S. Department of Health and Human Services). (n.d.). Summary of the HIPAA security rule.
Retrieved from http://www.hhs.gov/hipaa/for-professionals/security/laws-regulations/index.html
HHS. (2010). Guidance on risk analysis requirements under the HIPAA security rule. Washington, DC:
Department of Health and Human Services. Retrieved from
https://www.hhs.gov/sites/default/files/ocr/privacy/hipaa/administrative/securityrule/rafinalguidance
pdf.pdf
HHS Press Office. (2014, March 28). HHS releases security risk assessment tool to help providers
with HIPAA compliance. Retrieved from http://www.hhs.gov/about/news/2014/03/28/hhs-releases-
security-risk-assessment-tool-to-help-providers-with-hipaa-compliance.html
HIMSS (Health Information and Management Systems Society). (2013). Introduction to the risk
assessment toolkit and security risk assessment basics. Retrieved from
http://www.himss.org/ResourceLibrary/ResourceDetail.aspx?ItemNumber=17193
15
16. The Culture of Health Care
Privacy, Confidentiality, and Security
Lecture d
This material was developed by Oregon Health &
Science University, funded by the Department of
Health and Human Services, Office of the National
Coordinator for Health Information Technology
under Award Number IU24OC000015. This
material was updated in 2016 by Bellevue College
under Award Number 90WT0002.
16
Editor's Notes
No audio. Recording preparation.
Welcome to The Culture of Health Care: Privacy, Confidentiality, and Security. This is Lecture d.
The component, The Culture of Health Care, addresses job expectations in health care settings. It discusses how care is organized within a practice setting, privacy laws, and professional and ethical issues encountered in the workplace.
The objectives for Privacy, Confidentiality, and Security are to:
Define and discern the differences between privacy, confidentiality, and security
Discuss methods for using information technology to protect privacy and confidentiality
Describe and apply privacy, confidentiality, and security under the tenets of the HIPAA Privacy and Security rules
Discuss the intersection of a patient’s right to privacy with the need to share and exchange patient information.
This lecture discusses the Health Insurance Portability and Accountability Act (HIPAA) [hip-uh] Security Rule. There’s a very readable overview of the HIPAA Security Rule on the Centers for Medicare and Medicaid Services, or CMS, website called Security 101 for Covered Entities. A number of other documents that go into detail on the specifics of the Security Rule are publicly available through such sources as the Department of Health and Human Services (HHS) website. The Health Information and Management Systems Society, HIMSS, offers the Privacy and Security Toolkit, which contains analysis of the HIPAA law as well as tools and resources for understanding and implementing various elements of the law. This toolkit, like many other industry resources, provides HIPAA information on specific aspects of the rule, such as with mobile devices, health information exchange organizations, public health, and cloud computing. Many industry resources focus on a specific health care professional, such as physicians, nurses, business associates, and human resources.
The terminology of the HIPAA Security Rule is aligned with the Privacy Rule, so that presumably we could identify areas of the Security Rule that map back to the Privacy Rule.
The HIPAA Security Rule aims to minimize specificity and to be technology-neutral to allow covered entities scalability, flexibility, and adaptability as technologies change. As such, there are only thirteen required implementation specifics. The remainder of the rules are addressable; that is, they concern approaches that may or may not be reasonable for a particular covered entity. As with the HIPAA Privacy Rule, the Security Rule has been enhanced and modified under the Health Information Technology for Economic and Clinical Health Act (HITECH [high-tech]) and other legislative updates. Also, various state security laws must be addressed in conjunction with HIPAA requirements.
The general provisions of the Security Rule are that covered entities, their business associates, and subcontractors must ensure confidentiality, integrity, and availability of electronic protected health information (PHI) that is created, received, transmitted, and maintained by the entity. Entities must protect against reasonably anticipated threats and hazards to such information by having a secure data center and using encryption where appropriate. They also must protect against reasonably anticipated uses or disclosures that are not permitted or that are required by the Privacy Rule. Entities must also ensure compliance by their workforce in implementing the security and privacy rules.
HHS provides guidance on conducting risk assessments. One important feature of this reference is that it helps determine whether something that is addressable should be addressed by the provider. If the provider chooses not to address it, the decision should be documented in the risk analysis. There are many other publicly available risk assessment resources as well.
What are the required safeguards? They are grouped into three categories: administrative, physical, and technical.
Administrative safeguards are policies and procedures that are designed to prevent, detect, and contain security violations.
Physical safeguards include protecting facilities, equipment, and media where medical information is stored.
Technical safeguards are various technical policies and procedures governing use of and access to PHI.
The following slides show some features from each category, though these aren’t exhaustive. The overview article referenced earlier further enumerates all of these safeguards, as do many other sources of information. Security risk assessment is very similar to the risk analysis presented in Lecture c on the HIPAA Privacy Rule. Oversight and management of both the security and privacy risk assessment ideally should tie into the organization’s overall governance and risk management program.
This slide shows the first part of the list of administrative safeguards from the Security 101 document. Perhaps the most important of the required standards is a security management process that includes an analysis of risk, how risk is managed, and any sanction policy. Procedures for addressing security violations as well as an overall information system activity review are also needed. Additionally, security responsibility must be assigned, usually to the chief security officer. The role of the chief security officer includes providing administrative management within the organization as well as providing technical expertise. The security for the rest of the workforce is addressable, as are aspects of information access management with the exception of the requirement that health care clearinghouse functions must be isolated for analysis with regard to security issues.
Continuing with the administrative safeguards, security awareness and workforce training cover concerns such as security reminders, protection from malicious software like viruses and spyware, login monitoring, audit trails, and password management. All of these issues must be addressed, and a process must be in place for security incident procedures. Organizations also need a contingency plan, which includes data backup, disaster recovery, and emergency response procedures. There also needs to be evaluation of the security process as it pertains to the explicit agreements with an organization’s business associates and their subcontractors. A disaster recovery plan for the information technology department and the organization should be developed and tested annually.
The second category of safeguards is physical safeguards. Access to the facility is addressable, so the facility must have a security plan with contingency operations, maintenance records, and other controls. The facility includes the data center location and associated data center hardware, software, and network access points as well as physical access controls to the area. There are requirements for workstation use, physical security of the workstation, and dealing with devices and media. There are explicit regulations for how media containing PHI is disposed of or reused. There are also addressable issues on accountability for media and its backup and storage. Also, the secure use of various types of mobile devices must be addressed.
The third and final category is technical safeguards. This includes issues such as access control. According to the specifications, every user of a system containing PHI is required to have a unique, personal user identification, and there needs to be emergency access to information when appropriate.
One addressable specification is automatic logoff. Institutions must decide how quickly they want a system to automatically log off a user; in operational settings, different groups have different ideas on the length of time before automatic logoff should occur.
Encryption and decryption are listed as addressable specifications because the developers of the HIPAA security regulations realized that the technology would be changing and that people within organizations would be able to make the best decisions on specific encryption and decryption needs.
Audit controls are required under the technical safeguards, while integrity mechanisms that authenticate PHI are addressable. Authentication of the individual and/or the institution is a required specification; transmission security is addressable.
Business associates and all related subcontractors are required to implement safeguards to protect a covered entity’s PHI and report back to the covered entity any security incident. Business associates and subcontractors are subject to all breach notification rules when the number of patient records breached exceeds five hundred—that is, the breach must be reported to the local media and to the HHS Office for Civil Rights.
There are also regulations regarding the documentation of entity security practices and procedures that must be maintained for six years. The documentation must be made available to those responsible for implementing security, and it must be reviewed and updated periodically.
The meaningful use criteria of the HITECH Act also specify various government encryption standards, discussed in a previous lecture, such as advanced encryption standard (AES), the standard for encryption and decryption; transport layer security (TLS) and Internet Protocol Security (IPsec) [eye-pee-sehk], which cover how information moves across networks; and the latest secure hash algorithms (SHA-2) [S-H-A-two], which verify that information is transmitted intact from one point to another.
In bringing this discussion of privacy and confidentiality and security together, what can we conclude? Clearly, the ongoing breaches of data are getting worse, as discussed in previous lectures, so serious attention needs to be paid to privacy and security issues—they’re not to be taken lightly.
However, it’s also probable that complete security of all health information is impossible. Too many people access information, too many of the applications are not as robust as they could be, and as discussed in a previous lecture, security is a trade-off with ease of use.
As such, there needs to be a happy medium where the desired level of security can be attained without compromising the benefits of health IT, such as error prevention and improved quality.
Another question that comes up is, Will the theoretical (and some real) concerns about privacy and security be tempered somewhat when society sees more of the benefits of health IT?
A final question might be, would other societal changes lessen the impact of the problem? That is, would security risks be reduced if the legal system more rigorously prosecuted discrimination, if the health care finance system were more equitable, or if the health insurance system had a safety net to prevent people from losing their health coverage when, for example, they change jobs?
This concludes Lecture d of Privacy, Confidentiality and Security. In summary, the HIPAA Security Rule aims to be actionable but flexible. Its rules are either required or addressable, and they fall into three categories: administrative, physical, and technical.
This also concludes Privacy, Confidentiality, and Security. In summary, the major aspects of privacy, confidentiality, and security of health information were reviewed, and the HIPAA Privacy and Security Rules were explored. Privacy is the right to keep information to ourselves, whereas confidentiality is the right to keep information about ourselves from being disclosed to others. Security in this context is the protection of sensitive health information. There are many technologies to maintain security, but human vigilance is also required. Finally, the HIPAA Privacy and Security Rules spell out the requirements for health care organizations and those with whom they do business in the United States.