The passage discusses how the HITECH Act updated and strengthened the privacy and security requirements of the Health Insurance Portability and Accountability Act (HIPAA). It made HIPAA compliance more important and challenging for covered entities by extending requirements to business associates, increasing penalties, and requiring stricter auditing and breach notification. To comply with HIPAA, organizations need to implement an access governance framework that provides a unified view of user access across systems and enables dynamic access management, audit capabilities, and prevention of inappropriate access. The increased focus on compliance under HITECH presents an opportunity for organizations to improve access risk management and security.
What is HIPAA Compliance?
HIPAA stands for the Healthcare Insurance Portability and Accountability Act of 1996. This specifies laws for the protection and use of Personal (or Protected) Health Information (PHI) - essentially, your medical record. HIPAA sets the standard for protecting sensitive patient data. The Administrative Simplification provisions of the Act (HIPAA, Title II) require the U.S. Department of Health and Human Services (HHS) to adopt certain national standards. These cover electronic health care transactions, and national identifiers for providers, health plans, and employers.
Physical, network, and process security measures are involved. The HIPAA Privacy Rule covers the saving, accessing and sharing of medical and personal information for any individual. The HIPAA Security Rule outlines national security standards to protect health data created, received, maintained or transmitted electronically - also known as electronic protected health information (ePHI).
Meeting these standards? That's compliance.
The document advertises a webinar on HIPAA compliance and electronic health records. It discusses recent changes to HIPAA regulations that expand its scope and increase penalties. The webinar will cover how the new rules impact electronic health records and what systems need to do to maintain compliance, such as tracking all access to patient records. It aims to help attendees understand and meet new HIPAA requirements for adopting electronic records while qualifying for federal incentive programs.
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.
HIPAA Security Trends and Future ExpectationsPYA, P.C.
PYA Principal Barry Mathis, a former CIO, CTO, senior IT audit manager, and IT risk management consultant, presented at teh TSCPA Health Care Conference. His presentation, “HIPAA Security Trends and Future Expectations” will focuses on:
- Current HIPAA enforcement activities and future developments.
- Case studies that highlight the changing HIPAA landscape.
- Cyber threats that impact covered entities and business associates.
The top 3 HIPAA violations could be happening under your watch.
1. Inadequate Tracking of Media
2. Inadequate Security
3. Inadequate Policies
If you deal with ePHI, you must comply. Find out how to remain compliant with our tips.
Dental Compliance for Dentists and Business Associatesgppcpa
This presentation will discuss covered entities, protected health information (PHI) as it relates to dental practices and business associates of those practices.It will update you on major legislation relating to patient privacy laws and explain why PHI Information is important and the consequences for non-compliance with state and federal laws.
The document provides an overview of HIPAA basics, including key terminology, the background and purpose of HIPAA, its main components and requirements, compliance strategies, common violations, and additional resources. Specifically, it outlines the Privacy Rule for protecting personal health information, the Security Rule for securing electronic data, and how the HITECH Act expanded enforcement. It emphasizes the importance of conducting risk analyses, implementing documentation like policies and procedures, and providing annual employee training to ensure HIPAA compliance.
The document outlines best practices for securing healthcare data in the cloud. It discusses how healthcare organizations are increasingly adopting cloud services but have concerns about data security. Breaches of healthcare data are common due to the high value of medical records on black markets. The document then provides recommendations for securing data, including understanding what data needs to be in the cloud, defining access policies, complying with regulations like HIPAA, and using encryption or tokenization techniques. Following these best practices can help healthcare organizations take advantage of cloud services while maintaining strong data security.
What is HIPAA Compliance?
HIPAA stands for the Healthcare Insurance Portability and Accountability Act of 1996. This specifies laws for the protection and use of Personal (or Protected) Health Information (PHI) - essentially, your medical record. HIPAA sets the standard for protecting sensitive patient data. The Administrative Simplification provisions of the Act (HIPAA, Title II) require the U.S. Department of Health and Human Services (HHS) to adopt certain national standards. These cover electronic health care transactions, and national identifiers for providers, health plans, and employers.
Physical, network, and process security measures are involved. The HIPAA Privacy Rule covers the saving, accessing and sharing of medical and personal information for any individual. The HIPAA Security Rule outlines national security standards to protect health data created, received, maintained or transmitted electronically - also known as electronic protected health information (ePHI).
Meeting these standards? That's compliance.
The document advertises a webinar on HIPAA compliance and electronic health records. It discusses recent changes to HIPAA regulations that expand its scope and increase penalties. The webinar will cover how the new rules impact electronic health records and what systems need to do to maintain compliance, such as tracking all access to patient records. It aims to help attendees understand and meet new HIPAA requirements for adopting electronic records while qualifying for federal incentive programs.
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.
HIPAA Security Trends and Future ExpectationsPYA, P.C.
PYA Principal Barry Mathis, a former CIO, CTO, senior IT audit manager, and IT risk management consultant, presented at teh TSCPA Health Care Conference. His presentation, “HIPAA Security Trends and Future Expectations” will focuses on:
- Current HIPAA enforcement activities and future developments.
- Case studies that highlight the changing HIPAA landscape.
- Cyber threats that impact covered entities and business associates.
The top 3 HIPAA violations could be happening under your watch.
1. Inadequate Tracking of Media
2. Inadequate Security
3. Inadequate Policies
If you deal with ePHI, you must comply. Find out how to remain compliant with our tips.
Dental Compliance for Dentists and Business Associatesgppcpa
This presentation will discuss covered entities, protected health information (PHI) as it relates to dental practices and business associates of those practices.It will update you on major legislation relating to patient privacy laws and explain why PHI Information is important and the consequences for non-compliance with state and federal laws.
The document provides an overview of HIPAA basics, including key terminology, the background and purpose of HIPAA, its main components and requirements, compliance strategies, common violations, and additional resources. Specifically, it outlines the Privacy Rule for protecting personal health information, the Security Rule for securing electronic data, and how the HITECH Act expanded enforcement. It emphasizes the importance of conducting risk analyses, implementing documentation like policies and procedures, and providing annual employee training to ensure HIPAA compliance.
The document outlines best practices for securing healthcare data in the cloud. It discusses how healthcare organizations are increasingly adopting cloud services but have concerns about data security. Breaches of healthcare data are common due to the high value of medical records on black markets. The document then provides recommendations for securing data, including understanding what data needs to be in the cloud, defining access policies, complying with regulations like HIPAA, and using encryption or tokenization techniques. Following these best practices can help healthcare organizations take advantage of cloud services while maintaining strong data security.
While the Health Insurance Portability and Accountability Act (HIPAA) is best known for its multitude of requirements that govern the way health care providers can use, disclose, and safeguard protected health information (PHI), its reach goes far beyond that to health plans and business associates that only handle PHI on a limited basis. HIPAA implementation in these environments creates unique challenges—for example, which provisions actually need to be addressed—but with 2016 marking an all-time high for HIPAA enforcement cases, it may be more important now than ever to address HIPAA compliance.
HIPAA compliance for Business Associates- The value of compliance, how to acq...Compliancy Group
HIPAA compliance for Business Associates has become critical as you deal with medical professionals. During this webinar we will explain the law and what Business Associates need to know and do and how to differentiate your firm to acquire new and maintain current clients.
In this webinar, we will discuss:
-The steps on how to become HIPAA compliant as a Business Associate
-What an effective BAA should include
-How to help existing and new healthcare clients with compliance
-Why it is important to differentiate yourself as HIPAA compliant
The document provides an overview of the steps startups need to take to achieve HIPAA compliance when working with health systems and protected health information. It discusses the key rules under HIPAA including the Privacy Rule, Security Rule, and Breach Notification Rule. It outlines a high-level roadmap for startups to become HIPAA compliant which involves developing an understanding of HIPAA, embedding it into operations, documenting efforts, and ultimately conducting a self-assessment and audit. The document aims to prepare entrepreneurs to address the compliance concerns of health systems regarding data security and privacy.
Redspin & Phyllis and Associates Webinar- HIPAA,HITECH,Meaninful Use,IT SecurityRedspin, Inc.
Slides from our 1/20/2011 webinar - HIPAA & HITECH Requirements, Compliance, Meaningful Use, and IT security assessments...we know it’s confusing!
Let’s focus on what you need to know!
The document discusses three major security compliance models - checklists, risk-based, and hybrid approaches. It analyzes examples of each: HIPAA uses a hybrid model combining checklists and risk-based guidance; PCI relies solely on checklists; and GLBA emphasizes a risk-based approach allowing flexibility for organizations. Regulators design compliance models based on objectives, goals and industry characteristics.
This document provides information on how to implement HIPAA compliance. It begins by explaining what HIPAA is and who it impacts, such as health care providers, health plans, and clearinghouses. It defines protected health information and the obligations of covered entities and business associates. It emphasizes the importance of having business associate agreements, security policies, training programs, and conducting audits. It provides tips for securing data transmission, backups, access controls, and shredding paper records. The document stresses that HIPAA compliance is essential to avoid penalties for violations and data breaches.
HIPAA Security Audits in 2012-What to Expect. Are You Ready?Redspin, Inc.
Within the 2009 American Recovery and Reinvestment Act (ARRA) was a legislative gem, the HITECH Act. HITECH provided a much needed “shot in the arm” (no pun intended) for the vanguard of healthcare technology advocates (including industry leaders, academics, economists, politicians, and concerned citizens), who had been promoting the necessity of modernizing the U.S. healthcare system for years.
Assuring regulatory compliance, ePHI protection, and secure healthcare deliveryTrend Micro
The document summarizes Trend Micro's enterprise security solutions for the healthcare industry. It discusses regulatory compliance requirements around protected health information (PHI) and how Trend Micro solutions can help organizations comply with regulations like HIPAA, HITECH, and PCI. It also addresses challenges in the healthcare industry like securing mobile devices, websites, medical devices, and virtual/cloud environments. Trend Micro provides integrated solutions that consolidate security infrastructure and automate risk management.
The HIPAA Security Rule - An overview and preview for 2014, from Summit Security Group. Summit Security Group is a business partner to Resource One, managed IT services provider for over 15 years to small and mid-sized businesses in the Portland Metro and Southwest Washington area.
Healthcare IT thought leadership and practice managers continually seek ways to foster a culture of alertness when it comes to HIPAA compliance. They have the dual challenge of staying on the right side of federal regulators and stopping would-be hackers. This is especially true given the potential impact a data breach can have on their organization’s reputation and bottom line. By reflecting on 2015, it becomes clear that covered entities and business associates alike will continue to prepare to mitigate the threat of cyber-attacks and the planned ramp up of OCR Phase 2 Audits.
HIPAA compliance Tune-up for 2016 is the topic of this webinar – which will be focused on mitigation strategies Covered Entities and BA’s alike can take to minimize the risk of data breach or actions prompting an OCR Audit.
Failure to Execute a HIPAA Business Associate Agreement Results in $1.55 Mill...Brian Dickerson
The U.S. Department of Health and Human Services announced that North Memorial Health System agreed to pay $1.55 million to settle potential HIPAA violations. North Memorial failed to have a written business associate agreement with its third-party billing company, Accretive, resulting in the improper disclosure of protected health information of over 289,000 patients. Additionally, North Memorial did not conduct a thorough risk analysis of its information technology systems. This settlement illustrates the importance of having compliant business associate agreements and conducting comprehensive risk analyses to protect patient information.
This document provides an overview of HIPAA privacy rules regarding access to medical records. It defines key terms like covered entity, business associate, and protected health information. It explains that patients have rights under HIPAA to access, inspect, and obtain copies of their medical records, as well as request amendments. There are additional rules for mental health and psychotherapy notes. Covered entities may charge reasonable fees for copying and mailing records.
HIPAA Security Risk Analysis for Business AssociatesRedspin, Inc.
A 8-slide primer on why Business Associates should conduct a HIPAA Security Risk Analysis to meet their new compliance and risk management needs. Includes updates from HITECH Act and HIPAA Omnibus Rule.
This webinar discusses HIPAA compliance and preparing for audits. It covers increased fines for noncompliance, mandatory audits by HHS, and documentation required. Attendees will learn about recent rule changes, audit procedures, and how to develop security policies to meet requirements. The webinar founder has 30 years of healthcare compliance experience and will provide tools and best practices for avoiding penalties.
A brief introduction to hipaa compliancePrince George
As you can imagine, complying with federal regulations around privacy and healthcare data is no small task. This presentation is to help you wade through what you need to know about HIPAA compliance as it relates to your application and what steps you’ll need to take to ensure you don’t end up in violation of the law.
There is plenty to research about HIPAA guidelines. This presentation is not meant to be comprehensive, but rather give you a framework and reference to help you understand the major portions of the law.
What Is Security Risk Analysis? By: MedSafeMedSafe
What exactly is a Security Risk Analysis? Most practices ask, we deliver. This presentation covers all you should be concerned with. Go to www.MedSafe.com for more information!
Feasibility study of mtbe physical adsorption from polluted water on gac, pac...eSAT Publishing House
IJRET : International Journal of Research in Engineering and Technology is an international peer reviewed, online journal published by eSAT Publishing House for the enhancement of research in various disciplines of Engineering and Technology. The aim and scope of the journal is to provide an academic medium and an important reference for the advancement and dissemination of research results that support high-level learning, teaching and research in the fields of Engineering and Technology. We bring together Scientists, Academician, Field Engineers, Scholars and Students of related fields of Engineering and Technology
To prevent future crashes of the live Confluence environment after releases, performance tests were conducted on a dedicated physical machine configured similarly to the live environment using tests from Atlassian and JMeter. Key performance indicators like 90% line, throughput, and error rate were measured against baselines to ensure the changes would not overload the live system.
The document discusses the iceberg phenomenon, where only 10% of an iceberg is visible above water while 90% is below the surface. It states this also applies to humans, where only a small portion of one's knowledge, skills, attitudes and behaviors are visible to others, while much remains unseen below the surface. It also provides quotes about the importance of maintaining a positive attitude.
This document lists the artworks and mediums included in Ye Jin Jeon's AP Drawing portfolio. The breadth section includes 12 pieces in various mediums like pencil, charcoal, conte crayon, colored pencil, oil pastel, tempera resist, and acrylic. The concentration section focused on "Backstage" and includes 12 additional pieces exploring watercolor, oil pastel, mixed media, and acrylic. The artist statement reflects on how the portfolio allowed for unrestricted exploration and creation without fear.
While the Health Insurance Portability and Accountability Act (HIPAA) is best known for its multitude of requirements that govern the way health care providers can use, disclose, and safeguard protected health information (PHI), its reach goes far beyond that to health plans and business associates that only handle PHI on a limited basis. HIPAA implementation in these environments creates unique challenges—for example, which provisions actually need to be addressed—but with 2016 marking an all-time high for HIPAA enforcement cases, it may be more important now than ever to address HIPAA compliance.
HIPAA compliance for Business Associates- The value of compliance, how to acq...Compliancy Group
HIPAA compliance for Business Associates has become critical as you deal with medical professionals. During this webinar we will explain the law and what Business Associates need to know and do and how to differentiate your firm to acquire new and maintain current clients.
In this webinar, we will discuss:
-The steps on how to become HIPAA compliant as a Business Associate
-What an effective BAA should include
-How to help existing and new healthcare clients with compliance
-Why it is important to differentiate yourself as HIPAA compliant
The document provides an overview of the steps startups need to take to achieve HIPAA compliance when working with health systems and protected health information. It discusses the key rules under HIPAA including the Privacy Rule, Security Rule, and Breach Notification Rule. It outlines a high-level roadmap for startups to become HIPAA compliant which involves developing an understanding of HIPAA, embedding it into operations, documenting efforts, and ultimately conducting a self-assessment and audit. The document aims to prepare entrepreneurs to address the compliance concerns of health systems regarding data security and privacy.
Redspin & Phyllis and Associates Webinar- HIPAA,HITECH,Meaninful Use,IT SecurityRedspin, Inc.
Slides from our 1/20/2011 webinar - HIPAA & HITECH Requirements, Compliance, Meaningful Use, and IT security assessments...we know it’s confusing!
Let’s focus on what you need to know!
The document discusses three major security compliance models - checklists, risk-based, and hybrid approaches. It analyzes examples of each: HIPAA uses a hybrid model combining checklists and risk-based guidance; PCI relies solely on checklists; and GLBA emphasizes a risk-based approach allowing flexibility for organizations. Regulators design compliance models based on objectives, goals and industry characteristics.
This document provides information on how to implement HIPAA compliance. It begins by explaining what HIPAA is and who it impacts, such as health care providers, health plans, and clearinghouses. It defines protected health information and the obligations of covered entities and business associates. It emphasizes the importance of having business associate agreements, security policies, training programs, and conducting audits. It provides tips for securing data transmission, backups, access controls, and shredding paper records. The document stresses that HIPAA compliance is essential to avoid penalties for violations and data breaches.
HIPAA Security Audits in 2012-What to Expect. Are You Ready?Redspin, Inc.
Within the 2009 American Recovery and Reinvestment Act (ARRA) was a legislative gem, the HITECH Act. HITECH provided a much needed “shot in the arm” (no pun intended) for the vanguard of healthcare technology advocates (including industry leaders, academics, economists, politicians, and concerned citizens), who had been promoting the necessity of modernizing the U.S. healthcare system for years.
Assuring regulatory compliance, ePHI protection, and secure healthcare deliveryTrend Micro
The document summarizes Trend Micro's enterprise security solutions for the healthcare industry. It discusses regulatory compliance requirements around protected health information (PHI) and how Trend Micro solutions can help organizations comply with regulations like HIPAA, HITECH, and PCI. It also addresses challenges in the healthcare industry like securing mobile devices, websites, medical devices, and virtual/cloud environments. Trend Micro provides integrated solutions that consolidate security infrastructure and automate risk management.
The HIPAA Security Rule - An overview and preview for 2014, from Summit Security Group. Summit Security Group is a business partner to Resource One, managed IT services provider for over 15 years to small and mid-sized businesses in the Portland Metro and Southwest Washington area.
Healthcare IT thought leadership and practice managers continually seek ways to foster a culture of alertness when it comes to HIPAA compliance. They have the dual challenge of staying on the right side of federal regulators and stopping would-be hackers. This is especially true given the potential impact a data breach can have on their organization’s reputation and bottom line. By reflecting on 2015, it becomes clear that covered entities and business associates alike will continue to prepare to mitigate the threat of cyber-attacks and the planned ramp up of OCR Phase 2 Audits.
HIPAA compliance Tune-up for 2016 is the topic of this webinar – which will be focused on mitigation strategies Covered Entities and BA’s alike can take to minimize the risk of data breach or actions prompting an OCR Audit.
Failure to Execute a HIPAA Business Associate Agreement Results in $1.55 Mill...Brian Dickerson
The U.S. Department of Health and Human Services announced that North Memorial Health System agreed to pay $1.55 million to settle potential HIPAA violations. North Memorial failed to have a written business associate agreement with its third-party billing company, Accretive, resulting in the improper disclosure of protected health information of over 289,000 patients. Additionally, North Memorial did not conduct a thorough risk analysis of its information technology systems. This settlement illustrates the importance of having compliant business associate agreements and conducting comprehensive risk analyses to protect patient information.
This document provides an overview of HIPAA privacy rules regarding access to medical records. It defines key terms like covered entity, business associate, and protected health information. It explains that patients have rights under HIPAA to access, inspect, and obtain copies of their medical records, as well as request amendments. There are additional rules for mental health and psychotherapy notes. Covered entities may charge reasonable fees for copying and mailing records.
HIPAA Security Risk Analysis for Business AssociatesRedspin, Inc.
A 8-slide primer on why Business Associates should conduct a HIPAA Security Risk Analysis to meet their new compliance and risk management needs. Includes updates from HITECH Act and HIPAA Omnibus Rule.
This webinar discusses HIPAA compliance and preparing for audits. It covers increased fines for noncompliance, mandatory audits by HHS, and documentation required. Attendees will learn about recent rule changes, audit procedures, and how to develop security policies to meet requirements. The webinar founder has 30 years of healthcare compliance experience and will provide tools and best practices for avoiding penalties.
A brief introduction to hipaa compliancePrince George
As you can imagine, complying with federal regulations around privacy and healthcare data is no small task. This presentation is to help you wade through what you need to know about HIPAA compliance as it relates to your application and what steps you’ll need to take to ensure you don’t end up in violation of the law.
There is plenty to research about HIPAA guidelines. This presentation is not meant to be comprehensive, but rather give you a framework and reference to help you understand the major portions of the law.
What Is Security Risk Analysis? By: MedSafeMedSafe
What exactly is a Security Risk Analysis? Most practices ask, we deliver. This presentation covers all you should be concerned with. Go to www.MedSafe.com for more information!
Feasibility study of mtbe physical adsorption from polluted water on gac, pac...eSAT Publishing House
IJRET : International Journal of Research in Engineering and Technology is an international peer reviewed, online journal published by eSAT Publishing House for the enhancement of research in various disciplines of Engineering and Technology. The aim and scope of the journal is to provide an academic medium and an important reference for the advancement and dissemination of research results that support high-level learning, teaching and research in the fields of Engineering and Technology. We bring together Scientists, Academician, Field Engineers, Scholars and Students of related fields of Engineering and Technology
To prevent future crashes of the live Confluence environment after releases, performance tests were conducted on a dedicated physical machine configured similarly to the live environment using tests from Atlassian and JMeter. Key performance indicators like 90% line, throughput, and error rate were measured against baselines to ensure the changes would not overload the live system.
The document discusses the iceberg phenomenon, where only 10% of an iceberg is visible above water while 90% is below the surface. It states this also applies to humans, where only a small portion of one's knowledge, skills, attitudes and behaviors are visible to others, while much remains unseen below the surface. It also provides quotes about the importance of maintaining a positive attitude.
This document lists the artworks and mediums included in Ye Jin Jeon's AP Drawing portfolio. The breadth section includes 12 pieces in various mediums like pencil, charcoal, conte crayon, colored pencil, oil pastel, tempera resist, and acrylic. The concentration section focused on "Backstage" and includes 12 additional pieces exploring watercolor, oil pastel, mixed media, and acrylic. The artist statement reflects on how the portfolio allowed for unrestricted exploration and creation without fear.
The document summarizes information about the Canada lynx, including its scientific name (Lynx Canadensis), range throughout North America, diet of small mammals like hares and rodents, physical description and average sizes, breeding habits of 2-4 kittens born in dens, solitary hunting behavior, and ability to swim despite being a cat. The conclusion thanks the reader for learning about the strange and elusive lynx.
Trabalho desenvolvido para a área de segurança do trabalho. trata-se de um apanhado de especificações técnicas obtidas de fabricantes, fornecedores e sites de referencia com o foco de padronizar a compra de equipamentos de proteção individual (EPI´s) pela empresa.
Pandemiya is a new commercial Trojan malware that has been promoted as an alternative to Zeus malware. It is designed to secretly steal sensitive information from infected computers. The malware is modular, making it easy to expand functionality. It sells for $1500-$2000 and does not use Zeus source code. It infects computers through exploit kits and installs by writing files to the system and registry to inject itself into new processes. Removal involves deleting registry keys and files used by the malware.
This document provides an overview of Renaissance art and its key characteristics. It discusses how the Renaissance began in Florence, Italy in the 1300s as a period of rebirth and creativity. Some of the causes that enabled the Renaissance included the rediscovery of Greek and Roman ideas and art, the bubonic plague, the rise of the merchant class, and the invention of the printing press. The document then outlines characteristics of Renaissance art like use of perspective, realism, contrast of light and dark, and depicting people in classical Greek and Roman styles. It highlights some of the most famous Renaissance artists like Michelangelo, Donatello, Leonardo Da Vinci, and Raphael and provides examples of their artworks.
Money reduces transaction costs and allows for mutually beneficial trade. Without money, transactions would be more difficult and people would not be able to easily trade goods and services. While some trades may seem bad, incentives generally cause people to trade in a way that makes both parties better off. Trade allows individuals to gain profit by buying low and selling high, and to improve their overall utility by obtaining goods they value more.
The document discusses how converged TV and on-demand viewing habits will affect viewership. It provides data on consumer expectations for more convenient, personalized content access across devices. The data shows growing preference for on-demand and pay-for-content options when legal alternatives are available. However, many markets still lack sufficient legal digital content, which the report argues must be addressed through policies that increase availability of lawful digital services and accommodate reasonable consumer expectations like time- and place-shifting to promote innovation while displacing illegal access.
The document discusses HIPAA compliance and the HITRUST framework. It provides an overview of HIPAA requirements including the Privacy Rule, Security Rule, and breach notification. It outlines fines and penalties for non-compliance. It then discusses the mission and objectives of HITRUST, which provides a certifiable framework to demonstrate HIPAA compliance. The document argues that organizations can use HITRUST certification to address challenges in demonstrating HIPAA compliance through its standardized tools and processes.
The document discusses HIPAA compliance requirements and how organizations can demonstrate compliance through HITRUST certification. It provides an overview of HIPAA, HITECH, and Omnibus Rule regulations regarding privacy, security, breach notification and business associate responsibilities. It then outlines the mission and objectives of HITRUST to establish trust in healthcare information sharing through a certifiable compliance framework. The document explains how organizations can address HIPAA compliance gaps and demonstrate compliance to auditors by pursuing HITRUST certification.
Importance of Following HITECH Compliance Guidelines Aegify Inc.
HITECH is an ungraded and improvised version of HIPAA (Health Insurance Portability and Accountability Act) that was implementes in 1996. Since then, most healthcare institutions have been adhering to it.
HIPAA was enacted in 1996 to improve healthcare efficiency and protect patient privacy and confidentiality. It established rules for handling protected health information that apply to health plans, providers, and clearinghouses. The rules aim to 1) give patients access to their health information and control over its use, 2) improve care by restoring trust in the healthcare system, and 3) make the delivery of healthcare more efficient by creating a framework for privacy. HIPAA requires covered entities to provide training to educate workers on privacy policies, procedures for preventing breaches of patient data, and consequences for violations.
The document advertises a live webinar on HIPAA and EHR compliance with new rules. The webinar will discuss recent and proposed changes to HIPAA regulations that impact electronic health records and provide guidance on how to achieve and audit compliance. Attendees include compliance directors, CEOs, and other leadership and IT roles. Individual registration is $189 or a group of up to 10 can register for $499. The webinar speaker is an experienced healthcare compliance consultant.
HIPAA-Compliant App Development Guide for the Healthcare Industry.pdfSuccessiveDigital
This is an article about HIPAA-compliant app development for the healthcare industry. It discusses the importance of HIPAA compliance and the risks of non-compliance. The article also outlines the steps involved in developing a HIPAA-compliant app. Some of the important points from this article are that HIPAA compliance is an ongoing process and that there is no certification required to build a HIPAA-secure app.
HIPAA Violations and Penalties power pointDeena Fetrow
This document discusses HIPAA violations and penalties. It provides background on privacy acts leading to HIPAA and outlines stakeholders covered by HIPAA regulations like patients, physicians, hospitals, payers, and communities. The document presents the problem statement that theft of personal information has become easy and discusses HIPAA components and a PICOT question regarding if stricter penalties would reduce future violations. Literature on HIPAA violations in various countries supports stricter penalties. The proposed solution is to increase penalties to incentivize covered entities to take responsibilities more seriously and protect patient data.
Hipaa journal com - HIPAA compliance guideFelipe Prado
The document provides an overview of HIPAA compliance guidelines. It discusses the background and objectives of HIPAA legislation over time, including the original 1996 act and subsequent additions through 2013. Key points covered include the HIPAA Privacy and Security Rules, Enforcement Rule, Breach Notification Rule, and the goals of initiatives like HITECH and Meaningful Use to incentivize electronic health records and expand coverage. The document aims to help healthcare organizations understand and implement the necessary administrative, physical, and technical safeguards to protect patient information as required by HIPAA.
The document discusses challenges small healthcare providers face in complying with HIPAA security regulations. It notes that while HIPAA and HITECH were meant to improve privacy and security of electronic health records, smaller practices and hospitals struggle with understanding and implementing security standards due to limited resources and technical expertise. This leaves them at greater risk of data breaches compared to larger organizations. Revising HIPAA and providing better guidance tailored to small providers' needs could help address these challenges.
HIPAA includes punishments for violating patient privacy and calls on healthcare workers to learn and follow the rules of privacy and confidentiality in order to build patient trust. Under HIPAA, patients have the right to control who sees their protected health information. HIPAA was enacted in 1996 and established national standards for protecting health information held by health plans, providers, and clearinghouses, with the goals of protecting patient access to their own health records, improving quality of care, and increasing efficiency. HIPAA training for covered entities focuses on properly handling protected health information and avoiding violations.
PSOW 2016 - HIPAA Compliance for EMS CommunityPSOW
The document discusses changes to HIPAA regulations and compliance requirements for emergency medical services organizations. Key points include:
- Major changes from HIPAA/HITECH include an expanded definition of business associates, new requirements for business associate agreements and breach notification, and increased civil penalties.
- Non-compliance can result in significant fines from audits by the Office for Civil Rights. Fines have been issued in the millions for violations like unencrypted devices being stolen.
- Third party assistance can help EMS organizations establish HIPAA compliance programs and avoid "willful neglect" violations that carry mandatory minimum fines. Regular risk analysis and security practices are important to maintain compliance.
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) establishes national standards for electronic health care transactions, national identifiers, and security/privacy rules to protect personal health information. HIPAA compliance requirements took effect in 2003, applying to covered entities like health plans, providers, and businesses with access to protected health information. Covered entities must implement policies governing access to and handling of personal health information.
Explain the security implications of HIPPA requirements for hospital.pdfarjunenterprises1978
Explain the security implications of HIPPA requirements for hospital networks.
your responce should be 300 words
Solution
HIPAAstands for Health Insurance Portability and Accountability Act.
Passed in 1996 HIPAA is a federal law that sets a national standard to protect medical records
and other personal health information. The rule defines \"protected health information\" as health
information that:
1. Identifies an individual and
2. Is maintained or exchanged electronically or in hard copy.
If the information has any components that could be used to identify a person, it would be
protected. The protection would stay with the information as long as the information is in the
hands of a covered entity or a business associate.
HIPAA Security Rules
The portion of the HIPAA law that most impacts technology interests is the section on
Administrative Simplification (Title II, Subtitle F). Administrative Simplification seeks to force
uniform standards in the electronic interchange of health information (through the Transaction
Rule) and also mandates guidelines for the security (Security rules) and privacy (Privacy rules)
of that information whether in transit or stored. The HIPAA Security regulations apply to that
protected health information that is electronically maintained or used in an electronic
transmission1
. Administrative Simplification is divided in to Transaction, Security and Privacy Rules.
The HIPAA Security rules are divided into four sections:
· Administrative Safeguards
· Physical Safeguards
· Security Services
· Security Mechanisms
Administrative safeguards deal with those administrative policies, procedures and practices that
are used by a covered entity to handle protected health information. These generally take the
form of written policies and procedures that are practiced in normal day-to-day operations.
Physical safeguards deal with physical access to data and facilities within that contain protected
health information. Security services and security mechanisms specifically address technical
systems, networks and applications that possess or transmit protected
health information.
The HIPAA Security rules mandate that if healthcare information (also referred to in the HIPAA
text as protected health information) is stored or processed electronically, then the security rule
applies to that covered entity. This would seem to exempt pure paper-based operations from the
Security rules, but even
these organizations likely use fax technology, which is covered by the HIPAA security rule.
Accordingly, there are very few healthcare organizations that will escape the grasp of the HIPAA
regulations as very few are entirely paper-based.
HIPAA Security rules essentially resemble a collection of the recommended best practices for
security management and operations. For this reason, if the healthcare organization has already
adopted sound security practices, the HIPAA-compliance effort should be minimal. Given that
Security is not a prime conc.
This document provides an overview and compliance guidance for covered entities regarding the HIPAA Final Omnibus Rule. It outlines key changes to the HIPAA Privacy, Security, and Breach Notification Rules. It also provides a checklist for covered entities to develop compliance strategies and update policies, procedures, risk assessments, training programs, and notices by the September 2013 deadline. The document is intended to help covered entities understand requirements and avoid penalties for noncompliance.
The document discusses the HIPAA Omnibus Rule which strengthens privacy and security protection of personal health information and requires compliance by September 2013. It outlines key aspects of the Rule such as its goals to address electronic health records, requirements for covered entities and business associates to protect private health information, and consequences for noncompliance. It also describes how a data loss prevention solution can help organizations meet the new compliance standards by preventing and reporting on improper access to protected health information.
This document discusses HIPAA compliance and the HITRUST framework. It provides an overview of HIPAA requirements including the Privacy Rule, Security Rule, and Breach Notification Rule. It outlines fines and penalties for non-compliance. It then discusses the mission and objectives of HITRUST, which provides a certifiable framework to demonstrate HIPAA compliance. Key components of HITRUST's CSF Assurance Program include standardized tools and processes to assess risk and compliance through a HITRUST report. Challenges in demonstrating HIPAA compliance and the case for using HITRUST are also reviewed.
Understanding the Importance of HIPAA Compliance in Medical Billing Software.pdfOmniMD Healthcare
These days, it is essential that medical billing software be compliant with the Health Insurance Portability and Accountability Act, 1996 (HIPAA). This is because of several reasons. Mainly, HIPAA compliance ensures the safety and privacy of electronic health information. The act also lays the foundation for creating national standards to safeguard private patient information.
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.
The HIPAA Privacy Rule establishes standards to protect individuals' medical records and personal health information. It requires implementation of appropriate safeguards for protected health information and limits on access and disclosure of data. The HIPAA Security Rule also requires technical, administrative, and physical security safeguards to protect electronic protected health information. Both rules aim to ensure privacy and security of patient health information as required by the Health Insurance Portability and Accountability Act.
HIPAA requires all healthcare providers to obtain patient consent before accessing medical records and information. Regulatory compliance involves ensuring healthcare organizations follow laws and regulations, including training staff on HIPAA privacy rules. Examples of regulatory standards healthcare agencies must comply with are CMS, JCAHO, state laws, HIPAA, and EMTALA. Risk management helps monitor compliance with HIPAA regulations regarding privacy of patient information. HIPAA established patients' rights to access, authorize release, and request medical records, which most institutions provide through informed consent forms. Compliance with HIPAA privacy and security rules poses challenges for electronic health records systems in maintaining appropriate security measures. All healthcare employees should receive training, including new hire training and annual
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Role-Based Access Governance and HIPAA Compliance: A Pragmatic Approach
1. White Paper
Executive Summary
The Health Information Technology for Economic and Clinical Health Act (HITECH) has
made significant changes to the Health Insurance Portability and Accountability Act
(HIPAA). Previously a reactive and vaguely defined statute, the HITECH act brings depth
of requirements and steps up enforcement and penalties to HIPAA violations. In addi-
tion, HITECH extends HIPAA coverage to related entities. For example, a healthcare
provider is now responsible for the HIPAA posture of its out-of-house pharmacy servic-
es, billing services, claims processing services and overseas support desks. The updates
reflect the reality of the increasingly distributed and interconnected reality of most
healthcare organizations. As a result, HIPAA compliance has become more important
(and challenging) than ever.
The act will impose more stringent regulatory and security requirements to the privacy
rules of HIPAA, such as extending the covered entities to include business associates
and related third-party vendors in the healthcare industry, increased audit require-
ments, more proactive measures to protect personal healthcare information (PHI),
increased civil penalties for a compliance violation of HIPAA and stricter notification
requirements of security breaches of protected information.
The result should be better governance and risk management, but it will come at the
cost of increased challenges for covered organizations. IT Security and business unit
stakeholders in particular, will be challenged in a variety of ways. Compliance with
guidelines can be difficult for organizations without strong access governance processes
and policies. Complicating matters, demonstrating compliance through an annual user
access review and certification process can be even more complex and time consuming,
which results in less time available for organizations to focus on patient care and related
activities. The net result is higher operational and regulatory risk exposure.
One area that leads to a significant number of audit findings — access change manage-
ment — will become even more of a challenge under the more stringent guidelines of
HIPAA. To practice effective access risk management, organizations will need to shore
up processes governing initial access requests (joiners), changes to access due to trans-
fers (movers), and termination of access (leavers). The joiner/mover/leaver framework
provides a useful mechanism for entitles to use as a basis for a risk-based approach to
access governance.
It follows that forward thinking organizations should use the passage of the HITECH
as an opportunity to take a more risk-oriented approach by implementing an access
governance framework and modernizing how patient information is stored and accessed
through electronic health records (EHR). Such an approach will yield increased customer
trust, decreased operational burden, streamlined operations and superior access risk
management — all of which leads to improved organizational value.
ROLE-BASED ACCESS GOVERNANCE
AND HIPAA COMPLIANCE:
A PRAGMATIC APPROACH
The joiner/mover/leaver framework
provides a useful mechanism for
entitles to use as a basis for a risk
based approach to access governance.
2. PAGE 2
Background
The digital revolution in healthcare has provided an opportunity to greatly stream-
line operations and increase levels of patient care and efficiency. But it has not been
without consequences. Risks of compromise of PHI are very real. The Identity Theft
Resource Center estimated that healthcare organizations were responsible for 20.5%
of all data breaches in 2008, and the prevailing causes of these issues, while difficult
to solve, are well-known. Access governance is at the core of this issue. At the 2008
HIMSS Conference, 64% of audience members identified user access as their number
one IT security concern.
Legislative bodies have long recognized the importance of risk management in healthcare.
HIPAA was passed by congress in 1996 as a means to amend existing regulation to reflect
the realities of modern healthcare. The act recognized the need to move towards freer
but more secure exchange of PHI, and included specific provisions aimed towards admin-
istrative simplification and the privacy/security of electronic data interchange (EDI).
Although well intentioned, the act was fraught with several problems. As with many
regulatory mandates, the specific privacy and security components were exceedingly
vague. Well-intentioned (but perhaps understaffed) organizations, in the absence of
specific prescriptive controls definitions, often struggle to determine what the appro-
priate level of control should be. This can lead to over-controlled or, more frequently,
under-controlled environments. Neither is efficient.
With the vacuum left by vaguely worded requirements, organizations were left to fill the
middle ground with interpretations of best practice. Partially as a result, the privacy and
security components of the act did not become effective until 2003-2005. Enforcement
of the Act didn’t begin until 2006, a full ten years after its passage. When enforcement
of HIPAA began, the penalties were not severe enough to encourage full and widespread
adoption and compliance. As a result, security and privacy suffered.
The HITECH Act was passed as part of the American Recovery and Reinvestment Act of
2009, and addresses the major shortcomings of the HIPAA Act, while updating the regu-
latory framework to account for changes in technology. The act imposes more stringent
regulatory and security requirements to the privacy rules of HIPAA, such as extending
the covered entities to include business associates and related third-party vendors in the
healthcare industry, more proactive measures to protect PHI and increased civil penal-
ties for a compliance violation of HIPAA. Additionally, the HITECH Act authorizes state
attorney general’s to bring civil actions on behalf of state residents adversely affected or
threatened by violations of HIPAA.
One particularly interesting aspect (and potentially challenging aspect) of HITECH is
increased focus on audit and notification. Part of HITECH enforcement that will impact
covered entities is on-demand audit requests from patients with regard to who had ac-
cess to their PHI. As a result, organizations need to be continually ready to demonstrate
compliance. Related notification requirements have been stepped up, and organizations
are required to not only notify potentially compromised patients, but provide a full ac-
counting of the incident (what was compromised, when and by whom).
At the 2008 HIMSS Conference, 64% of
audience members identified user access
as their number one IT security concern.
3. PAGE 3
Regulatory Oversight
The Department of Health and Human Services (HHS) maintains the bulk of regulatory
oversight duties for HIPAA compliance. Enforcement is now handled by the Center for
Medicare and Medicaid Services (CMS). Fines can be substantial (up to $250,000), and
criminal penalties can also be imposed. Enforcement, which was previously inconsistent,
has been noticeably ramped up with the passing of the 1996 enforcement deadline and
the HITECH Act.
At the same time, high-profile violations have been becoming more prevalent; and as
public concern over privacy becomes more widespread, the publicity of a HIPAA viola-
tion can impart significant reputation and brand damage. At the University of California
Los Angeles (UCLA), university staff took advantage of inappropriate access to leak in-
formation on celebrities to the press, creating a serious HIPAA violation, and damaging
the reputation for the university. The long-term effects of such an incident can easily
eclipse any regulatory fines and penalties.
From an information security audit standpoint, organizations are required to demon-
strate compliance with several basic tenets and requirements within the security and
privacy rules. The rules describe, at a high level, best practices that organizations must
adopt to protect the confidentiality, integrity and availability of electronic protected
health information.
Within the broad security rule classification, safeguards are segregated into three types
of standards:
•• Administrative Safeguards describe high level procedural and strategic control
•• Physical Safeguards describe “brick and mortar” safeguarding of facilities and records
•• Technical Safeguards describe specific technology controls that govern the access of
electronic health records
To show compliance with the three standards of the security rule, organizations need to
demonstrate mechanisms for the security and confidentiality of all healthcare-related
data, complying with the following minimum requirements:
•• The confidentiality, integrity & availability of all PHI
•• Protection against reasonably anticipated threats or hazards to the PHI the entity
creates, receives, maintains or transmits
•• Protection against reasonably anticipated uses or disclosures of PHI
•• Visibility, control & auditing into and of all information flow
•• Workforce compliance with HIPAA and minimization of the threat of data being stolen
for financial gain
•• Periodic review of security measures as needed to ensure reasonable and appropriate
protection of PHI
High profile violations have been
becoming more prevalent, and as public
concern over privacy becomes more
widespread, the publicity of a HIPAA
violation can impart significant reputa-
tion and brand damage.
4. PAGE 4
Getting Compliant
Healthcare organizations often struggle to maintain a consistent approach across in-
formation resources to govern user access, and as a result, may have an incomplete or
fragmented posture of compliance throughout the organization. Reasons for this gener-
ally include the sheer volume of change and churn in the user population of a large or-
ganization. User relationships and roles are constantly changing as employees move into
and out of different job functions and operational groups. Healthcare systems are often
fragmented and widely diverse, with patient data being stored in multiple systems and
locations. The trend for outsourcing patient data is often stored outside the organization
with outsourced providers such as billing services. This fragmentation and distribution
further complicates the ability for an IT team to gain a clear picture of the access reality
and ensure that entitlements are governed accordingly.
Change becomes such an overwhelming force in most organizations that the process
for governing access is unable to keep up with reality. In the joiner/mover/leaver con-
trol framework, organizations frequently do an adequate job controlling initial access
requests. When new patient billing processors do not have access to the information
resources they need, they are certain to raise the issue to appropriate resolution. Users
that transfer or terminate their relationship with the organization are more problematic,
as most organizations lack a standardized process for dealing with these access change
events, which can lead to orphaned accounts, segregation of duties violations and other
audit related problems.
Certification and review are the standard safeguards against access violations from poor
change management. Often, these are manual processes performed in spreadsheets,
which can be laden with error. Even when manual processes do detect error, these safe-
guards are detective in nature, not preventative, and catch problems long after the fact.
The complexity, fragmentation and manual processes that are used to manage access
change make compliance with such safeguards a significant undertaking.
HIPAA security requirements, although high level, are largely overlapping with other
best practice access governance frameworks and regulations.
For organizations with fragmented control frameworks in place, HIPAA/HITECH presents
an excellent opportunity to proactively implement an access governance framework that
leverages the overlap with other common control standards such as ISO 27001/2 (for-
merly 17799), COBiT, NIST or ITIL or in other regulatory obligations such as Sarbanes
Oxley. Overlap between the standards is detailed below:
•• Security Management Process: is detailed in HIPAA §164.308(a)(1) and is also ad-
dressed in ISO 27002 domains 6 and 13 and COBiT control objectives PO4 and ME2
and is implicitly required under SOX 404
•• Workforce Security: is detailed in HIPAA § 164.308(a)(3) and is also addressed in ISO
27002 domains 8, 10 and 11, COBiT control objectives PO7 and DS7
•• Information Access Management: is detailed in HIPAA § 164.308(a)(4) and is also
addressed in ISO 27002 domain 11 and COBiT control objectives AI4 and AI6 and is
implicitly required under SOX 404
•• Evaluation is detailed in HIPAA §164.308(a)(8) and is also addressed in ISO 27002
domain 15 and COBiT control objectives ME1 and ME2
•• Access Control: is detailed in HIPAA §164.312(a)(1), and is also addressed in ISO
27002 domain 11 and COBiT control objectives AI4 and AI6 and is implicitly required
under SOX 404
•• Audit Controls is detailed in HIPAA §164.312(b) and is also addressed in ISO 27002
domain 15 and COBiT control objectives ME1 and ME2
For organizations with fragmented control
frameworks in place, HIPAA/HITECH
presents and excellent opportunity to
proactively implement an access gover-
nance framework that leverages the over-
lap with other common control standards
such as ISO 27001/2 (formerly 17799),
COBiT, NIST or ITIL or in other regulatory
obligations such as Sarbanes Oxley.
5. PAGE 5
Entities who manage information security and regulatory compliance need to perform
due diligence to account for subtleties present in the HIPAA standard, but the ground-
work for the majority of requirements should exist in such entities.
As such, an initial HIPAA compliance program should start with a readiness assessment
and gap analysis, followed by a mapping exercise to the existing control framework.
Organizations with a comprehensive control framework in place will have a leg up on the
process, but for other entities this can represent an opportunity to build such a frame-
work. As we will discuss later in this paper, implementing such a control framework for
access governance will pay dividends both in terms of operational and compliance risk
reduction as well as in a reduction of the operational overhead required with ongoing
compliance processes. Regulatory compliance management is an ongoing process and
should not be treated as a one-time project.
Administrative Safeguards
Standards Sections Requirements
Addressed
by RSA
Administrative
Safeguards
§ 164.304
•• Administrative Actions, Policies &
Procedures to Protect Health
Information
ü
Security Manage-
ment Process
§ 164.308(a)(1) •• Risk Analysis & Management ü
Workforce Security § 164.308(a)(3)
•• Authorization and/or Supervision
•• Workforce Clearance Procedure
•• Termination Procedures
ü
Information Access
Management
§ 164.308(a)(4)
•• Isolate Health Care Clearinghouse
Functions
•• Access Authorization
•• Access Establishment & Modification
ü
Evaluation § 164.308(a)(8) •• Testing ü
Technical Safeguards
Access Control § 164.312(a)(1)
•• Unique User Identification
(App & Entitlement)
•• Emergency Access procedure
ü
Audit Controls § 164.312(b) •• Visibility into Access ü
An initial HIPAA compliance program
should start with a readiness assess-
ment and gap analysis, followed by a
mapping exercise to the existing control
framework.
6. PAGE 6
Access Governance Requirements
A Unified View of Access Reality
To become compliant with specific HIPAA security requirements, organizations first
require a unified, enterprise-wide view to user access. Without this unified view, it is
impossible to manage authorization requests under requirement 164.308(a)(4). A single
view of user access is almost impossible for most organizations without a centralized
access governance framework in place, as they tend to manage access at the information
resource level (application, data, system, host). Having such a framework in place pro-
vides a comprehensive view of enterprise access reality - understanding who has what
access to what information resources and what can they do at a fine-grained entitlement
level. Since most organizations manage access in an ad hoc and siloed manner, there is
no easy way to aggregate user access data to get a consolidated view. And managing
access at an application or technical level (user provisioning) only provides a coarse-
grained view, which will not provide the fine-grained view required for compliance.
An access governance system that spans applications’ information resources enables
a foundation for providing the audit access required in 164.312(b). The standard
requires a mechanism in place that can record and examine all activity in any infor-
mation system containing PHI. In a siloed environment, such audit access can quickly
become prohibitively expensive or outright impossible. Controls can be applied at the
application or resource level, but it becomes difficult to implement controls spanning
multiple applications. This can easily lead to SOD violations, because controls instanti-
ated in a McKesson application, for example, have no visibility into the access rights
granted in a Eclipse application.
A unified view providing a window into the access reality and a single system of record
for access governance, also provides the ability to satisfy HIPAA requirement 164.312(a)
(2)(i), which stipulates a unique identifier for tracking enterprise user identity. In com-
plex environments, specifically those with legacy systems, it can be nearly impossible to
correlate a single point of user access across the entire enterprise. HIPAA requires the
ability to correlate any single-user identifier with all instances of access to information
resources for that same user. In fragmented environments, this is extraordinarily dif-
ficult, but with a single correlated view of user access it becomes a reality.
“Rubber stamping” is a common occurrence in organizations with poor access gov-
ernance. It occurs due to a language gap between business stakeholders, who are
required to certify compliance, and the technical view of access entitlements they are
forced to used to do their certification. Because entitlements are represented in a
cryptic security syntax, business stakeholders that must certify access don’t have the
context to understand what the entitlement means. A common language for describing
access must be provided to bridge the language gap between the business and IT secu-
rity teams, ensuring that violations are identified and remediated.
HIPAA requires the ability to correlate
any single user identifier with all instances
of access to information resources for
that same user.
7. PAGE 7
Dynamic and Preventative Access Controls
Formalizing an access risk management program is also a core requirement of the se-
curity rule, covered in requirement 308(a)(1). Additionally, Segregation of Duties (SOD)
is required in 164.308(a)(4)(ii)(A), where organizations are required to segregate access
between users who have access to PHI and members of the larger organization who do
not. Under HITECH, this scope has been expanded, and organizations now must ensure
that appropriate controls for access extend between themselves and their outsourced
functions (e.g. patient billing and collection processing).
Most organizations rely on manual, detective controls in this area, catching potential
violations through periodic audit and review processes. Automated preventative controls
are far superior, and a strong access governance program should contain the ability
to stop segregation of duties violations and toxic combinations from being granted in
the first place. A roles-based approach to access change management will reduce the
administrative burden involved with access delivery. As a result, fewer control violations
go unnoticed and access reviews and risk management efforts become much less labor
intensive.
A roles-based approach provides a preventative safeguard at the place of change. Rules
are run dynamically at the point of request. For instance, when a mover changes roles,
this approach will ensure that it does not cause a toxic combination. Rules can be used to
automatically spawn an approval process at the point of request, providing a preventa-
tive control before any toxic combination is created. The result is that control violations
are avoided in the first place, rather than being detected after the fact at the next peri-
odic review cycle. From a risk management standpoint, this is a far superior approach.
Automated Audit and Evaluation
Evaluation, as detailed in 164.308(a)(8), is a critical component of the HIPAA security
rule and often proves problematic for organizations that have fragmented and complex
enterprises. Business-reviewing managements need to make sense of siloed user access
data from disparate sources in disparate formats in order to certify the appropriateness
of a user’s access. The data then needs to be collated and the findings presented in a
logical context. Manual generation of such reports can be a long and expensive process.
Worse yet, a static audit report is out of date shortly after it’s produced, due to the pace
of user access change. The net effect is an audit review process that is manual, error-
prone and lacking in control rigor.
The process can be made far less painful with a roles-based approach to access gov-
ernance. Roles can reduce organizational burden. Roles provide a way to reduce this
burden, enabling the organization to certify access by role rather than individual. For
an example, a department of 300 users might be represented by four or five business
process roles. By certifying the role structure — the specific entitlements that make up
the role — the amount of effort and time required by the business for certification goes
down dramatically. If no member of the role has entitlements outside of the role, and
the entitlements within the role structure are in compliance, then everyone that is a
member of that role automatically inherits the compliance.
Evaluation under HIPAA is also eased by the dynamic, rules-based approach to change
management outlined previously. Such an approach can automate a set of processes for
event-driven reviews that require a review of access only when it changes. As a result,
user access that has been subject to the dynamic rule at the point of change can be
excluded from the next audit review cycle (within a certain period).
A roles based approach to access change
management will reduce the administra-
tive burden involved with access delivery.
8. PAGE 8
Automation is the Solution
To meet the objective of being auditably compliant in a cost-effective and streamlined
fashion, organizations should invest in an automated access governance program with
regulatory compliance as a core component. The automated access governance frame-
work should provide:
•• Enterprise-wide visibility to user access aggregated and correlated to present a uni-
fied view and business friendly context
•• A regular automated access reviews and certification processes
•• Dynamic and preventative access controls
•• Role-based access
•• Closed-loop access rights remediation and validation
•• An auditable system of record
•• Metrics and reporting for access decision support
An automated approach to role-based access governance reduces compliance fatigue
by automating the function and audit of risk-management controls. This approach will
ease both the initial setup of a HIPAA compliance program, as well as streamline the
ongoing therefore maintenance, reducing organizational costs and mitigating access
risk exposure.
With such an access governance framework in place, healthcare organizations will be
well on their way to managing the business and regulatory risks of inappropriate access
to its information resources. The right solution requires a strategic approach to access
governance based on auditable business processes that provide complete visibility and
accountability for user access.
To meet the objective of being auditably
compliant in a cost effective and stream-
lined fashion, organizations should invest
in an automated access governance
program, with regulatory compliance as
a core component.
9. PAGE 9
HIPAA Administrative Procedures
Standard Summary of Requirements RSA Solution
Administrative
Safeguards § 164.304
Administrative actions, policies
and procedures, to protect
electronically protected health in-
formation (ePHI) and manage the
conduct of the covered entity’s
workforce in relation to protec-
tion of this information
RSA Access Governance Plat-
form institutes policy as a set of
controls to ensure that access is
appropriate for a particular job
or functional role and automates
regular review process
Security Manage-
ment Process §
164.308(a)(1)
Implemented policies and proce-
dures to prevent, detect, contain
and correct security violations
RSA Access Governance Platform
provides visibility and control
that ensures access is appropri-
ate for a particular user’s role and
can remediate any compliance
violations
Risk Management
§ 164.308(a)(1)(ii)(B)
Implement security measures
sufficient to reduce risks and vul-
nerabilities to a reasonable and
appropriate level
RSA Access Governance Platform
provides information resource risk
classification that can be coupled
to access with rules/controls
Workforce Clearance
§ 164.308(a)(3)
Implement policies and proce-
dures to ensure that all members
of its workforce have appropriate
access to ePHI and to prevent
those workforce members who
do not have access from obtain-
ing access to ePHI
RSA Access Governance Platform
provides a continuous access
change management process and
controls automation that ensures
access is appropriate for any user
Termination
Procedures
§ 164.308(a)(3)(ii)(C)
Implement procedures for termi-
nating access to electronic pro-
tected health information when
the employment of a workforce
member ends
RSA Access Governance Platform
has event-driven change man-
agement rules and closed-loop
validation to ensure entitlements
have been revoked
Information Access
Management
§ 164.308(a)(4)
Implement policies and proce-
dures for authorizing access to
electronic protected health infor-
mation that are consistent with
the applicable requirements
RSA Access Governance Platform
provides the necessary controls
automation to ensure that access
policies are applied consistently
Isolating Healthcare
Clearing House
Functions
§ 164.308(a)(4)(ii)(A)
If a health care clearinghouse is
part of a larger organization, the
clearinghouse must implement
policies and procedures that
protect the electronic protected
health information of the clear-
inghouse from unauthorized
access by the larger organization
RSA Access Governance Platform
can enforce segregation of duties
rules for access
10. PAGE10
HIPAA Administrative Procedures
Standard Summary of Requirements RSA Solution
Access Authorization
§ 164.308(a)(4)(ii)(B)
Implement policies and pro-
cedures for granting access to
electronicly protected health
information
RSA Access Governance Platform
provides an access governance
model that is based on job or
function roles that ensures that
access is appropriate and changes
to access do not create compliance
violations or business risks
Access Establish-
ment &
Modification
§ 164.308(a)(4)(ii)(C)
Implement policies and proce-
dures that, based upon the entity’s
access authorization policies,
establish, document, review and
modify a user’s right of access
Evaluation
§ 164.308(a)(8)
Perform a periodic technical and
nontechnical evaluation, based
initially upon the standards
implemented under this rule and
subsequently, in response to envi-
ronmental or operations changes
affecting the security of electron-
ic protected health information
RSA Access Governance Platform
enables a comprehensive access
review and certification process,
as well as provides the auditable
evidence of compliance
Unique User Access
Identification
§ 164.312(a)(2)(i)
Assign a unique name and/or
number for identifying and track-
ing user identity
RSA Access Governance Platform
provides a correlated view to user
identities, roles and specific ac-
cess rights across all information
resources to determine “who has
access to what”
Emergency Access
Procedure
§ 164.312(a)(2)(ii)
Establish (and implement as
needed) procedures for obtaining
necessary electronic protected
health information during an
emergency
RSA Access Governance model
can enable event-driven access
requirements for out-of-role
entitlements based on rules (con-
ditionals)
Audit Access
§ 164.312(b)
Implement hardware, software,
and/or procedural mechanisms
that record and examine activity
in information systems that con-
tain or use electronic protected
health insurance
RSA Access Governance Platform is
an auditable system of record that
provides the visibility into; who
has access to what, how they got
access, who approved the access,
whether they use their access and
who certified the appropriateness
of their access