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EHR20.COM [email protected] 866-276-8309 HIPAA/HITECH REQUIREMENTS AND SECURITY RISK ANALYSIS

HIPAA/HITECH REQUIREMENTS AND SECURITY RISK ANALYSIS · 2017-08-08 · 7. Social Security number 8. Medical record number 9. Health plan beneficiary number 10.Account number 11.Certificate/license

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Page 1: HIPAA/HITECH REQUIREMENTS AND SECURITY RISK ANALYSIS · 2017-08-08 · 7. Social Security number 8. Medical record number 9. Health plan beneficiary number 10.Account number 11.Certificate/license

[email protected]

866-276-8309

HIPAA/HITECH REQUIREMENTS ANDSECURITY RISK ANALYSIS

Page 2: HIPAA/HITECH REQUIREMENTS AND SECURITY RISK ANALYSIS · 2017-08-08 · 7. Social Security number 8. Medical record number 9. Health plan beneficiary number 10.Account number 11.Certificate/license

EDUCATIONOnline Training, Webinars and Customized Workshop

CONSULTINGProfessional servicesto help you with your Compliance needs

WHO WE ARE …

Assist healthcare organizations to develop and implement practices to secure IT systems and comply with

HIPAA/HITECH regulations

1

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DISCLAIMERConsult your attorney

2ALL WEBINARS ARE RECORDED AND AVAILABLE AS AN “ON DEMAND” SUBSCRIPTION

This webinar has been provided for educational and informational purposes only and is not intended and should not be construed to constitute legal advice.

Please consult your attorneys in connection with any fact-specific situation under federal law and the applicable state or local laws that may impose additional obligations on you and your company.

Page 4: HIPAA/HITECH REQUIREMENTS AND SECURITY RISK ANALYSIS · 2017-08-08 · 7. Social Security number 8. Medical record number 9. Health plan beneficiary number 10.Account number 11.Certificate/license

1 Background

2 HIPAA Basics

3 Requirements

7 Our Approach

4 Security Risk Analysis

6 Key Takeaways3

AGENDA

8 Questions & Answers

5 Other Requirements

Always available via email to answer any questions

Page 5: HIPAA/HITECH REQUIREMENTS AND SECURITY RISK ANALYSIS · 2017-08-08 · 7. Social Security number 8. Medical record number 9. Health plan beneficiary number 10.Account number 11.Certificate/license

4

TERMS YOU MAY HEAR …

Acronyms

HHS

HIPAA

PHI

OCR

HITECH

Anyone who is not handling patients directly

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TOP 5 REASONS FOR CONDUCTING A SECURITY RISK ASSESSMENT

1. Frequent threat of security breaches2. First set of documents requested by OCR/CMS

auditors3. Security best practices, identify areas to improve4. Avoid Civil Money Penalties (CMP)5. Maintain patient trust

5Basic building blocks for demonstrating HIPAA Compliance

Page 7: HIPAA/HITECH REQUIREMENTS AND SECURITY RISK ANALYSIS · 2017-08-08 · 7. Social Security number 8. Medical record number 9. Health plan beneficiary number 10.Account number 11.Certificate/license

6

DATA BREACHES IN PUBLIC HEALTH

Unencrypted Tape Inadvertent E-mailPoor Data Disposal Theft by Staff Hacking

Unencrypted Tape Inadvertent E-mailPoor Data Disposal Theft by Staff Hacking

Stolen medical data fetches the max. amount in the black market

Page 8: HIPAA/HITECH REQUIREMENTS AND SECURITY RISK ANALYSIS · 2017-08-08 · 7. Social Security number 8. Medical record number 9. Health plan beneficiary number 10.Account number 11.Certificate/license

7

Careless handling of HIV information jeopardizes patient’s privacy, costs entity $387k - May 23, 2017

Texas health system settles potential HIPAA violations for disclosing patient information - May 10, 2017

$2.5 million settlement shows that not understanding HIPAA requirements creates risk – April 24, 2017

No Business Associate Agreement? $31K Mistake - April 20, 2017Overlooking risks leads to breach, $400,000 settlement - April 12, 2017

and many more …

LATEST HHS SETTLEMENTS

Settlements and CMP are not the same

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HHS Resolution Agreements

Encryption is your silver bullet from data breach incidents8

• Sept. 2016• Settlement amount is 400k• Missing unencrypted backup tape • Failed to obtain updated BA

Agreement

• March 2014• Settlement amount is 215k• Public web server access of

~1000 patients• Failed to provide breach

notification

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9

OCR Audit

Program

Civil Money Penalties

Anyone who is not handling patients directly

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CIVIL MONEY PENALTIES

Violation category Each violation

Did Not Know $100–$50,000

Reasonable Cause 1,000–50,000

Willful Neglect-Corrected

10,000–50,000

Willful Neglect-Not Corrected

50,000

OCR/HHS is hiring lot of HIPAA auditors to handle complaints and data breach reporting.

• Max. of $1.5m per calendar year

• No. of days violated

• No. of regulatory provisions violated

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11

HIPAA PHASE 2 AUDIT

Onsite Audit

51

Communication from OCR

Pre-audit Questionnaire

2 3

Desk Audit

4

Potential Compliance

Review

6

Sample Selection

Office for Civil Right Under HHS conducts HIPAA Phase 2 Audit

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HIPAA/HITECH RULESReview

Privacy• Confidentiality

of PHI

Security• Protection of

ePHI

Breach• Notification

12

Enforcement/Audit

Business AssociatesBusiness Associates need to comply with limited privacy rule

Page 14: HIPAA/HITECH REQUIREMENTS AND SECURITY RISK ANALYSIS · 2017-08-08 · 7. Social Security number 8. Medical record number 9. Health plan beneficiary number 10.Account number 11.Certificate/license

HITECH MODIFICATIONS TO HIPAA

13

• Creating incentives for developing a meaningful use of electronic health records

• Changing the liability and responsibilities of Business Associates• Redefining what a breach is• Creating stricter notification standards• Tightening enforcement• Raising the penalties for a violation• Creating new code and transaction sets (HIPAA 5010, ICD10)

Since 2011 Medicare/Medicaid have paid more than 30+ billion as incentive for adopting EHR

Page 15: HIPAA/HITECH REQUIREMENTS AND SECURITY RISK ANALYSIS · 2017-08-08 · 7. Social Security number 8. Medical record number 9. Health plan beneficiary number 10.Account number 11.Certificate/license

HIP

AA T

ITLE

S

14

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HIP

AA S

ECU

RITY

RU

LE

15Required and Addressable rules

Page 17: HIPAA/HITECH REQUIREMENTS AND SECURITY RISK ANALYSIS · 2017-08-08 · 7. Social Security number 8. Medical record number 9. Health plan beneficiary number 10.Account number 11.Certificate/license

PROTECTED HEALTH INFORMATION BASICS

16

PHI Health Data

PIIPatient Identifiable Information

1. Medical records: • electronic and paper

case histories• treatment records• tests• charts• progress reports• X-rays• MRI's

2. Claims 3. Payments4. Eligibility 5. Other health plan related

insurance data

1. Name2. Address3. Dates related to an individual4. Telephone numbers5. Fax number6. Email address7. Social Security number8. Medical record number9. Health plan beneficiary number10. Account number11. Certificate/license number12. Any vehicle or other device serial13. Device identifiers or serial numbers14. Web URL15. Internet Protocol (IP) address16. Finger or voice prints17. Photographic images18. Any other characteristic that would

uniquely identify the individual

PII when combined with health data becomes PHI

Highly Sensitive Patient Data:HIV status, sexually transmitted diseases, medications, sexual orientation, mental health diagnosis, and physical abuse, etc.

Page 18: HIPAA/HITECH REQUIREMENTS AND SECURITY RISK ANALYSIS · 2017-08-08 · 7. Social Security number 8. Medical record number 9. Health plan beneficiary number 10.Account number 11.Certificate/license

HIPAA/ HITECH

Policies and

Procedures

Docume-ntation

Staff Training

BA Agreemen

t and Contracts

Risk Analysis and Mgmt.

HIPAA/HITECH REQUIREMENTS

Documentation is to be maintained for 6 years

Page 19: HIPAA/HITECH REQUIREMENTS AND SECURITY RISK ANALYSIS · 2017-08-08 · 7. Social Security number 8. Medical record number 9. Health plan beneficiary number 10.Account number 11.Certificate/license

SCOPE

• EHR/LIS/PMS• Computers • Storage Devices (HD, FD, CD, DVD)

• Networking Devices (Routers, Switches, & Wireless)

• Smart-Phones, Tablets • Cloud-Based Services• Any other interfaces

18

Any device that electronically stores or transmits information using a EHR software

program Up to date ePHI inventory sheet to be maintained

Page 20: HIPAA/HITECH REQUIREMENTS AND SECURITY RISK ANALYSIS · 2017-08-08 · 7. Social Security number 8. Medical record number 9. Health plan beneficiary number 10.Account number 11.Certificate/license

Sample Risk Analysis Prioritization

19

LikelihoodHigh Medium Low

Impa

ct

High Unencrypted laptop ePHI

Lack of auditing on EHR systems Missing security patches on

web server hosting patient information

Medium Unsecured wireless network in doctor’s

office

Outdated anti-virus software

External hard drives not being backed up

Low Sales presentation on USB thumb drive

Web server backup tape not stored in a secured

location

Weak password on internal document server

Updated risk management plan to be maintained

Page 21: HIPAA/HITECH REQUIREMENTS AND SECURITY RISK ANALYSIS · 2017-08-08 · 7. Social Security number 8. Medical record number 9. Health plan beneficiary number 10.Account number 11.Certificate/license

POLICIES AND PROCEDURES

20

Physical Security Policy Maintenance record Disposal Access

Information Security Policy Access Policy Sanction Policy

Contingency Plan Policy

Security Incident Procedure/Breach

• Master Security Policy

• Master Privacy Policy

• Master Breach Policy

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ROLE-BASED TRAINING

21

Privacy and Security Officers

Workforce Handling PHI (End-Users, Clinical Staff)

IT Team/Practice Administration (Admin)

Senior Management

Frequent user awareness training and assessment

Page 23: HIPAA/HITECH REQUIREMENTS AND SECURITY RISK ANALYSIS · 2017-08-08 · 7. Social Security number 8. Medical record number 9. Health plan beneficiary number 10.Account number 11.Certificate/license

BA AGREEMENTS

22

A person or entity that performs certain functions or activities, on behalf of a covered entity (CE), that involve the use or disclosure of protected health information

BA contract must be signed/in-place before accessing PHI

Keep an up-to-date list of BA vendors

Page 24: HIPAA/HITECH REQUIREMENTS AND SECURITY RISK ANALYSIS · 2017-08-08 · 7. Social Security number 8. Medical record number 9. Health plan beneficiary number 10.Account number 11.Certificate/license

Documentation

23

Privacy and Security Notices Health Record Request Log Training Records PHI/Chart Access Review Inventory List User Access Levels Maintenance Log

Potentially up to 6 years worth of documentation are required

Page 25: HIPAA/HITECH REQUIREMENTS AND SECURITY RISK ANALYSIS · 2017-08-08 · 7. Social Security number 8. Medical record number 9. Health plan beneficiary number 10.Account number 11.Certificate/license

HIPAA and Crypto

In case of a third-party vendor ensure approved encryption technology is used.24

HIPAA Technical Safeguard Requirements

Crypto Tools Examples

Access Control Encryption AES, Triple-DES

Integrity Hash Functions, MACs, Digital Signatures

SHA-1, SHA-2HMAC, CMAC

Person or Entity Authentication Digital Signatures DSA, ECDSA, RSA

Transmission Security Encryption, Hash Functions, MACs, Digital Signatures

Page 26: HIPAA/HITECH REQUIREMENTS AND SECURITY RISK ANALYSIS · 2017-08-08 · 7. Social Security number 8. Medical record number 9. Health plan beneficiary number 10.Account number 11.Certificate/license

KEY TAKEAWAYS• HHS/OCR enforcement on HIPAA Covered Entities and Business

Associates • Processing of PHI elements drives HIPAA compliance

requirements• Security risk analysis, training and policies and procedures are

key required documents• Public health departments have wide footprint of patient data • Budget, Type and Size of the entity doesn’t matter

25Annual update is required

Page 27: HIPAA/HITECH REQUIREMENTS AND SECURITY RISK ANALYSIS · 2017-08-08 · 7. Social Security number 8. Medical record number 9. Health plan beneficiary number 10.Account number 11.Certificate/license

REFERENCES

HHS Wall of Shame

HHS FAQ on Business Associates

NIST SP 800-111, Guide to Storage Encryption Technologies

HHS Public Health Guidance

26Protected Health Information is the focus of HIPAA

Page 28: HIPAA/HITECH REQUIREMENTS AND SECURITY RISK ANALYSIS · 2017-08-08 · 7. Social Security number 8. Medical record number 9. Health plan beneficiary number 10.Account number 11.Certificate/license

Deliverables

© 2013 EHR 2.0. All rights reserved. To purchase reprints of this document, please email [email protected].

ePHI Inventory SheetScoping and Profiling

Security Risk Analysis ReportVulnerability assessment

Risk Management PlanUpdated Policies and Procedures Online User TrainingExecutive Summary ReportPortal Access

We provide audit support/guarantee for all our consulting customers

Page 29: HIPAA/HITECH REQUIREMENTS AND SECURITY RISK ANALYSIS · 2017-08-08 · 7. Social Security number 8. Medical record number 9. Health plan beneficiary number 10.Account number 11.Certificate/license

28

CO

MPL

IAN

CE

POR

TAL

Page 30: HIPAA/HITECH REQUIREMENTS AND SECURITY RISK ANALYSIS · 2017-08-08 · 7. Social Security number 8. Medical record number 9. Health plan beneficiary number 10.Account number 11.Certificate/license

1. Submit a Request for Quote: https://ehr20.com/request-for-quote/

2. Follow-up call, if required. Otherwise, quote will be provided within 24 hours

3. Signed contract4. 2 to 4 weeks to complete the engagement and

share the final deliverables

NEXT STEPS

We provide audit support/guarantee for all our consulting customers

Page 31: HIPAA/HITECH REQUIREMENTS AND SECURITY RISK ANALYSIS · 2017-08-08 · 7. Social Security number 8. Medical record number 9. Health plan beneficiary number 10.Account number 11.Certificate/license

CALL US866-276 8309

[email protected]

LOCATION150, Cornerstone

Dr. Cary, NC

SOCIALIZEFacebook

Twitter

FIND US

Twitter: @ehr_20 Facebook: ehr2030

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31

Please don’t hesitate to ask

Questions

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32

for your attention!

Thank You

Page 34: HIPAA/HITECH REQUIREMENTS AND SECURITY RISK ANALYSIS · 2017-08-08 · 7. Social Security number 8. Medical record number 9. Health plan beneficiary number 10.Account number 11.Certificate/license

Thank you for joining us today

25 May, 2017

33

To purchase reprints of this document, please email [email protected].

Page 35: HIPAA/HITECH REQUIREMENTS AND SECURITY RISK ANALYSIS · 2017-08-08 · 7. Social Security number 8. Medical record number 9. Health plan beneficiary number 10.Account number 11.Certificate/license

34

PRICING GUIDANCEEstimated amount

Scope of Work Amount Additional Unit Price

1 Up to 30 users and 2 sites(User calculation is based on ePHI usage)

$3000 $100/user, $1000/Site

2EHR/Other Patient Data Servers hosted on premise(Third-party systems, cloud vendors are already included as part of item #1)

$500 $500/System

3 External Network Assessment (Up to 5 IP) $500 $100/IP

Security Risk Assessment Consulting*

* Comprehensive HIPA/HITECH assessment including privacy/breach is available as an add-on option* Implementation of recommended action items is not included