Protect your patients’ data and your reputation.
Who Needs ItThere are two primary components of HIPAA to understand in regard to your information security obligations. These components are commonly referred to as the Privacy Rule and the Security Rule. These rules apply to “covered entities” (as defined by 45 C.F.R. § 160.103), which include:
- Health plans (e.g., health insurance companies, HMOs, employer health plans, government programs)
- Health care clearinghouses (i.e., those organizations that process health information they receive from another organization)
- Health care providers who transmit any health information in electronic form in connection with certain financial and administrative transactions, such as electronic billing and fund transfers (e.g., doctors, clinics, psychologists, dentists, chiropractors, nursing homes, pharmacies)
The Privacy RuleThe Privacy Rule regulates the use and disclosure of Protected Health Information (PHI) in both paper and electronic formats. The U.S. Department of Health & Human Services (HHS) states that the Privacy Rule requires:
- Notifying patients about their privacy rights and how their information can be used.
- Adopting and implementing privacy procedures for its practice, hospital, or plan.
- Training employees so that they understand the privacy procedures.
- Designating an individual to be responsible for seeing that the privacy procedures are adopted and followed.
- Securing patient records containing individually identifiable health information so that they are not readily available to those who do not need them.
The Security RuleThe Security Rule specifies what administrative, physical and technical safeguards must be in place to assure the confidentiality, integrity and availability of Electronic Protected Health Information (EPHI or e-PHI). Specifically, covered entities must (as defined in 45 C.F.R. § 164.306(a)):
- Ensure the confidentiality, integrity, and availability of all e-PHI they create, receive, maintain or transmit;
- Identify and protect against reasonably anticipated threats to the security or integrity of the information;
- Protect against reasonably anticipated, impermissible uses or disclosures; and
- Ensure compliance by their workforce.
HITECHThe HITECH Act extends HIPAA’s privacy and security requirements to business associates and augments notification requirements when PHI is breached or disclosed.
- For breaches that affect 500 or more individuals, organizations must notify affected individuals, the HHS and the media.
- For breaches that affect less than 500 individuals, organizations must notify the HHS annually.
What We Do
To demonstrate compliance with HIPAA and HITECH, Sikich works with your team to:
- Facilitate a risk assessment identifying the impact of potential risks and implemented countermeasures,
- Perform a specialized IT audit that benchmarks your organization against the HIPAA/HITECH requirements to identify any gaps with your current compliance,
- Provide remediation guidance to help you meet your privacy and security obligations, and
- Create a breach notification plan to establish proper procedures and reporting requirements in the event of a data breach.
- Security Management Process
- Assigned Security Responsibility
- Workforce Security
- Information Access Management
- Security Awareness and Training
- Security Incident Procedures
- Contingency Plan
- Evaluation of Requirements
- Business Associate Contracts and Other Arrangements
- Facility Access Controls
- Workstation Use
- Workstation Security
- Device and Media Controls
- Access Controls
- Audit Controls
- Integrity Controls
- Person or Entity Authentication
- Transmission Security
- Written Security Policies and Procedures
- Written Records of Required Actions, Activities or Assessments
- Review and Updates
After we have assessed these four major areas, we will provide a final report that outlines the HIPAA/HITECH requirements and your compliance with the specific requirements applicable to your organization.
meet your hipaa/hitech security requirements.
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