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Resource Overview

Conducting an SRA in accordance with HIPAA policy is a complex task, especially for small to medium providers such as community health centers. The HIPAA Security Rule mandates security standards to safeguard electronic Protected Health Information (ePHI) maintained by electronic health record (EHR) technology, with detailed attention to how ePHI is stored, accessed, transmitted, and audited. This rule is different from the HIPAA Privacy Rule, which requires safeguards to protect the privacy of PHI and sets limits and conditions on it use and disclosure. Meaningful Use supports the HIPAA Security Rule. In order to successfully attest to Meaningful Use, providers must conduct a security risk assessment (SRA), implement updates as needed, and correctly identify security deficiencies. By conducting an SRA regularly, providers can identify and document potential threats and vulnerabilities related to data security, and develop a plan of action to mitigate them.

Security vulnerabilities must be addressed before the SRA can be considered complete. Providers must document the process and steps taken to mitigate risks in three main areas: administration, physical environment, and technical hardware and software. The following set of resources provide education, strategies and tools for conducting SRA.

Security Risk Analysis Resources
Health Center Breach Awareness
HITEQ Center

Health Center Breach Awareness

The U.S. Department of Health and Human Services Office for Civil Rights Breach Portal

Healthcare providers have become a lucrative target for cyber criminals and many reported breaches are occuring at health centers. Since 2009, when the Department of Health and Human Services started tracking breaches that involved protected health information exposure of 500 patients or more, upwards of 1700 cases have been reported. These breach incidences are highlighted on the U.S. Department of Health and Human Services, Office for Civil Rights Breach Portal.

It is important for Health Centers to be aware of breaches that are occuring, the ways in which health systems were attacked, and the types of information stolen so that they can properly address these issues within their security risk assessment documentation. The HHS Breach Portal documents aspects such as the health care provider involved, the number individuals affected, the type of breach and the location of breached information (e.g. email vs network server).

From the HHS website: "As required by section 13402(e)(4) of the HITECH Act, the Secretary must post a list of breaches of unsecured protected health information affecting 500 or more individuals. These breaches are now posted in a new, more accessible format that allows users to search and sort the posted breaches. Additionally, this new format includes brief summaries of the breach cases that OCR has investigated and closed, as well as the names of private practice providers who have reported breaches of unsecured protected health information to the Secretary."

Use the link below to find out more about breaches that have recently occurred within health centers and other health care providers across the U.S.

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Acknowledgements

This resource collection was cultivated and developed by the HITEQ team with valuable suggestions and contributions from HITEQ Project collaborators.

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The Quadruple Aim
Quadruple Aim

A Conceptual Framework

Improving the U.S. health care system requires four aims: improving the experience of care, improving the health of populations, reducing per capita costs and improving care team well-being. HITEQ Center resources seek to provide content and direction aligned with the goals of the Quadruple Aim

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