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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
Creating and Managing Strong Passwords at Your Health Center

Creating and Managing Strong Passwords at Your Health Center

Guidance in relation to updated NIST security requirements and HIPAA

Question: Is it acceptable/recommended for health centers to adopt the new password policy guidelines under NIST Special Publication 800-63B and will that still uphold the HIPAA security rule?

This question had been posed to the HITEQ Center asking whether we had any guidance or recommendations on implementing the new NIST Guidelines regarding password security.  New Digital Identity Guidelines under NIST Special Publication 800-63-B presents new guidelines regarding password security that are much more user-friendly and consequently more likely to be observed by health center staff since constantly changing, complex password on multiple systems can be a source of frustration for the end user. 

After consulting with HITEQ cybersecurity experts and consultants who have helped publish cybersecurity guidelines, the recommendations outlined below were communicated.

Answer: The short answer is Yes. HIPAA is not prescriptive and takes the general stance that authentication mechanisms should be “reasonable and appropriate” for the risk they present. Being able to say that you are implementing NIST Standards is a good way to show that you are implementing “reasonable and appropriate” controls.

Some standards are relaxed in regards to password change and complexity, those items shouldn’t be taken in isolation. The additional controls in the 800-63 recommendations should also be put in place and can include:

  • Having users check passwords against password lists from breaches (e.g., https://haveibeenpwned.com/Passwords )
  • Increasing the length requirements
  • Getting rid of password reminder questions
  • Increasing usability

Further Guidance from NCCIC/US-CERT: NCCIC/US-CERT reminds users of the importance of creating and managing strong passwords. Passwords are often the only barrier between you and your personal information. There are several programs attackers can use to help guess or "crack" passwords. However, choosing strong passwords and keeping them confidential can make it more difficult for others to access your information.

NCCIC/US-CERT recommends users take the following actions:

  • Use multi-factor authentication when available.
  • Use different passwords on different systems and accounts.
  • Don't use passwords that are based on personal information that can be easily accessed or guessed.
  • Use the longest password or passphrase permissible by each password system.
  • Don't use words that can be found in any dictionary of any language.
  • Refer to Tips on Choosing and Protecting Passwords and Supplementing Passwords for best practices and additional information.
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Intended AudienceCIO's, Privacy & Security Staff, health center staff

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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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