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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
Emergency Situations: Preparedness, Planning, and Response
Office for Civil Rights
/ Categories: Privacy and Security, HIPAA

Emergency Situations: Preparedness, Planning, and Response

Guidance from the Office for Civil Rights

From the OCR: The Privacy Rule protects individually identifiable health information from unauthorized or impermissible uses and disclosures. The Rule is carefully designed to protect the privacy of health information, while allowing important health care communications to occur. These pages address the release of protected health information for planning or response activities in emergency situations.  In addition, please view the Civil Rights Emergency Preparedness page to learn how nondiscrimination laws apply during an emergency.

Outlined in the OCR article are detailed actions for:

  • Planning - Access an interactive decision tool designed to assist emergency preparedness and recovery planners in determining how to gain access to and use health information about persons with disabilities or others consistent with the Privacy Rule.
  • Response - In this section, access guidance about sharing patient information under the Privacy Rule in emergency situations, such as to assist patients in receiving the care they need, as well as to assist in disaster relief, public health, and law enforcement efforts.
  • Waivers - If the President declares an emergency or disaster and the Secretary of HHS declares a public health emergency, the Secretary may waive sanctions and penalties against a covered hospital that does not comply with certain provisions of the Privacy Rule.  The Privacy Rule remains in effect.  The waivers are limited and apply only for limited periods of time.

 

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Intended AudienceHealth Center IT Leadership, 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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