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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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Overview

This section contains resources that help health centers to successfully implement EHRs, including leadership teams needed, workflow adoption, transitioning between EHRs, meaningful use, and patient safety issues.

Implementing EHR
42 CFR Part 2 Final Rule and Health Center Compliance
42 CFR Part 2 Final Rule and Health Center Compliance

42 CFR Part 2 Final Rule and Health Center Compliance

This 2017 webinar explored the history and recent changes of 42 CFR Part 2, reviewed common definitions, and how the changes may affect integrated medication-assisted treatment (MAT) and Screening, Brief Intervention, and Referral to Treatment (SBIRT) programs, and discussion on LifeLong Medical Care’s experience.

Behavioral Health Consent Management
Behavioral Health Consent Management

Behavioral Health Consent Management

The timely exchange of health information between behavioral health providers and physical health providers to support care coordination is a critical element of the National Quality Strategy and health reform efforts. However, privacy and confidentiality concerns are currently limiting the inclusion of behavioral health data in electronic health information exchange efforts.

Creating and Managing Strong Passwords at Your Health Center
Creating and Managing Strong Passwords at Your Health Center

Creating and Managing Strong Passwords at Your Health Center

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. 

Emergency Situations: Preparedness, Planning, and Response
Emergency Situations: Preparedness, Planning, and Response

Emergency Situations: Preparedness, Planning, and Response

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.

Guidance on the HIPAA Privacy, Security, and Breach Notification Audit Program
Guidance on the HIPAA Privacy, Security, and Breach Notification Audit Program

Guidance on the HIPAA Privacy, Security, and Breach Notification Audit Program

The HHS Office for Civil Rights has started its next phase of audits of covered entities and their business associates. The 2016 Phase 2 HIPAA Audit Program will review the policies and procedures adopted and employed by covered entities and their business associates to meet selected standards and implementation specifications of the Privacy, Security, and Breach Notification Rules. 

Health Center Defense Against the Dark Web Presentation
Health Center Defense Against the Dark Web Presentation

Health Center Defense Against the Dark Web Presentation

It is of critical importance to motivate and educate healthcare professionals on current critical privacy and security concepts and methods for defense of health data. Aspects of security awareness training, breach protection, incident response, and related topics all play a role toward organization-wide information protection. Healthcare cybersecurity is the ultimate team sport. The responsibility goes beyond the IT staff and includes front and back office staff, doctors and nurses, patients, executives, and the board of directors. The attached presentation is directed to all levels of the healthcare organization so that they may be proactive and aware.

Health Center Information Blocking Avenger
Health Center Information Blocking Avenger

Health Center Information Blocking Avenger

In March 2019, the Office of the National Coordinator for Health Information Technology (ONC) issued a Proposed Rule, 21st Century Cures Act: Interoperability, Information Blocking, and the ONC Health IT Certification Program. ONC released a final rule in March 2020, published in the Federal Register on May 1, 2020. The Final Rule on Information Blocking prohibits actors from blocking the exchange of electronic health information and seeks to increase the ease and choices available for patients to access their data

Click Read More below to understand how this impacts health centers.
Health Center Resilience in the Face of Cyber Adversity
Health Center Resilience in the Face of Cyber Adversity

Health Center Resilience in the Face of Cyber Adversity

The use of ransomware — malicious software that restricts access to computer systems with financial demands — has escalated, targeting health centers and putting countless lives at risk. This dire reality came to the forefront during the alarming ransomware attack on the Family Health Center of Worcester, Inc. (FHCW), where the personal health information and care continuity for thousands of patients were compromised. This resource uses FHCW's experience as a case study to demonstrate the imperative of preparedness and the strength of a community-centered response in ensuring the continuity of healthcare services amidst the ever-growing tide of cyber vulnerabilities.
Health Industry Cybersecurity Practices: Managing Threats and Protecting Patients
Health Industry Cybersecurity Practices: Managing Threats and Protecting Patients

Health Industry Cybersecurity Practices: Managing Threats and Protecting Patients

The HIPAA Security Rule establishes the requirements for protection of electronic patient health information. The safeguards identified are made up of three domains that include administrative, physical, and technical safeguards that need to be addressed. The technical safeguards as defined within 45 CFR §164.312 of the HIPAA Security Rule can be some of the most difficult to comprehend and implement for smaller Health Centers with lower levels of IT and security staffing. Resources and tools that help Health Centers better process and implement these security requirements are much needed and require well-documented methods for planning and maintaining critical security controls.

HIPAA and Telehealth
HIPAA and Telehealth

HIPAA and Telehealth

Fact Sheet outlining a three-step process to make sure you’re in compliance with HIPAA and if not, the steps that can be taken to make sure you are. This fact sheet also includes questions to ask potential business associates and things to keep in mind in case there is a breach.

Limited Waiver of HIPAA Sanctions and Penalties During Declared Emergency
Limited Waiver of HIPAA Sanctions and Penalties During Declared Emergency

Limited Waiver of HIPAA Sanctions and Penalties During Declared Emergency

From the OCR: Severe disasters – such as Hurricanes Harvey, Irma, and Maria – impose additional challenges on health care providers. Often questions arise about the ability of entities covered by the HIPAA regulations to share information, including with friends and family, public health officials, and emergency personnel. As summarized in more detail below, the HIPAA Privacy Rule allows patient information to be shared to assist in disaster relief efforts, and to assist patients in receiving the care they need. In addition, while the HIPAA Privacy Rule is not suspended during a public health or other emergency, the Secretary of HHS may waive certain provisions of the Privacy Rule under the Project Bioshield Act of 2004 (PL 108-276) and section 1135(b)(7) of the Social Security Act.

Minor and Parental Access to Patient Portals
Minor and Parental Access to Patient Portals

Minor and Parental Access to Patient Portals

This guide provides examples and overviews of patient portal considerations for minors as it relates to Meaningful Use, HIPAA. state consent laws and associated policies. The articles and presentations included for download and linked to from related websites include use cases and examples from multiple states and national level guidelines.

Mitigating Office for Civil Rights Auditing Risks
Mitigating Office for Civil Rights Auditing Risks

Mitigating Office for Civil Rights Auditing Risks

The Office for Civil Rights (OCR) has recently announced the release of a new set of FAQs that seeks to address whether business associates of a HIPAA covered entity may block or terminate access by the covered entity to the protected health information maintained by the business associate for or on behalf of the covered entity.

Navigating Compliance Challenges with the Information Blocking Rule: A Collection of Case Studies
Navigating Compliance Challenges with the Information Blocking Rule: A Collection of Case Studies

Navigating Compliance Challenges with the Information Blocking Rule: A Collection of Case Studies

The Office of the National Coordinator for Health Information Technology’s (ONC) 21st Century Cures Act Information Blocking Rule (Info Blocking Rule) prohibits covered actors – including health care providers, health IT developers of certified health IT, and health information exchanges/health information networks– from engaging in practices likely to interfere with, prevent, or materially discourage access, exchange, or use of electronic health information (EHI). The Info Blocking Rule includes eight exceptions that provide actors with certainty that, when their practice interferes with the access, exchange, or use of EHI and meets the conditions of one or more exception, such practice will not be considered information blocking. An actor’s practice that does not meet all the conditions of an exception will be evaluated on a case-by-case basis to determine whether information blocking has occurred.

Online Reputation Management for Health Centers
Online Reputation Management for Health Centers

Online Reputation Management for Health Centers

A Health Center’s online reputation plays an ever-growing role in client satisfaction, as 6 out of 10 patients use online patient reviews before selecting a physician. This webinar and related handouts recommend three specific steps to managing your reputation online to improve patient engagement.

SAMHSA 42 CFR Part 2 Revised Rule
SAMHSA 42 CFR Part 2 Revised Rule

SAMHSA 42 CFR Part 2 Revised Rule

New guidelines from SAMHSA released in July 2020 are designed to improve coordination of care for patients in treatment for substance disorder, while protecting confidentiality against unauthorized disclosure and use of patient information. View this HITEQ webinar on changes to SAMHSA’s 42 CFR Part 2 rule (Part 2) which protects individuals receiving substance use disorder treatment by defining privacy and security requirements for written, electronic and verbal information. This webinar features expert presenters from the University of New Hampshire Institute for Health Policy and Practice and the Center of Excellence for Protected Health Information who present on the new final Part 2 rule and future changes in the CARES Act, including what has changed, what has not changed, what this means for health centers in regard to consents and disclosures, and the implications for care coordination. This presentation also addresses privacy considerations for tele-behavioral health and exceptions during the state of emergency waiver.

Security Implications of BYOD in Health Care
Security Implications of BYOD in Health Care

Security Implications of BYOD in Health Care

This article from Optum provides a breakdown on Bring Your Own Device (BYOD) policy considerations based on the mix of devices your organization is trying to support, the size of your healthcare organization and implementation factors that may have an impact on success.

Security Risk Analysis Tip Sheet
Security Risk Analysis Tip Sheet

Security Risk Analysis Tip Sheet

Conducting or reviewing a security risk analysis to meet the standards of Health Insurance Portability and Accountability Act of 1996 (HIPAA) Security Rule is included in the meaningful use requirements of the Medicare and Medicaid EHR Incentive Programs.

Sensitive Information and the Electronic Patient Record
Sensitive Information and the Electronic Patient Record

Sensitive Information and the Electronic Patient Record

With nearly 100% of community health centers utilizing electronic health records (EHR) to care for patients, focus has pivoted from implementation and new workflow development to enhancement in order to drive value and reflect patient needs and population trends. EHR technology presents potential opportunities and significant constraints. Providers frequently document and share potentially sensitive information in the EHR, such as risk for intimate partner violence (IPV), consistent offers of pre-exposure prophylaxis (PrEP), or patient sexual orientation and gender identity (SOGI). Capturing such information can be immensely helpful in providing care tailored to individuals’ needs, but additionally challenges teams to develop workflows that keep the data private rather than risk harm to patients through improper or unintended disclosure.

Sharing Behavioral Health Data over an HIE
Sharing Behavioral Health Data over an HIE

Sharing Behavioral Health Data over an HIE

This is a recent presentation by the Substance Abuse and Mental Health Services Administration's Health IT effort that provides an overview of their Consent2Share project. Consent2Share is a tool for consent management and data segmentation that is designed to integrate within existing electronic health record (EHR) and Health Information Exchange (HIE) systems.

This overview is provided to health center leadership and staff to help them better understand new practices and technologies in the field that can assist in compliance with HIPAA 42 CFR Part 2 regulations when trying to participate in health information exchange activities.

Strategic Cybersecurity Breach Protection and Incident Response
Strategic Cybersecurity Breach Protection and Incident Response

Strategic Cybersecurity Breach Protection and Incident Response

General cybersecurity guidance would suggest that Health IT breach should not be considered a matter of “if”, but rather a matter of “when”. How Health Centers prepare and respond to an episode of a breach is just as important as defending itself from the breach.

Substance Abuse Confidentiality Regulations - 42 CFR Part 2
Substance Abuse Confidentiality Regulations - 42 CFR Part 2

Substance Abuse Confidentiality Regulations - 42 CFR Part 2

Frequently Asked Questions (FAQs) and Fact Sheets regarding the Substance Abuse Confidentiality Regulations. 

Two fact sheets include: 

FAQs about Applying the Substance Abuse Confidentiality Regulations, answers provided by Substance Abuse and Mental Health Services Administration (SAMHSA)

Acknowledgements

This resource collection was compiled by the HITEQ Center staff with guidance from HITEQ Advisory Committee members and collaborators of the HITEQ Center.