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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

Maui Ransomware to Target the Healthcare and Public Health Sector

An alert from the FBI, CISA, and the Department of the Treasury

HITEQ Center 0 1599

The Federal Bureau of Investigation (FBI), Cybersecurity and Infrastructure Security Agency (CISA), and the Department of the Treasury (Treasury) are releasing this joint Cybersecurity Advisory (CSA) to provide information on Maui ransomware, which has been used by North Korean state-sponsored cyber actors since at least May 2021 to target Healthcare and Public Health (HPH) Sector organizations.

Ransomware Alert and Guidance for Health Centers

Updated 10/29/2020 with Ransomware Alert Notification and Documentation from CISA

HITEQ Center 0 43999

The Cybersecurity and Infrastructure Security Agency (CISA), the Federal Bureau of Investigation (FBI), and the U.S. Department of Health and Human Services (HHS) have announced an increased and imminent cybercrime threat to U.S. hospitals and healthcare providers.  
 
CISA, FBI, and HHS have released AA20-302A Ransomware Activity Targeting the Healthcare and Public Health Sector that details both the threat and practices that healthcare organizations should continuously engage in to help manage the risk posed by ransomware and other cyber threats. The advisory references the joint CISA MS-ISAC Ransomware Guide that provides a ransomware response checklist that can serve as a ransomware-specific addendum to organization cyber incident response plans. 

It has been noted that hackers are using Ryuk ransomware — malicious software used to encrypt data and keep it locked up — and the Trickbot network of infected computers to steal data, disrupt health care services and extort money from health care facilities. Such data hijacking often cripples online systems, forcing many to pay up to millions of dollars to restore their services.

Find links and further documentation below

Strategic Cybersecurity Breach Protection and Incident Response

Guidance and Resources for Health Centers

HITEQ Center 0 20084

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.

Health Center Defense Against the Dark Web Presentation

Strategies for Building Security Awareness, Education and Compliance

HITEQ Center 0 24141

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 Industry Cybersecurity Practices: Managing Threats and Protecting Patients

A publication of the Cybersecurity Act of 2015, Section 405(d) Task Group

HITEQ Center 0 23385

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.

Security Risk Assessment Overview Presentation and Templates for Health Centers

A HITEQ Privacy & Security Resource - October 2018 updates for the ONC SRA tool

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To successfully attest, 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.

Creating and Managing Strong Passwords at Your Health Center

Guidance in relation to updated NIST security requirements and HIPAA

HITEQ Center 0 38914

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. 

Health IT Privacy & Security Skill Sets

The Importance of Information Security for all Health Center Staff

Since 2010, the healthcare industry has seen a remarkable increase in the use of technology in the administration and delivery in healthcare. This has led to a mass migration of data from paper charts and isolated systems to Electronic Medical Records (EMRs) and interconnected systems that transmit patient health and financial information across trusted and untrusted networks. While this has been a boon for the industry in its ability to provide timely information to those who need it the most, this transition has introduced a great deal of risk to the confidentiality and integrity of the information. Coupled with the fact that the information can be quickly monetized by criminals through insurance fraud and identity theft, the ecosystem is target-rich.

Exploring the ONC Security Risk Assessment Tool

Health IT Privacy & Security Technology Learning Community

Office of the National Coordinator 0 20652

ONC hosted a webinar to launch the Health IT Privacy & Security Technology Learning Community. This learning community is exploring the ONC Security Risk Assessment (SRA) Tool. It is looking to leverage stakeholder expertise to help inform health care delivery system reform and advance the use of interoperable health IT to improve the quality, safety, and efficiency of healthcare. The webinar was held on October 25 at 2pm ET.

There is not a recording available at the moment, but the link below will take users to a YouTube overview of SRA tool use.

Security Risk Analysis Toolkit

A resource from the Office of the National Coordinator

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A well-done security risk assessment (SRA) will identify security vulnerabilities across the breadth of a healthcare organization's health information systems. Factors will include policy, organizational and technical related requirements to privacy and security measures. ONC, in recognizing the complexity of this task for small to medium healthcare providers developed a toolkit to assist in conducting SRAs.

Encrypting Data at Rest on Servers

Implications for Health Centers

HITEQ & HLN Consulting 0 22209

It is common practice today to encrypt data at rest, that is, data stored on servers. This is especially applicable to health centers who are less frequently actively transporting data across disparate networks. Like many smaller healthcare organizations, Health Centers are particularly vulnerable to potential attack and infiltration by data hackers for several reasons: they tend to have fewer technical support staff, resource limitations make it harder to assess, implement, and maintain safe data practices, and organizational inertia limits preventive action when no threat is perceived. 

How to Establish an Ongoing Security Program and Meet Meaningful Use Requirements for Security Risk Analysis

An SRA brief for Health Centers

HITEQ Center 0 11250

In order to comply with the Security Rule of the Health Insurance Portability and Accountability Act (HIPAA), you need to maintain an ongoing security program. 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 protected health information (PHI) and sets limits and conditions on the use and disclosure of PHI. 

Improving Health Center Cybersecurity: Risk Assessment, Breach Defense, Mitigation, and Response - Session 4 Cybersecurity Incident Response Planning for Health Centers

HITEQ Learning Collaborative Series

Jodie Albert 0 506

 

It's time to reconsider your strategy if you still treat cyber risk as an annual project or initiative. Having a thorough ongoing program in place means that even in the worst-case scenario, you'll be ready to demonstrate that you did what was reasonable and appropriate to protect your systems and patient data. Nothing can guarantee that a cyberattack won't become a breach. Health Centers are a domain with a high potential for data breaches. As a result, it is crucial for health center leadership to adopt breach prevention strategies across their entire organization, as opposed to relegating it to the IT department. This learning collaborative will address health center breach mitigation tactics, operationalizing cybersecurity to better mitigate risks, telehealth risk management strategies, and incident response planning from a cybersecurity perspective.

 

This series will equip health centers and their staff to:  

 

  1. Describe resources, frameworks, and methods for strategic implementation of cybersecurity infrastructure and services
  2. Describe essential cybersecurity tools and services that can help decrease the risk of a data breach
  3. Use best practices in cybersecurity when implementing modern telehealth tools and RPM initiatives
  4. Adopt cybersecurity risk management paradigms and incident response planning templates.

 

This learning collaborative will provide participating health centers a series of four structured virtual learning sessions where they will engage with facilitators, subject matter experts and their colleagues in peer-to-peer learning and discussion.

 

Improving Health Center Cybersecurity: Risk Assessment, Breach Defense, Mitigation and Response - Session 3 Mitigating Cybersecurity Risk for RPM and Telehealth Programs

HITEQ Learning Collaborative Series

Jodie Albert 0 566

 

It's time to reconsider your strategy if you still treat cyber risk as an annual project or initiative. Having a thorough ongoing program in place means that even in the worst-case scenario, you'll be ready to demonstrate that you did what was reasonable and appropriate to protect your systems and patient data. Nothing can guarantee that a cyberattack won't become a breach. Health Centers are a domain with a high potential for data breaches. As a result, it is crucial for health center leadership to adopt breach prevention strategies across their entire organization, as opposed to relegating it to the IT department. This learning collaborative will address health center breach mitigation tactics, operationalizing cybersecurity to better mitigate risks, telehealth risk management strategies, and incident response planning from a cybersecurity perspective.

 

This series will equip health centers and their staff to:  

 

  1. Describe resources, frameworks, and methods for strategic implementation of cybersecurity infrastructure and services
  2. Describe essential cybersecurity tools and services that can help decrease the risk of a data breach
  3. Use best practices in cybersecurity when implementing modern telehealth tools and RPM initiatives
  4. Adopt cybersecurity risk management paradigms and incident response planning templates.

 

This learning collaborative will provide participating health centers a series of four structured virtual learning sessions where they will engage with facilitators, subject matter experts and their colleagues in peer-to-peer learning and discussion.

 

Improving Health Center Cybersecurity: Risk Assessment, Breach Defense, Mitigation and Response - Session 2 Health Center Hacking Combat and Breach Response Strategies

HITEQ Learning Collaborative Series

Jodie Albert 0 485

 

It's time to reconsider your strategy if you still treat cyber risk as an annual project or initiative. Having a thorough ongoing program in place means that even in the worst-case scenario, you'll be ready to demonstrate that you did what was reasonable and appropriate to protect your systems and patient data. Nothing can guarantee that a cyberattack won't become a breach. Health Centers are a domain with a high potential for data breaches. As a result, it is crucial for health center leadership to adopt breach prevention strategies across their entire organization, as opposed to relegating it to the IT department. This learning collaborative will address health center breach mitigation tactics, operationalizing cybersecurity to better mitigate risks, telehealth risk management strategies, and incident response planning from a cybersecurity perspective.

 

This series will equip health centers and their staff to:  

 

  1. Describe resources, frameworks, and methods for strategic implementation of cybersecurity infrastructure and services
  2. Describe essential cybersecurity tools and services that can help decrease the risk of a data breach
  3. Use best practices in cybersecurity when implementing modern telehealth tools and RPM initiatives
  4. Adopt cybersecurity risk management paradigms and incident response planning templates.

 

This learning collaborative will provide participating health centers a series of four structured virtual learning sessions where they will engage with facilitators, subject matter experts and their colleagues in peer-to-peer learning and discussion.

 

Improving Health Center Cybersecurity: Risk Assessment, Breach Defense, Mitigation and Response - Session 1 Identifying and Assessing Cybersecurity Risks at Your Health Center

HITEQ Learning Collaborative Series

Jodie Albert 0 916

 

It's time to reconsider your strategy if you still treat cyber risk as an annual project or initiative. Having a thorough ongoing program in place means that even in the worst-case scenario, you'll be ready to demonstrate that you did what was reasonable and appropriate to protect your systems and patient data. Nothing can guarantee that a cyberattack won't become a breach. Health Centers are a domain with a high potential for data breaches. As a result, it is crucial for health center leadership to adopt breach prevention strategies across their entire organization, as opposed to relegating it to the IT department. This learning collaborative will address health center breach mitigation tactics, operationalizing cybersecurity to better mitigate risks, telehealth risk management strategies, and incident response planning from a cybersecurity perspective.

 

This series will equip health centers and their staff to:  

 

  1. Describe resources, frameworks, and methods for strategic implementation of cybersecurity infrastructure and services
  2. Describe essential cybersecurity tools and services that can help decrease the risk of a data breach
  3. Use best practices in cybersecurity when implementing modern telehealth tools and RPM initiatives
  4. Adopt cybersecurity risk management paradigms and incident response planning templates.

 

This learning collaborative will provide participating health centers a series of four structured virtual learning sessions where they will engage with facilitators, subject matter experts and their colleagues in peer-to-peer learning and discussion.

 

Cybersecurity CIO Roundtable

Session 1: Strategic Investments in Cybersecurity for Health Centers in 2021 and Beyond

Jodie Albert 0 6866

This two session roundtable series brought together CIOs, CISOs, and other IT leadership from health centers to discuss strategic investments in cybersecurity, including those that can leverage recent ARP funding but sustain beyond the coming years. Participants had the opportunity to connect with each other and subject matter experts about implementation, considerations, and the future of cybersecurity and data protection in health centers.

Cybersecurity CIO Roundtable

Session 2: Strategic Investments in Cybersecurity for Health Centers in 2021 and Beyond

Jodie Albert 0 5717

This two session roundtable series brought together CIOs, CISOs, and other IT leadership from health centers to discuss strategic investments in cybersecurity, including those that can leverage recent ARP funding but sustain beyond the coming years. Participants had the opportunity to connect with each other and subject matter experts about implementation, considerations, and the future of cybersecurity and data protection in health centers.

 

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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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Quadruple Aim

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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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