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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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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 Resilience in the Face of Cyber Adversity

A Case Study of the Family Health Center of Worcester’s Ransomware Incident, February 2024

Molly Rafferty 0 1640
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.

Ransomware Alert and Guidance for Health Centers

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

HITEQ Center 0 50981

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 26512

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 28643

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 28933

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

Anonym 0 39286

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 44256

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.

Security Risk Analysis Toolkit

A resource from the Office of the National Coordinator

HITEQ Center 0 22095

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 28213

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 13128

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. 

AI Fundamentals and Applications in Primary Care Live Webinar

Wednesday, October 26 1 pm Eastern | 10 am Pacific

Caitlin Tricomi 0 1477

 

The Weitzman Institute and the Moses/Weitzman Health System are pleased to present the latest installment of our series of informative discussions with an exclusive panel of global experts driving the development of Artificial Intelligence (AI). April Joy Damian, PhD, MSc, CHPM, PMP, Vice President and Director of the Weitzman Institute will moderate this latest discussion, "AI Fundamentals and Applications in Primary Care," on Wednesday, October 26 at 1 pm Eastern| 10 am Pacific.  

This webinar will bring together industry AI leaders with an evidence-based applied perspective on using AI in primary care to:

  • Understand AI history, definitions, methodology, benefits, and healthcare use cases
  • Explore the most common and validated use cases in primary care
  • Examine implications of AI in promoting health equity and improving healthcare access and outcomes

Information Blocking Rule Requirements for Part 2 Data in Patient Portals

Considerations for Entities that Maintain Part 2-Protected Data

Nye Day 0 1588

CoE-PHI resource that describes the Information Blocking Rule and explains that it does not preempt stricter privacy laws and regulations such as 42 CFR Part 2.

Key Points:

  • Information blocking includes practices that would “interfere with, prevent, or materially discourage the access, exchange, or use of electronic health information.”
  • Following a legal requirement to obtain patient consent for a disclosure meets the “privacy exception” in the Information Blocking Rule and is not considered information blocking.
  • If a portal cannot segment Part 2-protected records or prevent a patient’s proxy from unconsented access to such records, the healthcare provider should not share Part 2-protected records on the portal.

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

Virtual Learning Collaborative

Nye Day 0 2181

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, and the risk continues to grow as health centers use new tools and the introduction of artificial intelligence (AI). 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. 

To support health centers in their cybersecurity strategy and implementation, the HITEQ Center offered a free learning collaborative -- Improving Health Center Cybersecurity: Risk Assessment, Breach Defense, Mitigation, and Response. This learning collaborative involved four structured virtual learning sessions. During the series participants engaged with subject matter experts and their colleagues in peer-to-peer learning and discussion. Topics included: health center breach mitigation tactics, operationalizing cybersecurity to better mitigate risks, cybersecurity implications of generative artificial intelligence in health centers, and incident response planning from a cybersecurity perspective.

 

Session 4: Cybersecurity Incident Response Planning for Health Centers

According to IBM's annual Cost of Data Breach Report, the average cost of a data breach for a healthcare organization is more than $10 million. Having a well-documented cybersecurity incident response plan is essential and required for all Health Centers due to the sensitivity of the patient data they are responsible for maintaining. The cost and damage caused by a data breach is often exorbitant, but a strategic incident plan can help to significantly mitigate such effects, and potentially, prevent them from occurring in the first place. This session will provide an overview of incident response planning requirements for health centers and review established workflows for common incident response scenarios such as ransomware attacks.

 

Improving Health Center Cybersecurity: Risk Assessment, Breach Defense, Mitigation, and Response Learning Collaborative - Session 3

Virtual Learning Collaborative

Nye Day 0 2008

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, and the risk continues to grow as health centers use new tools and the introduction of artificial intelligence (AI). 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. 

To support health centers in their cybersecurity strategy and implementation, the HITEQ Center is offering a free learning collaborative -- Improving Health Center Cybersecurity: Risk Assessment, Breach Defense, Mitigation, and Response. This learning collaborative will involve four structured virtual learning sessions. During the series participants engaged with subject matter experts and their colleagues in peer-to-peer learning and discussion. Topics included: health center breach mitigation tactics, operationalizing cybersecurity to better mitigate risks, cybersecurity implications of generative artificial intelligence in health centers, and incident response planning from a cybersecurity perspective.

Session 3: Cybersecurity Implications of Generative Artificial Intelligence in Health Centers

Generative Artificial Intelligence (AI) technologies (e.g., ChatGPT, Google Bard) has exploded in 2023, catapulting new forms of rapid processing of text, audio, visual data (i.e., large language models and machine learning) to the forefront including in healthcare. The rapid rise forces health centers to grapple with what possibilities AI has to offer and it’s many potential risks. Both in terms of provision of care as well as in management of IT and related services. As these new tools are introduced and integrated to address acute and future needs, it becomes critically important to ensure that patients' data remains secure. This session will discuss recommendations and strategies for assessing risk and improving cybersecurity policies and procedures in relation to AI and it’s attendant technologies.

 

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

Virtual Learning Collaborative

Nye Day 0 1889

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, and the risk continues to grow as health centers use new tools and the introduction of artificial intelligence (AI). 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. 

To support health centers in their cybersecurity strategy and implementation, the HITEQ Center is offering a free learning collaborative -- Improving Health Center Cybersecurity: Risk Assessment, Breach Defense, Mitigation, and Response. This learning collaborative will involve four structured virtual learning sessions. During the series participants will engage with subject matter experts and their colleagues in peer-to-peer learning and discussion. Topics will include: health center breach mitigation tactics, operationalizing cybersecurity to better mitigate risks, cybersecurity implications of generative artificial intelligence in health centers, and incident response planning from a cybersecurity perspective.

Session 2: Health Center Hacking Combat and Breach Response Strategies for Awareness, Management, and Training

In this session, we discussed breach mitigation, ways in which to operationalize cybersecurity in order to better mitigate risks, reviewed risk management tools, and methods for defending against cybersecurity attacks. Breach can occur through both internal and external network leaks, through malware such as ransomware and through physical means on site. We covered topics related to general knowledge about breach mitigation, methods for mitigating against breach incidences, and addressing gaps in health center defenses.

 

 

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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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