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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

Strategic Cybersecurity Breach Protection and Incident Response

Guidance and Resources for Health Centers

HITEQ Center 0 279

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 5928

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 2426

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.

Substance Abuse Confidentiality Regulations - 42 CFR Part 2

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

HITEQ Center 0 10581

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)

Creating and Managing Strong Passwords at Your Health Center

Guidance in relation to updated NIST security requirements and HIPAA

HITEQ Center 0 13740

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. 

The Health Center CIO’s Guide to HIPAA Compliant Text Messaging

2019 Updates on Methods for Successful Patient Text Messaging Strategies

HITEQ Center 0 29870

This slide deck provides health centers with information and a presentation template overview of the HIPAA and electronic PHI risks related to texting and messaging that are important for health center leadership and IT managers to understand in making organizational decisions for these types of tools.

Online Reputation Management for Health Centers

Maintaining a Good Name in the Digital Era, from Wyoming Primary Care Association

Wyoming PCA 0 16719

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.

Emergency Situations: Preparedness, Planning, and Response

Guidance from the Office for Civil Rights

Office for Civil Rights 0 14834

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.

Limited Waiver of HIPAA Sanctions and Penalties During Declared Emergency

Guidance from the Office for Civil Rights

Office for Civil Rights 0 16223

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.

42 CFR Part 2 Final Rule and Health Center Compliance

A HITEQ Webinar in collaboration with the California Primary Care Association (CPCA)

HITEQ Center 0 20927

The conference will explore the history and recent changes of 42 CFR Part 2, review 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.

HIPAA and Telehealth

A Stepwise Guide to Compliance

Telehealth Resource Centers 0 9672

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.

Sharing Behavioral Health Data over an HIE

A use case example from the Arizona Health-e Connection and SAMHSA Consent2Share project

SAMHSA and AzHeC 0 10544

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.

Minor and Parental Access to Patient Portals

National and State-based examples and use cases

HITEQ Center 0 15771

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.

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

Overview and details for 2016 provided by the Office for Civil Rights

HHS Office for Civil Rights 0 8692

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. 

Mitigating Office for Civil Rights Auditing Risks

Guidance from the Office for Civil Rights

HITEQ Center 0 8151

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.

Security Risk Analysis Tip Sheet

Protect Patient Health Information - Updated March 2016

CMS and OCR 0 10381

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.

My entity just experienced a cyber-attack! What do we do now?

A Quick-Response Checklist from the HHS, Office for Civil Rights (OCR)

Alyssa Thomas 0 12293

The U.S. Department of Health & Human Services (HHS), Office for Civil Rights (OCR) has developed a Cyber Security Checklist and a corresponding Cyber Security Infographic that explains the steps for a HIPAA covered entity or its business associate (the entity) to take in response to a cyber-related security incident. 

Overcoming Cloud Challenges and Avoiding Failure While Transforming Healthcare Operations

A HIMSS Learning Center Webinar

Alyssa Thomas 0 9785

74% of Healthcare organizations report leveraging the Cloud to achieve financial savings and operational efficiencies. However, recent findings show over 60% of these organizations are experiencing Cloud adoption challenges and Security anxiety. It is essential for Healthcare organizations to overcome these challenges as there is a much larger digital transformational trend ahead, where Cloud will become a crucial component of patient care innovation.

Join Healthcare IT veterans from Microsoft & Synoptek, as they discuss the future of Cloud for Healthcare and best practices to help you overcome Cloud challenges and achieve higher levels of operational efficiency, security, and HIPAA compliance in the Cloud.

Conference on Safeguarding Health Information: Building Assurance through HIPAA Secrurity

A National Institute for Standards and Technology (NIST) and Office for Civil Rights (OCR) Conference

Alyssa Thomas 0 6725

The National Institute for Standards and Technology (NIST) and the Department of Health and Human Services (HHS), Office for Civil Rights (OCR) are pleased to co-host the 9th annual conference, Safeguarding Health Information: Building Assurance through HIPAA Security, on October 19-20, 2016 at the Capital Hilton, Washington, D.C.

The conference will explore the current healthcare cybersecurity landscape and the Health Insurance Portability and Accountability Act (HIPAA) Security Rule. It will highlight the present state of healthcare cybersecurity, and practical strategies, tips and techniques for implementing the HIPAA Security Rule.

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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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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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