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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
Center of Excellence for Protected Health Information
HITEQ Center
/ Categories: Privacy and Security

Center of Excellence for Protected Health Information

FOCUS: PHI is a SAMHSA-funded source for clear and accurate information about patient privacy and confidentiality

According to the Center of Excellence for Protected Health Information, federal privacy laws and regulations, like the Health Insurance Portability and Accountability Act (HIPAA), the federal substance use disorder privacy law and regulations (including 42 CFR Part 2), and the Family Educational Rights and Privacy Act (FERPA), were put in place to protect the information of patients getting or seeking treatment. These privacy laws govern the sharing of patient information with healthcare providers, family members, schools, and other community organizations.

Clear and accurate information about confidentiality is important to ensure that patient privacy is protected and that privacy laws are not erroneously interpreted to prevent disclosure of patient information. Individuals living with mental illness or substance use disorders may not seek care without guarantees of confidentiality and privacy protections. A recent survey completed by SAMHSA found that concerns about privacy and confidentiality among individuals with behavioral health needs is a primary reason for not receiving treatment. Clarifying privacy protections and promoting communication of patient records is critical for improving patients’ access to care and quality of treatment once in care.

The Center for Excellence for Protected Health information is supported by SAMHSA and includes the following key resources:

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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

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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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