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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 Industry Cybersecurity Practices: Managing Threats and Protecting Patients

Health Industry Cybersecurity Practices: Managing Threats and Protecting Patients

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

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.

Toward this objective, in 2017, HHS established the CSA 405(d) Task Group, which leveraged the Healthcare and Public Health (HPH) Sector Critical Infrastructure Security and Resilience Public-Private Partnership and was made up of over 100 participants and experts across domains that include cybersecurity, privacy, healthcare practitioners, and Health IT organizations.

In December of 2018 this task force published the Health Industry Cyber Preparedness (HICP) document, which is a cyber-preparedness “cookbook” designed to assist small providers in prioritizing cybersecurity threats and implementing controls to address them. 

The publication includes a main document, two technical volumes, and a set of resources and templates that include:

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Intended AudienceCIO, CSO, CISO, Health Center Leadership, Security Staff
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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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