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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

HITEQ Center
/ Categories: EHR Selection and Implementation, EHR Implementation, Information Blocking, Video Library

Sample Information Blocking policies, procedures, and templates

Tools for Health Centers to Comply with Rules Prohibiting Information Blocking

Steps in using sample information blocking policies, procedures, and templates from HITEQ:

(available for download at the bottom of this page)

 

  1. Conduct Initial Information Blocking Risk Assessment (Appendix A) as part of the organizational record, and update annually thereafter.
  2. For any organizational practices that appear on the list of suspected practices for Information Blocking (Appendix A, Section VI)
    1. Record the exact practice and current workflow, and assess whether any of the 21st Century Cures Act ONC exceptions apply using Appendix D: Information Blocking Exceptions and other references. 
    2. For any practices that are reviewed where no exceptions apply, cannot be modified, and is/are necessary, document that the organization does not intend for the practice to result in information blocking.
  3. Develop/review policy/ procedure for reviewing/fulfilling requests for information.
    1. Ensure that process is non-discriminatory and expedient.
    2. Ensure that electronic and physical information requests are consistent in terms of consent, privacy, and legal requirements.
  4. Develop a process for documenting exceptions to requests
    1. Ensure that process aligns with the eight possible exceptions, noting that five allow for not fulfilling the request while the other three refer to procedures for fulfilling requests.
    2. Use other HITEQ information blocking process resources, including Appendix D: information blocking exceptions
  5. Implement documentation for exceptions on a case-by-case basis
  6. Develop a process for responding to requests, either where information will be shared and access maintained or where the request will not be fulfilled, and the reason needs to be communicated. 
  7. Review and adopt information blocking complaint procedures (Appendix E)
    1. Use Appendix G as a template for investigation workflow.
    2. Use Appendix H to document the investigation.
  8. Document complaints, incidents, and related responses and/ or actions
    1. Use Appendix F - Incidence Response Log to document this.

Download all of these documents below.

Disclaimer: Information blocking forms become part of the record and can be reviewed by OIG during an investigation. The HITEQ Center and related entities are not liable for any direct or indirect consequences resulting from information given herein and advises legal counsel review of these and all forms prior to use.

The HITEQ Center project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of awards totaling $779,625 with 0% financed with non-governmental sources. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS, or the U.S. Government. For more information, please visit HRSA.gov.

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Tags: ONCtemplatesPolicyinformation blockinginformation exchangeONC’s Cures Act Final Rule

Documents to download

Related Resources

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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