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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
Using non-traditional technology for telehealth during COVID-19 Pandemic

Using non-traditional technology for telehealth during COVID-19 Pandemic

Issue Brief for implementing commercial applications for telehealth consistent with March 2020 OCR Guidance

Health and Human Services’ Office of Civil Rights (OCR), the entity responsible for enforcing regulations under HIPAA, stated, effective immediately, it will exercise enforcement discretion and will not impose penalties for HIPAA violations against covered healthcare providers if patients are served on a good faith basis during the COVID-19 nationwide public health emergency. OCR has clarified that, during this public health emergency, these technologies can be used for any services, not only those specific to COVID-19. OCR’s guidance states, “covered healthcare providers may use popular applications that allow for video chats, including Apple FaceTime, Facebook Messenger video chat, Google Hangouts video, or Skype, to provide telehealth without risk that OCR might seek to impose a penalty for noncompliance with the HIPAA Rules.” Providers should ensure communication products are non-public facing.

Using one of these technologies should be a last resort, secondary to using traditional telehealth, such as traditional telehealth modalities have healthcare-specific features and security. OCR stresses the importance of using HIPAA-compliant telehealth applications whenever possible from vendors who will enter into Business Association Agreements (BAAs).

Download the resource below for Issue Brief to support implementation of this guidance, including at-a-glance reference of acceptable and unacceptable apps as well as list of Dos and Don'ts.

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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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