HANDBOOK

Description

The Health Insurance Portability and Accountability Act (HIPAA) Privacy, Security and Breach Notification Rules require covered entities and their business associates to safeguard electronic protected health information (ePHI) through reasonable and appropriate security measures, and make the appropriate notifications when a breach of the privacy or security of ePHI occurs.

Suffering through a breach incident costs money, takes time, and diverts your staff’s attention from proper patient care.  But taking the time to evaluate your information security risks and implement plans to mitigate them can yield a big payoff in the reduction and impact of surprise events like breaches.

One of these measures required by the Security Rule, is a risk analysis, which directs covered entities and business associates to conduct a thorough and accurate assessment the risks and vulnerabilities to ePHI (See 45 CFR § 164.308(a)(1)(ii)(A)). Conducting a risk analysis is the first step in identifying and implementing safeguards that ensure the confidentiality, integrity, and availability of ePHI.  A Gap Analysis, to review conformance with the requirements of the HIPAA Rules, is a useful tool to identify whether certain standards and implementation specifications of the Security Rule have been met, and a Risk Assessment of each information handling process is essential to identifying and planning the mitigation of risks to the confidentiality, integrity, and availability of ePHI.

Organizations that have not performed the complete process of Risk Analysis, including Gap Analysis and Risk Assessments, are more likely to suffer incidents and breaches of ePHI, including those caused by inappropriate un-reviewed or uncontrolled internal access, and those caused by external actors, such as Ransomware incidents that can bring an organization to its knees.  Even relatively simple processes, like ensuring that all portable devices holding ePHI are properly secured, if undiscovered, can lead to significant breaches and resulting penalties.  These kinds of incidents have resulted in the need for notifications to patients and penalties in the millions of dollars for the affected organizations, and could likely have been prevented by performing and following through on a thorough Gap Analysis, Risk Assessment, and Risk Analysis process.

The costs of compliance through Gap Analysis, Risk Assessment, and Risk Analysis are far lower than the costs of not doing what’s required, and then as a result suffering the significant expense and consequences of incidents, breaches, and enforcement actions.  This session will focus on how you can use the issues most frequently encountered in breaches and enforcement actions as part of an analysis process to give you actionable plans and documentation of considerations made in the process.

If you don’t take the proper steps to ensure your patients’ health information is being protected according to the HIPAA Security Rule, you can be hit with significant fines and penalties.  With the increased HIPAA fines beginning at $10,000 in cases of willful neglect, providing good information security and being in compliance are more important than ever, and a good Risk Analysis is key to that compliance.

We will explore the typical risk issues that lead to breaches of health information.  The results of prior enforcement actions and HHS audits (and their penalties), especially those relating to Risk Analysis, will be discussed, including recent actions involving multi-million dollar fines and settlements.  In addition, new trends in information security risks will be discussed so you can start to plan for the work you’ll need to do to stay in compliance and keep patient information private and secure.

Key Focus Areas:

  • Requirements for risk management in the HIPAA Security Rule will be explained.
  • The results of not managing risks, such as incidents, breaches, and enforcement actions, will be examined.
  • How to use risk management methods, such as Gap Analysis, Risk Assessment, and Risk Analysis, to find issues and mitigate them before they cause an incident or a breach.
  • Finding and filling any gaps in your policies and procedures.
  • Understanding the organization-wide risk picture and balancing risk mitigation needs with resource availability.
  • Planning the management of risks over time and maintaining the information security management process.
  • Planning your next reviews and your information security management process

Learning Objectives:

  • Comparing information-handling practices to the requirements of HIPAA in order to identify gaps between current and required practices.
  • Risk analysis to determine security risks to electronic information and implementation of measures to reduce those risks and vulnerabilities to a reasonable and appropriate level, and doing so is essential to the prevention of breaches. It is essential to perform an accurate and thorough entity-wide risk analysis to find and mitigate the risks of breaches and incidents and avoid the significant penalties for violations of the rules
  • Confidentiality, integrity, and availability of electronic PHI will be explained, and processes for performing the required risk analysis will be presented and discussed.
  • Exploring situations that have led to breaches and enforcement actions, and that provide clear examples of what not to do, and what is likely to lead to a breach.
  • Steps to take to protect your office from the significant damage of breaches will be detailed and explained.

Suggested Audiences:

  • CEO
  • CFO
  • Compliance Director
  • Privacy Officer
  • Security Officer
  • Information Systems Manager
  • HIPAA Officer
  • Chief Information Officer
  • Health Information Manager
  • Healthcare Counsel/lawyer
  • Office Manager
  • Contracts Manager

About Our Speaker:

Jim Sheldon-Dean is the founder and director of compliance services at Lewis Creek Systems, LLC, a Vermont-based consulting firm founded in 1982, providing information privacy and security regulatory compliance services to a wide variety of health care entities.  He is a frequent speaker regarding HIPAA, including speaking engagements at numerous regional and national healthcare association conferences and conventions and the annual NIST/OCR HIPAA Security Conference.  Sheldon-Dean has more than 18 years of experience specializing in HIPAA compliance, more than 36 years of experience in policy analysis and implementation, business process analysis, information systems and software development, and eight years of experience doing hands-on medical work as a Vermont certified volunteer emergency medical technician.  Sheldon-Dean received his B.S. degree, summa cum laude, from the University of Vermont and his master’s degree from the Massachusetts Institute of Technology.

Our Speaker’s Previous Webinar Snippet: