The HIPAA Security Rule requires physicians to protect patients' electronically stored, protected health information (known as “ePHI”) by using appropriate administrative, physical and technical safeguards to ensure the confidentiality, integrity and security of this information. Essentially, the Security Rule operationalizes the protections contained in the Privacy Rule by addressing the technical and nontechnical safeguards that covered entities must implement to secure ePHI. Show All covered entities must assess their security risks, even those entities who utilize certified electronic health record (EHR) technology. Those entities must put in place administrative, physical and technical safeguards to maintain compliance with the Security Rule and document every security compliance measure. HIPAA defines administrative safeguards as, “Administrative actions, and policies and procedures, to manage the selection, development, implementation, and maintenance of security measures to protect electronic protected health information and to manage the conduct of the covered entity’s workforce in relation to the protection of that information.” (45 C.F.R. § 164.304). These are, like the definition says, policies and procedures that set out what the covered entity does to protect its PHI. Rather than actual physical safeguards or technical requirements, these requirements cover training and procedures for employees of the entity, whether or not they have direct access to PHI. Physical safeguards involve access both to the physical structures of a covered entity and its electronic equipment (45 CFR §164.310). ePHI and the computer systems in which it resides must be protected from unauthorized access, in accordance with defined policies and procedures. Some of these requirements can be accomplished by using electronic security systems, but physicians should not rely on use of certified electronic health records technology (CEHRT) to satisfy their Security Rule compliance obligations. Technical safeguards encompass the technology, as well and the policies and procedures for its use, that protect ePHI and control access to it. They are often the most difficult regulations to comprehend and implement (45 CFR §164.312). The Security Rule incorporates the concepts of scalability, flexibility and generalization. In other words, the regulations do not expect the same security precautions from small or rural providers as are demanded of large covered entities with significant resources. Security is recognized as an evolving target, and so HIPAA’s security requirements are not linked to specific technologies or products. HHS has stated it is focused more on what needs to be done and less on how it should be accomplished. The security regulations consist of a 3-tiered system of requirements. First, there is a series of standards, legal requirements that all entities are expected to meet. Second, there may be implementation specifications that provide detailed instructions and steps to take in order to be in compliance with the standard. In an effort to make the Security Rule more flexible and applicable to covered entities of all sizes, some implementation specifications are required, while others are only addressable. Required implementation specifications must be implemented by all covered entities. Addressable implementation specifications require a covered entity to assess whether the specification is a reasonable and appropriate safeguard in the entity’s environment. If the specification is reasonable and appropriate, the covered entity must implement the specification. If a covered entity determines that an addressable implementation specification is not reasonable and appropriate, it must document its assessment and basis for its decision and implement an alternative mechanism to meet the standard addressed by the implementation specification. To comply with the Security Rule’s implementation specifications, covered entities are required to conduct a risk assessment to determine the threats or hazards to the security of ePHI and implement measures to protect against these threats and such uses and disclosures of information that are not permitted by the Privacy Rule. A risk assessment should be tailored to the covered entity’s circumstances and environment, including the following:
Note, however, that HHS has made it clear that cost alone is not a sufficient basis for refusing to adopt a standard or an addressable implementation specification. Fortunately, the rules are not prescriptive and a number of tactics can achieve compliance. To assist physicians with the risk-assessment process, the U.S. Department of Health & Human Services (HHS) Office of Civil Rights has developed a downloadable "Security risk assessment tool." Behind every security compliance measure is a documentation requirement. Practically every facet of HIPAA compliance requires that policies and procedures be created and implemented. These documents must be retained for at least six years (and state requirements may mandate longer retention periods). Policies may be changed at any time, so long as the accompanying documentation is also updated. Regulations require periodic review of policies and responses to changes in the ePHI environment. This resource is provided for informational and reference purposes only and should not be construed as the legal advice of the American Medical Association. Specific legal questions regarding this information should be addressed by one's own counsel.
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When developing security procedures for remote workforce, the HIM director should reference which of the following?A) privacy and security rule, state statutes and other federal statutesB) privacy and security rule C) security rule, state statutes, othe The HIPAA Security Rule establishes national standards to protect individuals’ electronic personal health information that is created, received, used, or maintained by a covered entity. The Security Rule requires appropriate administrative, physical and technical safeguards to ensure the confidentiality, integrity, and security of electronic protected health information. The Security Rule is located at 45 CFR Part 160 and Subparts A and C of Part 164. View the combined regulation text of all HIPAA Administrative Simplification Regulations found at 45 CFR 160, 162, and 164. Security Rule HistoryJanuary 25, 2013 – Modifications to the HIPAA Privacy, Security, Enforcement, and Breach Notification Rules under the Health Information Technology for Economic and Clinical Health (HITECH) Act and the Genetic Information Nondiscrimination Act, and Other Modifications – Final Rule (The “Omnibus HIPAA Final Rule”) July 14, 2010 – Modifications to the HIPAA Privacy, Security, and Enforcement Rules under the HITECH Act – Proposed Rule August 4, 2009 – Federal Register notice of the Delegation of Authority to OCR (74 FR 38630) August 3, 2009 – View the Delegation of Authority Press Release February 20, 2003 – Security Standards – Final Rule August 12, 1998 – Security and Electronic Signature Standards - Proposed Rule HHS Security Risk Assessment ToolThe Office of the National Coordinator for Health Information Technology (ONC) and the HHS Office for Civil Rights (OCR) have jointly launched a HIPAA Security Risk Assessment Tool. The tool’s features make it useful in assisting small and medium-sized health care practices and business associates as they perform a risk assessment. HHS Security Risk Assessment Tool NIST HIPAA Security Rule ToolkitThe NIST HIPAA Security Toolkit Application is a self-assessment survey intended to help organizations better understand the requirements of the HIPAA Security Rule (HSR), implement those requirements, and assess those implementations in their operational environment. A comprehensive user guide and instructions for using the application are available along with the HSR application. NIST HSR Toolkit Risk Analysis GuidanceAdditional Security Rule GuidanceSee the Security Rule Guidance page for additional guidance. |
Which of the following would provide the best support of an organizations efforts towards compliance with the security Rule?
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