HEALTH INFORMATION SECURITY & COMPLIANCE Charles Nwasor, Xcellent Technologies.
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Transcript of HEALTH INFORMATION SECURITY & COMPLIANCE Charles Nwasor, Xcellent Technologies.
HEALTH INFORMATION SECURITY & COMPLIANCE
Charles Nwasor,Xcellent Technologies
Agenda
2
HIPAA1
Internal Compliance3
2 The New Healthcare Paradigm
Conclusion4
3
HIPAA1
4
HIPAA – Overview
Sets standards to assure the Confidentiality, Integrity, and Availability of PHI
Health Insurance Portability & Accountability Act (HIPAA)Privacy – individuals’ rights of privacy and standardsSecurity – security of ePHIBreach Notification – reporting breach information
Limits the use and disclosure of confidential information:Protected Health Information (PHI)Electronic Protected Health Information (ePHI)
HIPAA – PHI
5
PHI and Personally Identifiable InformationAny information (verbal, electronic, or written) that relates
to a person’s physical or mental health or payment information
Name
Postal Address
All elements of Date
Telephone Number
Fax Number
Email Address
URL
IP Address
Social Security Number
Account Numbers
License Number
Medical Record Number
Health Plan Number
Device Identifier
Vehicle Identifier
Biometric Identifier
Full-face Photos
Any other unique identifying number
Genetic information
HIPAA – CIA Triad
6
Confidentiality – keeping information from unauthorized access
Integrity – safeguarding against unauthorized modification
Availability – assuring the constant availability of information
HIPAA – Privacy Rule
7
Establishes rights of privacy and standards for disclosure
Permitted Disclosures Personal Representatives
Treatment, Payment and Healthcare Operations
Written Authorization/Verbal Consent
De-identified Data
Required Disclosures Public Health Activities
Law Enforcement
Verification Requirements
Notice of Privacy Practices
HIPAA – Security Rule
8
Requires control measures to safeguard the confidentiality, integrity and availability of electronic Protected Health Information (ePHI)
Organizational Requirements – Business Associate Agreements (BAAs)
Security Standards Administrative
Physical
Technical
Security Management Process
Information Access Management
Security Awareness and Training
HIPAA – Breach Notification Rule
9
Requires notifications to authorities and/or patients when unsecured PHI has been breached
Defines Breach as the inappropriate use or disclosure that compromises the security and privacy of PHI
Exceptions Unintentional Acquisition by a workforce member
Inadvertent Disclosure between workforce members
Recipient can not reasonably retain the information
Unsecured PHI – is PHI that has not been rendered unreadable or indecipherable to unauthorized persons
10
2 The New Healthcare Paradigm
The New Healthcare Paradigm
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12
Internal Compliance3
Internal Compliance Framework
13
Assess Risk •Security Risk Assessment
Plan Corrective Action •Prioritize Controls
Create & Implement Control Measures
•Remediate
Internal Compliance Framework
14
Information Security Policy & Technical Controls Acceptable Use Access controls & Physical Security Secure Software & Malicious Code Security Incident Management Sanctions Breach Notification Workforce Security Security Awareness and Training
Proper Conduct and Authorized Disclosures
Internal Compliance Framework
15
Impacts of Non-Compliance
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Regulatory Fines
Lawsuits and Liability
Loss of Business
Professional Sanctions
Current Examples
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Hospice of North Idaho - $50,000
Massachusetts Eye and Ear Associates Inc. - $1.5 Million
River Falls Medical Clinic – 2,400 Patient Records stolen
Shands Jacksonville Clinic – 261 Patient Records photographed
Goldthwait Associates, a Billing Service Provider - $140,000
Phoenix Cardiac Surgery, P.C. - $100,000
18
Conclusion4
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Assuring the Privacy and Security of Patients’ Information is a vital component of providing healthcare.
Questions
20
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Xcellent Technologies43155 Main Street Suite 2210-DNovi, MI 48375
(248) 956.0538 [email protected]
http://www.xcellenttechnologies.com