SECURETexas Health Information Privacy & Security Certification Program

Transcription

1 Partners in Texas Health Informa3on Protec3on SECURETexas Health Information Privacy & Security Certification Program 2015 HITRUST, Frisco, TX. All Rights Reserved.

2 Outline Introduction Background Benefits SECURETexas Certification Framework Criteria Process Tools Pricing About HITRUST About THSA 2

3 Introduction Background (1) Multitude of challenges Significant government oversight Evolving requirements Complex business relationships Uncertain standard of care Reasonable and appropriate? Adequate protection? 3

4 Introduction Background (2) Texas legislators concerned about health information protection Increased use of electronic health records Federal HIPAA guidance lacking Significant increase in data breaches Texas House Bill (HB) 300 Passed May 30, 2011 Signed June 17, 2011 Effective Sept. 1, 2012 Amended the following statutes: Texas Health and Safety Code Chapters 181 & 182; Texas Business and Commerce Code, Chapters 521 and 522; Texas Government Code, Chapter 531; and Texas Insurance Code, Chapter 602 4

5 Introduction Background (3) Maintains the broader, Texas definition of Covered Entity Covers any business or individual coming into contact with PHI Supports patient rights re: Electronic Health Records (EHRs) Provides for the collection/reporting of consumer complaints Increases penalties for non-compliance/breach $5K to $1.5M per year based on 5 factors, not just intent and risk of harm Capped at $250M per year based on specific circumstances A pattern of non-compliance could result in license revocation Establishes Texas standards for healthcare information privacy and security Standards ratified by Texas Health and Human Services Commission and codified at 1 TAC 390 Provides for certification of compliance with the Texas standards Potential to mitigate penalties from regulatory and legal penalties 5

6 Introduction Background (4) THSA selects HITRUST for SECURETexas Certification program HITRUST Risk Management Framework (RMF) provides robust support for SECURETexas Certification Comprehensive coverage, relevant to healthcare, that is scalable, prescriptive and tailorable to meet entity requirements Certification supports assertions of compliance Common framework & reporting provide significant efficiency & cost savings Most widely adopted information protection framework in U.S. healthcare industry simplifies adoption For this program to be successful, it must provide the appropriate level of assurance and verifica3on while s3ll being prac3cal and implementable; therefore, it was important we select the best possible partner for developing and implemen3ng the SECURETexas Health Informa3on Privacy and Security Cer3fica3on Program. We are confident in our choice given HITRUST s leading role in the assessment and cer3fica3on of compliance with mul3ple health informa3on protec3on regula3ons and best prac3ces through the HITRUST Common Security Framework (CSF). - Tony Gilman, CEO, THSA 6

7 Introduction Benefits In addition to the those provided by leveraging the HITRUST RMF, covered entities receive specific benefits from obtaining SECURETexas Certification Mitigation of civil and administrative penalties Evidence of good faith efforts to comply with federal and state requirements 7

8 SECURETexas Certification Framework (1) Resources and tools available by HITRUST CSF Scalable, prescriptive and certifiable framework incorporated a multitude of state and federal regulations, US and International Standards, and best practices maintained and updated for health care industry CSF Assurance A covered entity information protection certification program with an existing base of certified assessor organizations MyCSF Automated support for CSF assessment and certification CSF CSF Assurance HITRUST RMF Methods & Tools (e.g., MyCSF) 8

9 SECURETexas Certification Framework (2) HITRUST s healthcare-centric RMF Leverages international and U.S. RMFs Rationalizes multiple healthcare requirements Provides industry standard of due diligence and care Three risk-based control baselines Organizational, system and regulatory factors Texas compliance demonstrated through detailed mappings to the CSF control requirements 9

10 SECURETexas Certification Criteria Examples of Texas requirements mapped to the CSF CSF Control All HIPAA xrefs 02.e, Level 1 07.e, Level 1 11.a, TX Covered EnVVes TX Requirement Texas Health and Safety Code (THSC) a A covered envty, as that term is defined by 45 C.F.R. SecVon , shall comply with the Health Insurance Portability and Accountability Act and Privacy Standards. THSC (a) Each covered envty shall provide a training program to employees of the covered envty regarding the state and federal law concerning protected health informavon as it relates to the covered envty's parvcular course of business and each employee's scope of employment. THSC , referenced by 1 Texas AdministraVve Code (TAC) 390.2(a)(4)(A)(ii) Specifies that care shall be given to ensure sensivve informavon subject to special handling, e.g., HIV test results, mental health and substance abuse- related records, is idenvfied and appropriate labeling and handling requirements are expressly defined and implemented consistent with applicable federal and state legislavve and regulatory requirements and industry guidelines. THSC 577, referenced by 1 TAC 390.2(a)(4)(A)(ii) To comply with the requirements specified in THSC 577, private psychiatric (mental) hospitals, crisis stabilizavon units and other mental health facilives shall incorporate procedures in their security and privacy incident response programs to assist with state invesvgavons, including the release of otherwise confidenval informavon related to the invesvgavon, as required under THSSC 157. *Refer to the 2013 CSF, 2013 interim Summary of Changes, and the 2014 Summary of Changes for all the SECURETexas Certification requirements 10

11 SECURETexas Certification Process (1) SECURETexas Certification Completely flexible implementation, as organizations may: Request SECURETexas Certification with CSF (HIPAA) assessment Increment to SECURETexas Certification after CSF (HIPAA) assessment is done Varying levels and costs of assurance Risk Exposure HIGH MEDIUM CSF Assurance (Self) Compliance with HIPAA CSF Assurance (Remote) CSF Assurance (3rd Party) The CSF Assurance Program balances the cost of assurance with the risk exposure. The program is designed to cost effecvvely gather the informavon about privacy and security controls that is required to appropriately understand and mivgate risk. Compliance with ISO Compliance with PCI Compliance with NIST LOW 11 Cost of Assurance

12 SECURETexas Certification Process (2) Covered entity engages independent assessor organization* CSF Assessor conducts assessment against certification requirements CSF assessor submits assessment results to HITRUST for review HITRUST conducts QA review; resolves outstanding issues HITRUST prepares report with SecureTexas Certification Scorecard If covered entity achieves appropriate scores, HITRUST will provide a certification recommendation to be submitted to THSA THSA reviews recommendation and issues certification letter Covered entity is added to website listing certified covered entities Assessor engaged* Assessment conducted* Results submiied to HITRUST HITRUST conducts QA; prepares report HITRUST determines scoring; if appropriate recommends THSA grants or denies cervficavon OrganizaVon Listed on Website *Small organizavons may conduct a remote- assessment 12

13 SECURETexas Certification Tools (1) MyCSF GRC-based platform CSF controls Illustrative procedures Assessment scoping Workflow management Documentation repository Dashboards and reporting Automated submission for HITRUST validation and certification Simplifies SecureTexas Certification 13

14 SECURETexas Certification Tools (2) HITRUST Website General Support HITRUST RMF content News / updates Blogs / chats SecureTexas Certification Support Provide specific guidance Address user questions THSA SecureTexas Website SecureTexas Certification support Who should certify Benefits of certifying How to get started Pricing FAQs 14

15 Pricing (1) Covered entity assessment and report generation fee Certification Remote Assessment (if applicable) $3500 to perform remote assessment and generate recommendation for Texas Certification $1000 if adding SECURETexas Certification to an existing HITRUST certification Certification Third Party Assessment $ $7500 to review third party assessment and generate recommendation for Texas Certification $1500 if adding SECURETexas Certification to existing HITRUST certification Fees paid to HITRUST Covered entity certification fee Certification Remote Assessment: $100 to $1500 (less than $750, if 150 employees of fewer) Certification Assessment: $ $7500 (depending on revenue) Fees paid to THSA 15

16 Pricing (2) Fee Schedule TX Only Remote < $5M Third Party < $50M Third Party < $500M Third Party < $1B/yr Third Party < $10B Third Party >$10B Assessor Fees N/A TBD TBD TBD TBD TBD HITRUST Fees $3500 $3750 $4500 $5250 $6000 $7500 THSA Fees $1500 $2500 $3250 $5000 $6250 $7500 Total $5000 $6250 $7750 $10,250 $12,250 $15,000 Fee Schedule TX Added to CSF Remote < $5M Third Party < $50M Third Party < $500M Third Party < $1B/yr Third Party < $10B Third Party >$10B Assessor Fees N/A TBD TBD TBD TBD TBD HITRUST Fees $1000 $1500 $1500 $1500 $1500 $1500 THSA Fees $1500 $2500 $3250 $5000 $6250 $7500 Total $2500 $4000 $4750 $6500 $7750 $

17 Pricing (3) Fee Schedule For Small Businesses 1-25 employees employees employees employees Assessor Fees N/A N/A N/A N/A HITRUST Fees $1400 $1750 $2000 $2250 THSA Fees $100 $250 $500 $750 Total $1500 $2000 $2500 $

18 Summary The SECURETexas Health Information Privacy & Security Certification Is competitively priced and sufficiently robust to support wide adoption; Demonstrates compliance with the Texas Medical Records Privacy Act and associated standards; Specifically addresses high-risk threats associated with reported data breaches; Supports overall compliance with HIPAA (Final Omnibus Rule) implementation specifications; Leverages HITRUST s online GRC-based tool, MyCSF, to provide automated workflow for certification assessment, quality assurance and reporting; Provides a standardized method of reporting compliance and risk, including the recommendation for SECURETexas Certification; Facilitates the communication of assurances with other business partners, patients and their families, and other key stakeholders, such as federal and state regulators; and Provides for potential, limited safe harbor from regulatory and legal penalties 18

19 About HITRUST In 2007, the Health Information Trust Alliance or HITRUST was formed by a group of concerned healthcare organizations out of the belief improvements in the state of information security and privacy in the industry are critical to the broad adoption, utilization and confidence in health information systems, medical technologies and electronic exchanges of health information, all of which are necessary to improve the quality of patient care while lowering the cost of healthcare delivery. Key focus: Increase the protection of protected health and other sensitive information Mitigate and aid in the management of risk associated with health information Contain and manage costs associated with appropriately protecting sensitive information Increase consumer and governments confidence in the industry's ability to safeguard health information Address increasing concerns associated with business associate and 3rd party privacy, security and compliance Work with federal and state governments and agencies and other oversight bodies to collaborate with industry on information protection Facilitate sharing and collaboration relating to information protection amongst and between healthcare organizations of varying types and sizes Enhance and mature the knowledge and competency of health information protection professionals 19

20 About THSA In 2007, the Texas Legislature created THSA to help improve the Texas healthcare system Promote and coordinate HIE and HIT throughout the state Ensure the right information is available to right provider at the right time In 2011, the Texas Legislature authorized THSA to: Identify relevant privacy and security standards Develop a privacy and security certification for Texas covered entities In 2013, THSA partnered with HITRUST to create the SecureTexas Health Information Privacy and Security Certification Program 20

21 For more information