Putting It All Together:

Size: px
Start display at page:

Download "Putting It All Together:"

Transcription

1 Putting It All Together: The Interplay of Privacy & Security Regina Verde, MS, MBA, CHC Chief Corporate Compliance & Privacy Officer University of Virginia Health System 2017 ISPRO Conference October 24, 2017

2 Overview of HIPAA The Privacy Program The Security Program The Intersection of Privacy & Security Questions

3 HIPAA

4

5 Health Insurance Portability & Accountability Act Privacy Rule Security Rule 1996 Enacted 2003 Privacy Rule in effect 2005 Security Rule in effect 2009 Health Information for Technology for Economic & Clinical Health (HITECH) Act 2013 Omnibus Final Rule

6 Promotes Patient Rights The HIPAA Basics: There must be a Covered Entity There must be Protected Health Information (PHI) PHI requires both: Identifiers (1 or more of 18), and, Health Information (past, present or future) Framed by Needing to Know vs. Wanting to Know And be protected by using Reasonable Safeguards

7 Protected Health Information (PHI) Consists of all individually identifiable health information regarding past, present and future health care encounters Verbal Written/Paper Electronic

8

9 Components of HIPAA Portability & Accountability: Provides continuity of healthcare coverage, limits exclusions for pre-existing conditions, and prohibits discrimination based on health status

10 Administrative Simplification: Requires privacy & security protections for all forms of individually-identifiable health information

11 The Privacy Program

12 The Privacy Program: Overview of the Privacy Program Provides strategic and thought leadership Creates privacy policies, processes and internal controls Develops and maintains an appropriate framework on which the company collects, stores, processes and transfers personal data Privileged and Confidential

13 Overview of the Privacy Program Protects the privacy of protected health information (PHI), and sets limits and conditions on the uses and disclosures of PHI without patient authorization Implements appropriate training for Covered Persons", integrating policies and procedures for protecting and safeguarding PHI Acquires and develops necessary HIPAA related forms and documentation Privileged and Confidential

14 Privacy Program Components Privacy Program Components Policies & Procedures Protects Patient Rights Privacy Program Privacy Training Incident Response Privileged Confidential and Risk Management

15 HIPAA gives patients federal privacy rights The Notice of Privacy Practice explains these rights and describes how a Covered Entity will use and disclose PHI There are criminal and civil fines and sanctions for non-compliance All Covered Entities must have a sanctions policy

16 The Balancing Act The Balancing Act Access, Use and Disclosure of Minimum Necessary PHI for TPO: Treatment: Clinicians, providers and care team members Payment: Schedulers, registrars, coders and billers Healthcare Operations: Performing reviews, extracting necessary information, performing audits, surveys and investigations, etc. Upholding and Safeguarding Patient Rights under HIPAA: Itemized in the Notice of Privacy Practices Taken seriously by consumers and oversight agencies

17 The Interactive Privacy Officer The Interactive Privacy Officer Patients and Family Members Covered Individuals and Workforce Members Training, consultation, investigation, enforcement Business Associates Involved Third Parties Law enforcement, legal, Privileged religious and representatives, etc. Confidential Oversight Agencies

18 Roles and Responsibilities of the Privacy Function Builds a strategic and comprehensive privacy program that defines, develops, maintains and implements policies and processes that enable effective privacy practices Minimizes risk and ensures the confidentiality of PHI - oral, paper and/or electronic, across all media types Privileged and Confidential

19 Roles and Responsibilities of the Privacy Function Ensures privacy forms, policies, and procedures are up-to-date Conducts ongoing compliance monitoring in coordination with the organization's other compliance and operational assessment functions Privileged and Confidential

20 Roles and Responsibilities of the Privacy Function Oversees, develops and delivers initial and ongoing privacy training to the workforce Monitors all business associates and business associate agreements to ensure all privacy concerns, requirements, and responsibilities are addressed Privileged and Confidential

21 Roles and Responsibilities of the Privacy Function Manages all required breach determination and notification processes under HIPAA and applicable state confidentiality and/or breach rules and requirements Establishes and administers a process for investigating and acting on privacy and security complaints Privileged and Confidential

22 The Security Program

23

24 Overview of a Security Program Ensures that the data held at the organization remains secure Responsible for ensuring the Confidentiality, Integrity, and Availability (CIA) of data Responsible for the implementation of Administrative, Physical, and Technical Safeguards to protect sensitive data Heads the creation of policies and procedures to ensure this protection such as: Acceptable use Access control Data Handling and Retention Data Classification Ensures employees receive the proper training in order to enable them to protect sensitive information

25 Information Security protects PHI Confidentiality Only people with a need to know have access to patient records Integrity Lab results, etc., aren t changed or destroyed accidentally or maliciously Availability Patient records are there when you need them, computer systems are up and running, your user ID and password are working, etc.

26 Administrative Safeguards Careful hiring practices Training and education Policies and procedures Termination and separation protocols

27 Physical Safeguards Confidential patient care Document care and storage Document disposal and destruction

28 Electronic Safeguards User authentication Systems protection Safe hardware disposal

29 Components of a Security Program Security Policies Physical Security Personnel Security System & Data Identification Security Standards & Best Practices Incident Response System Security Plan System Development Life Cycle Organization s Security Policies & Programs Configuration Management Training & Awareness Laws & Regulations System Documentation Disaster Recovery Privileged and Confidential

30 Roles and Responsibilities of the Security Function Roles and Responsibilities of the Security Function Understanding the HIPAA Security Rule and keeping up-to-date with any and all changes to the law Developing and implementing policies and procedures to safeguard PHI Identifying and evaluating threats to the integrity of PHI Developing and implementing action plans for addressing risks to PHI Less people-centric than the privacy officer

31 The Intersection of the Privacy and Security Functions

32 How Does a Breach Affect Your Organization? Fines from government OCR can fine an organization up to $1.65 million per HIPAA provision violated per calendar year Litigation (class action) Breach notification costs/credit monitoring System downtime Reputational damage Patient loyalty Table: Categories of HIPAA Violations & Fine Amounts Violation category Each violation Violations of an identical provision (in a calendar year) Did Not Know $110-55,010 $1.65 million Reasonable Cause $1,100-55,010 $1.65 million Willful Neglect Corrected Willful Neglect Not Corrected $11,002-55,010 $1.65 million $55, M $1.65 million

33 Privacy and Security Relationship Privacy and security go hand-in-hand Privacy All PHI - Oral, written or electronic Rules on the use of PHI Who is authorized to access PHI Patient rights and access to their medical information Limits PHI uses & disclosures to the minimum amount necessary Training Data Safeguards Confidentiality Appropriate Access (paper, physical or electronic) Policies & procedures Contracts (BAA) Incident Mitigation Security e-phi - Electronic PHI received, maintained or transmitted Rules on how to Protect e- PHI Mechanisms to ensure authorized access to e-phi Assurances for data integrity and availability Reviews to evaluate potential risks of e-phi

34 Privacy and Security Shared Responsibilities The Privacy and Security Officers: Have a role in developing the policies and procedures and training the workforce in HIPAA s requirements Establish and maintain a culture of compliance within the organization Work together to safeguard patient PHI Oversee internal sanctions for failure to comply with HIPAA policies Internal contact point for a security or privacy incident and/or PHI breach Regularly review and edit internal policies and procedures A marriage between the technical person and the one who understands compliance requirements. - Angela Rose, director of HIM Practice Excellence at the American Health Information Management Association

35 Breach Notification By law the covered entity must notify the affected Individuals, Health and Human Services, and if 500+ individuals, the Media

36 Incident Response: Privacy and Security Privacy and Security are interconnected Both can contribute to workforce readiness and awareness A Security breach is often a Privacy breach both areas would mobilize in incident investigation and response

37 Incident Response: Privacy and Security Example: i. A breach occurs ii. The Chief Information Security Officer activates an incident response team which assesses the scope of the incident - What information was accessed or misused? iii. The Incident Response coordinator contacts the Privacy Officer to determine if there needs to be a breach declaration - Does the breach impact solely privacy, security, or a combination of both? iv. If there has been a breach of personal information, Privacy and Security will mutually determine the appropriate response and relief; e.g. patient notification, credit monitoring, etc.

38 Auditing and Monitoring: The Union of Privacy and Security Regulations that affect Privacy and Security: The Health Insurance Portability and Accountability Act of 1996 (HIPAA) The American Recovery and Reinvestment Act of 2009 (ARRA)- HITECH Modifications to the HIPAA Privacy, Security, and Enforcement Rules the Health Information Technology for Economic and Clinical Health Act; Final Rule The Payment Card Industry Data Security Standard (PCI DSS)

39 Auditing and Monitoring: The Union of Privacy and Security (Continued) The focus of the security program is to protect the Confidentiality, Availability, and Integrity of data Controls and procedures for both areas make up the umbrella which protects the organization from threats and unauthorized disclosures of protected information Compliance monitoring is important for both privacy and security The controls are only as good as they are effective! Must provide evidence that the controls are in working order for audits document!

40

41 Treat PHI as if it was your OWN!

42 Questions? Regina Verde, MS, MBA, CHC Chief Corporate Compliance and Privacy Officer University of Virginia Health System Corporate Compliance and Privacy Office Office: Mobile:

HIPAA Security and Privacy Policies & Procedures

HIPAA Security and Privacy Policies & Procedures Component of HIPAA Security Policy and Procedures Templates (Updated for HITECH) Total Cost: $495 Our HIPAA Security policy and procedures template suite have 71 policies and will save you at least 400

More information

HIPAA How to Comply with Limited Time & Resources. Jonathan Pantenburg, MHA, Senior Consultant August 17, 2017

HIPAA How to Comply with Limited Time & Resources. Jonathan Pantenburg, MHA, Senior Consultant August 17, 2017 HIPAA How to Comply with Limited Time & Resources Jonathan Pantenburg, MHA, Senior Consultant JPantenburg@Stroudwater.com August 17, 2017 Stroudwater Associates is a leading national healthcare consulting

More information

HIPAA Compliance: What it is, what it means, and what to do about it. Adam Carlson, Security Solutions Consultant Intapp

HIPAA Compliance: What it is, what it means, and what to do about it. Adam Carlson, Security Solutions Consultant Intapp HIPAA Compliance: What it is, what it means, and what to do about it. Adam Carlson, Security Solutions Consultant Intapp Agenda Introductions HIPAA Background and History Overview of HIPAA Requirements

More information

HIPAA FOR BROKERS. revised 10/17

HIPAA FOR BROKERS. revised 10/17 HIPAA FOR BROKERS revised 10/17 COURSE PURPOSE The purpose of this information is to help ensure that all Optima Health Brokers are prepared to protect the privacy and security of our members health information.

More information

MANUAL OF UNIVERSITY POLICIES PROCEDURES AND GUIDELINES. Applies to: faculty staff students student employees visitors contractors

MANUAL OF UNIVERSITY POLICIES PROCEDURES AND GUIDELINES. Applies to: faculty staff students student employees visitors contractors Page 1 of 6 Applies to: faculty staff students student employees visitors contractors Effective Date of This Revision: June 1, 2018 Contact for More Information: HIPAA Privacy Officer Board Policy Administrative

More information

Policy and Procedure: SDM Guidance for HIPAA Business Associates

Policy and Procedure: SDM Guidance for HIPAA Business Associates Policy and Procedure: SDM Guidance for HIPAA Business (Adapted from UPMC s Guidance for Business at http://www.upmc.com/aboutupmc/supplychainmanagement/documents/guidanceforbusinessassociates.pdf) Effective:

More information

01.0 Policy Responsibilities and Oversight

01.0 Policy Responsibilities and Oversight Number 1.0 Policy Owner Information Security and Technology Policy Policy Responsibility & Oversight Effective 01/01/2014 Last Revision 12/30/2013 Department of Innovation and Technology 1. Policy Responsibilities

More information

HIPAA Federal Security Rule H I P A A

HIPAA Federal Security Rule H I P A A H I P A A HIPAA Federal Security Rule nsurance ortability ccountability ct of 1996 HIPAA Introduction - What is HIPAA? HIPAA = The Health Insurance Portability and Accountability Act A Federal Law Created

More information

DATA PRIVACY & SECURITY THE CHANGING HIPAA CLIMATE

DATA PRIVACY & SECURITY THE CHANGING HIPAA CLIMATE DATA PRIVACY & SECURITY THE CHANGING HIPAA CLIMATE Melodi (Mel) M. Gates mgates@pattonboggs.com (303) 894-6111 October 25, 2013 THE CHANGING PRIVACY CLIMATE z HEALTH INSURANCE PORTABILITY & ACCOUNTABILITY

More information

HIPAA For Assisted Living WALA iii

HIPAA For Assisted Living WALA iii Table of Contents The Wisconsin Assisted Living Association... ix Mission... ix Vision... ix Values... ix Acknowledgments... ix Who Should Use This Manual... x How to Use This Manual... x Updates and Forms...

More information

The simplified guide to. HIPAA compliance

The simplified guide to. HIPAA compliance The simplified guide to HIPAA compliance Introduction HIPAA, the Health Insurance Portability and Accountability Act, sets the legal requirements for protecting sensitive patient data. It s also an act

More information

HIPAA Privacy, Security and Breach Notification

HIPAA Privacy, Security and Breach Notification HIPAA Privacy, Security and Breach Notification HCCA East Central Regional Annual Conference October 2013 Disclaimer The information contained in this document is provided by KPMG LLP for general guidance

More information

CERT Symposium: Cyber Security Incident Management for Health Information Exchanges

CERT Symposium: Cyber Security Incident Management for Health Information Exchanges Pennsylvania ehealth Partnership Authority Pennsylvania s Journey for Health Information Exchange CERT Symposium: Cyber Security Incident Management for Health Information Exchanges June 26, 2013 Pittsburgh,

More information

Don t Be the Next Headline! PHI and Cyber Security in Outsourced Services.

Don t Be the Next Headline! PHI and Cyber Security in Outsourced Services. Don t Be the Next Headline! PHI and Cyber Security in Outsourced Services. June 2017 Melanie Duerr Fazzi Associates Partner, Director of Coding Operations Jami Fisher Fazzi Associates Chief Information

More information

Federal Breach Notification Decision Tree and Tools

Federal Breach Notification Decision Tree and Tools Federal Breach Notification and Tools Disclaimer This document is copyright 2009 by the Long Term Care Consortium (LTCC). These materials may be reproduced and used only by long-term health care providers

More information

University of Wisconsin-Madison Policy and Procedure

University of Wisconsin-Madison Policy and Procedure Page 1 of 10 I. Policy The Health Information Technology for Economic and Clinical Health Act regulations ( HITECH ) amended the Health Information Portability and Accountability Act ( HIPAA ) to establish

More information

Healthcare Privacy and Security:

Healthcare Privacy and Security: Healthcare Privacy and Security: Breach prevention and mitigation/ Insuring for breach Colin J. Zick Foley Hoag LLP (617) 832-1000 www.foleyhoag.com www.securityprivacyandthelaw.com Boston Bar Association

More information

HIPAA & Privacy Compliance Update

HIPAA & Privacy Compliance Update HIPAA & Privacy Compliance Update Vermont Medical Society FREE Wednesday Webinar Series March 15, 2017 Anne Cramer and Shireen Hart Primmer Piper Eggleston & Cramer PC acramer@primmer.com shart@primmer.com

More information

Data Backup and Contingency Planning Procedure

Data Backup and Contingency Planning Procedure HIPAA Security Procedure HIPAA made Easy Data Backup and Contingency Planning Procedure Please fill in date implemented and updates for your facility: Goal: This document will serve as our back-up storage

More information

WHITE PAPER. HIPAA Breaches Continue to Rise: Avoid Becoming a Casualty

WHITE PAPER. HIPAA Breaches Continue to Rise: Avoid Becoming a Casualty WHITE PAPER HIPAA Breaches Continue to Rise: Avoid Becoming a Casualty WHITE PAPER HIPAA Breaches Continue to Rise: Avoid Becoming a Casualty By Jill Brooks, MD, CHCO and Katelyn Byrne, BSN, RN Data Breaches

More information

Elements of a Swift (and Effective) Response to a HIPAA Security Breach

Elements of a Swift (and Effective) Response to a HIPAA Security Breach Elements of a Swift (and Effective) Response to a HIPAA Security Breach Susan E. Ziel, RN BSN MPH JD Krieg DeVault LLP Past President, The American Association of Nurse Attorneys Disclaimer The information

More information

Cyber Risks in the Boardroom Conference

Cyber Risks in the Boardroom Conference Cyber Risks in the Boardroom Conference Managing Business, Legal and Reputational Risks Perspectives for Directors and Executive Officers Preparing Your Company to Identify, Mitigate and Respond to Risks

More information

HIPAA Tips and Advice for Your. Medical Practice

HIPAA Tips and Advice for Your. Medical Practice HIPAA Tips and Advice for Your Ericka L. Adler Medical Practice Rachel V. Rose WHY Header HIPAA PATIENT and Medical PORTALS? Practices HIPAA Basics Who is a covered entity? What is PHI? When can you disclose

More information

The HIPAA Security & Privacy Rule How Municipalities Can Prepare for Compliance

The HIPAA Security & Privacy Rule How Municipalities Can Prepare for Compliance The HIPAA Security & Privacy Rule How Municipalities Can Prepare for Compliance Russell L. Jones Partner Health Sciences Sector Deloitte & Touche LLP Security & Privacy IMLA 2013 Annual Conference San

More information

Checklist: Credit Union Information Security and Privacy Policies

Checklist: Credit Union Information Security and Privacy Policies Checklist: Credit Union Information Security and Privacy Policies Acceptable Use Access Control and Password Management Background Check Backup and Recovery Bank Secrecy Act/Anti-Money Laundering/OFAC

More information

Boerner Consulting, LLC Reinhart Boerner Van Deuren s.c.

Boerner Consulting, LLC Reinhart Boerner Van Deuren s.c. Catherine M. Boerner, Boerner Consulting LLC Heather Fields, 1 Discuss any aggregate results of the desk audits Explore the Sample(s) Requested and Inquire of Management requests for the full on-site audits

More information

PRIVACY-SECURITY INCIDENT REPORT

PRIVACY-SECURITY INCIDENT REPORT SECTION I GENERAL INFORMATION Name of Staff Member Reporting Incident PRIVACY-SECURITY INCIDENT REPORT Telephone Number Email Address Division/Office/Facility Unit/Section Supervisor SECTION II PRIVACY

More information

HIPAA Controls. Powered by Auditor Mapping.

HIPAA Controls. Powered by Auditor Mapping. HIPAA Controls Powered by Auditor Mapping www.tetherview.com About HIPAA The Health Insurance Portability and Accountability Act (HIPAA) is a set of standards created by Congress that aim to safeguard

More information

The ABCs of HIPAA Security

The ABCs of HIPAA Security The ABCs of HIPAA Security Daniel F. Shay, Esq 24 th Annual Health Law Institute Pennsylvania Bar Institute March 13, 2018 c. 2018 Alice G. Gosfield and Associates PC 1 Daniel F. Shay, Esq. Alice G. Gosfield

More information

Decrypting the Security Risk Assessment (SRA) Requirement for Meaningful Use

Decrypting the Security Risk Assessment (SRA) Requirement for Meaningful Use Click to edit Master title style Decrypting the Security Risk Assessment (SRA) Requirement for Meaningful Use Andy Petrovich, MHSA, MPH M-CEITA / Altarum Institute October 1, 2014 10/1/2014 1 1 Who is

More information

Employee Security Awareness Training Program

Employee Security Awareness Training Program Employee Security Awareness Training Program Date: September 15, 2015 Version: 2015 1. Scope This Employee Security Awareness Training Program is designed to educate any InComm employee, independent contractor,

More information

HIPAA COMPLIANCE AND DATA PROTECTION Page 1

HIPAA COMPLIANCE AND DATA PROTECTION Page 1 HIPAA COMPLIANCE AND DATA PROTECTION info@resultstechnology.com 877.435.8877 Page 1 CONTENTS Introduction..... 3 The HIPAA Security Rule... 4 The HIPAA Omnibus Rule... 6 HIPAA Compliance and RESULTS Cloud

More information

Altius IT Policy Collection Compliance and Standards Matrix

Altius IT Policy Collection Compliance and Standards Matrix Governance Context and Alignment Policy 4.1 4.4 800-26 164.308 12.4 EDM01 IT Governance Policy 5.1 800-30 12.5 EDM02 Leadership Mergers and Acquisitions Policy A.6.1.1 800-33 EDM03 Context Terms and Definitions

More information

HIPAA-HITECH: Privacy & Security Updates for 2015

HIPAA-HITECH: Privacy & Security Updates for 2015 South Atlantic Regional Annual Conference Orlando, FL February 6, 2015 1 HIPAA-HITECH: Privacy & Security Updates for 2015 Darrell W. Contreras, Esq., LHRM Gregory V. Kerr, CHPC, CHC Agenda 2 OCR On-Site

More information

Cybersecurity in Higher Ed

Cybersecurity in Higher Ed Cybersecurity in Higher Ed 1 Overview Universities are a treasure trove of information. With cyber threats constantly changing, there is a need to be vigilant in protecting information related to students,

More information

ORA HIPAA Security. All Affiliate Research Policy Subject: HIPAA Security File Under: For Researchers

ORA HIPAA Security. All Affiliate Research Policy Subject: HIPAA Security File Under: For Researchers All Affiliate Research Policy Subject: HIPAA File Under: For Researchers ORA HIPAA Issuing Department: Office of Research Administration Original Policy Date Page 1 of 5 Approved by: May 9,2005 Revision

More information

Security Rule for IT Staffs. J. T. Ash University of Hawaii System HIPAA Compliance Officer

Security Rule for IT Staffs. J. T. Ash University of Hawaii System HIPAA Compliance Officer Security Rule for IT Staffs J. T. Ash University of Hawaii System HIPAA Compliance Officer jtash@hawaii.edu hipaa@hawaii.edu Disclaimer HIPAA is a TEAM SPORT and everyone has a role in protecting protected

More information

HIPAA Privacy and Security Training Program

HIPAA Privacy and Security Training Program Note The following HIPAA training is intended for Vendors, Business Associates, Students, Pre Approved Shadowers, and Visitors. The following training module does not provide credit for annual training

More information

HIPAA COMPLIANCE WHAT YOU NEED TO DO TO ENSURE YOU HAVE CYBERSECURITY COVERED

HIPAA COMPLIANCE WHAT YOU NEED TO DO TO ENSURE YOU HAVE CYBERSECURITY COVERED HIPAA COMPLIANCE WHAT YOU NEED TO DO TO ENSURE YOU HAVE CYBERSECURITY COVERED HEALTHCARE ORGANIZATIONS ARE UNDER INTENSE SCRUTINY BY THE US FEDERAL GOVERNMENT TO ENSURE PATIENT DATA IS PROTECTED Within

More information

Neil Peters-Michaud, CHAMP Cascade Asset Management ITAM Awareness Month December 2016

Neil Peters-Michaud, CHAMP Cascade Asset Management ITAM Awareness Month December 2016 Breach New Heights The role of ITAM in preventing a data breach Neil Peters-Michaud, CHAMP Cascade Asset Management ITAM Awareness Month December 2016 Agenda Why Breaches Matter to the ITAM group The cost

More information

Integrating HIPAA into Your Managed Care Compliance Program

Integrating HIPAA into Your Managed Care Compliance Program Integrating HIPAA into Your Managed Care Compliance Program The First National HIPAA Summit October 16, 2000 Mark E. Lutes, Esq. Epstein Becker & Green, P.C. 1227 25th Street, N.W., Suite 700 Washington,

More information

Security and Privacy Breach Notification

Security and Privacy Breach Notification Security and Privacy Breach Notification Version Approval Date Owner 1.1 May 17, 2017 Privacy Officer 1. Purpose To ensure that the HealthShare Exchange of Southeastern Pennsylvania, Inc. (HSX) maintains

More information

IT SECURITY RISK ANALYSIS FOR MEANINGFUL USE STAGE I

IT SECURITY RISK ANALYSIS FOR MEANINGFUL USE STAGE I Standards Sections Checklist Section Security Management Process 164.308(a)(1) Information Security Program Risk Analysis (R) Assigned Security Responsibility 164.308(a)(2) Information Security Program

More information

The Relationship Between HIPAA Compliance and Business Associates

The Relationship Between HIPAA Compliance and Business Associates The Relationship Between HIPAA Compliance and Business Associates 1 HHS Wall of Shame 20% Involved Business Associates Based on HHS Breach Portal: Breaches Affecting 500 or More Individuals, Type of Breach

More information

Data Protection Policy

Data Protection Policy Data Protection Policy Data Protection Policy Version 3.00 May 2018 For more information, please contact: Technical Team T: 01903 228100 / 01903 550242 E: info@24x.com Page 1 The Data Protection Law...

More information

Lessons Learned from Recent HIPAA Enforcement Actions, Breaches, and Pilot Audits

Lessons Learned from Recent HIPAA Enforcement Actions, Breaches, and Pilot Audits Lessons Learned from Recent HIPAA Enforcement Actions, Breaches, and Pilot Audits Iliana L. Peters, J.D., LL.M. Senior Advisor for HIPAA Compliance and Enforcement OCR RULEMAKING UPDATE What s s Done?

More information

Compliance A primer. Surveys indicate that 80% of the spend on IT security technology is driven by the need to comply with regulatory legislation.

Compliance A primer. Surveys indicate that 80% of the spend on IT security technology is driven by the need to comply with regulatory legislation. Compliance A primer Surveys indicate that 80% of the spend on IT security technology is driven by the need to comply with regulatory legislation. The growth in the sharing of sensitive data combined with

More information

The HIPAA Omnibus Rule

The HIPAA Omnibus Rule The HIPAA Omnibus Rule What You Should Know and Do as Enforcement Begins Rebecca Fayed, Associate General Counsel and Privacy Officer Eric Banks, Information Security Officer 3 Biographies Rebecca C. Fayed

More information

Hospital Council of Western Pennsylvania. June 21, 2012

Hospital Council of Western Pennsylvania. June 21, 2012 Updates on OCR s HIPAA Enforcement and Regulations Hospital Council of Western Pennsylvania June 21, 2012 Topics HIPAA Privacy and Security Rule Enforcement HITECH Breach Notification OCR Audit Program

More information

CYBER RISK MANAGEMENT

CYBER RISK MANAGEMENT CYBER RISK MANAGEMENT AND BEST PRACTICES Heather Fields, JD, CHC, CCEP (414) 298-8166 hfields@reinhartlaw.com 1000 North Water Street, Suite 1700, Milwaukee, WI 53202 www.reinhartlaw.com 0 Agenda Role

More information

HIPAA Privacy & Security Training. Privacy and Security of Protected Health Information

HIPAA Privacy & Security Training. Privacy and Security of Protected Health Information HIPAA Privacy & Security Training Privacy and Security of Protected Health Information Course Competencies: This training module addresses the essential elements of maintaining the HIPAA Privacy and Security

More information

Update on HIPAA Administration and Enforcement. Marissa Gordon-Nguyen, JD, MPH October 7, 2016

Update on HIPAA Administration and Enforcement. Marissa Gordon-Nguyen, JD, MPH October 7, 2016 Update on HIPAA Administration and Enforcement Marissa Gordon-Nguyen, JD, MPH October 7, 2016 Updates Policy Development Breaches Enforcement Audit 2 POLICY DEVELOPMENT RECENTLY PUBLISHED: RIGHT OF ACCESS,

More information

Altius IT Policy Collection Compliance and Standards Matrix

Altius IT Policy Collection Compliance and Standards Matrix Governance Context and Alignment Policy 4.1 4.4 800-26 164.308 12.4 EDM01 IT Governance Policy 5.1 800-30 12.5 EDM02 Leadership Mergers and Acquisitions Policy A.6.1.1 800-33 EDM03 Context Terms and Definitions

More information

Checklist for Applying ISO 27000, PCI DSS v2 & NIST to Address HIPAA & HITECH Mandates. Ali Pabrai, MSEE, CISSP (ISSAP, ISSMP)

Checklist for Applying ISO 27000, PCI DSS v2 & NIST to Address HIPAA & HITECH Mandates. Ali Pabrai, MSEE, CISSP (ISSAP, ISSMP) Checklist for Applying ISO 27000, PCI DSS v2 & NIST to Address HIPAA & HITECH Mandates Ali Pabrai, MSEE, CISSP (ISSAP, ISSMP) ecfirst, chief executive Member, InfraGard Compliance Mandates Key Regulations

More information

How Secure Do You Feel About Your HIPAA Compliance Plan? Daniel F. Shay, Esq.

How Secure Do You Feel About Your HIPAA Compliance Plan? Daniel F. Shay, Esq. How Secure Do You Feel About Your HIPAA Compliance Plan? Daniel F. Shay, Esq. Word Count: 2,268 Physician practices have lived with the reality of HIPAA for over twenty years. In that time, it has likely

More information

Auditing and Monitoring for HIPAA Compliance. HCCA COMPLIANCE INSTITUTE 2003 April, Presented by: Suzie Draper Sheryl Vacca, CHC

Auditing and Monitoring for HIPAA Compliance. HCCA COMPLIANCE INSTITUTE 2003 April, Presented by: Suzie Draper Sheryl Vacca, CHC Auditing and Monitoring for HIPAA Compliance HCCA COMPLIANCE INSTITUTE 2003 April, 2003 Presented by: Suzie Draper Sheryl Vacca, CHC 1 The Elements of Corporate Compliance Program There are seven key elements

More information

HIPAA Security. 1 Security 101 for Covered Entities. Security Topics

HIPAA Security. 1 Security 101 for Covered Entities. Security Topics HIPAA Security SERIES Security Topics 1. Security 101 for Covered Entities 2. Security Standards - Administrative Safeguards 3. Security Standards - Physical Safeguards 4. Security Standards - Technical

More information

New York Department of Financial Services Cybersecurity Regulation Compliance and Certification Deadlines

New York Department of Financial Services Cybersecurity Regulation Compliance and Certification Deadlines New York Department of Financial Services Cybersecurity Regulation Compliance and Certification Deadlines New York Department of Financial Services ( DFS ) Regulation 23 NYCRR 500 requires that entities

More information

Security and Privacy Governance Program Guidelines

Security and Privacy Governance Program Guidelines Security and Privacy Governance Program Guidelines Effective Security and Privacy Programs start with attention to Governance. Governance refers to the roles and responsibilities that are established by

More information

HIPAA / HITECH Overview of Capabilities and Protected Health Information

HIPAA / HITECH Overview of Capabilities and Protected Health Information HIPAA / HITECH Overview of Capabilities and Protected Health Information August 2017 Rev 1.8.9 2017 DragonFly Athletics, LLC 2017, DragonFly Athletics, LLC. or its affiliates. All rights reserved. Notices

More information

Table of Contents. PCI Information Security Policy

Table of Contents. PCI Information Security Policy PCI Information Security Policy Policy Number: ECOMM-P-002 Effective Date: December, 14, 2016 Version Number: 1.0 Date Last Reviewed: December, 14, 2016 Classification: Business, Finance, and Technology

More information

Terms used, but not otherwise defined, in this Agreement shall have the same meaning as those terms in the HIPAA Privacy Rule.

Terms used, but not otherwise defined, in this Agreement shall have the same meaning as those terms in the HIPAA Privacy Rule. Medical Privacy Version 2018.03.26 Business Associate Agreement This Business Associate Agreement (the Agreement ) shall apply to the extent that the Lux Scientiae HIPAA Customer signee is a Covered Entity

More information

Introduction. Angela Holzworth, RHIA, CISA, GSEC. Kimberly Gray, Esq., CIPP/US. Sr. IT Infrastructure Analyst

Introduction. Angela Holzworth, RHIA, CISA, GSEC. Kimberly Gray, Esq., CIPP/US. Sr. IT Infrastructure Analyst Introduction Angela Holzworth, RHIA, CISA, GSEC Sr. IT Infrastructure Analyst Kimberly Gray, Esq., CIPP/US Chief Privacy Officer, Global, IMS Health 1 Incorporating Privacy into the CSF: Approach and Benefits

More information

HIPAA Compliance Officer Training By HITECH Compliance Associates. Building a Culture of Compliance

HIPAA Compliance Officer Training By HITECH Compliance Associates. Building a Culture of Compliance HIPAA Compliance Officer Training By HITECH Compliance Associates Building a Culture of Compliance Your Instructor Is Michael McCoy Nationally Recognized HIPAA Expert » Nothing contained herein should

More information

HIPAA/HITECH Act Update HCCA South Central Regional Annual Conference December 2, Looking Back at 2011

HIPAA/HITECH Act Update HCCA South Central Regional Annual Conference December 2, Looking Back at 2011 HIPAA/HITECH Act Update HCCA South Central Regional Annual Conference December 2, 2012 Phyllis F. Granade The Granade Law Firm Atlanta, GA (678) 705 2507 pgranade@granadelaw.com www.granadelaw.com Looking

More information

A Checklist for Compliance in the Cloud 1. A Checklist for Compliance in the Cloud

A Checklist for Compliance in the Cloud 1. A Checklist for Compliance in the Cloud A Checklist for Compliance in the Cloud 1 A Checklist for Compliance in the Cloud A Checklist for Compliance in the Cloud 1 With the industrialization of hacking and the enormous impact of security breaches,

More information

Core Elements of HIPAA The Privacy Rule establishes individuals privacy rights and addresses the use and disclosure of protected health information ( PHI ) by covered entities and business associates The

More information

Data Inventory and Classification, Physical Devices and Systems ID.AM-1, Software Platforms and Applications ID.AM-2 Inventory

Data Inventory and Classification, Physical Devices and Systems ID.AM-1, Software Platforms and Applications ID.AM-2 Inventory Audience: NDCBF IT Security Team Last Reviewed/Updated: March 2018 Contact: Henry Draughon hdraughon@processdeliveysystems.com Overview... 2 Sensitive Data Inventory and Classification... 3 Applicable

More information

How to Respond to a HIPAA Breach. Tuesday, Oct. 25, 2016

How to Respond to a HIPAA Breach. Tuesday, Oct. 25, 2016 How to Respond to a HIPAA Breach Tuesday, Oct. 25, 2016 This Webinar is Brought to You By. About HealthInsight and Mountain-Pacific Quality Health HealthInsight and Mountain-Pacific Quality Health are

More information

HIPAA Security. An Ounce of Prevention is Worth a Pound of Cure

HIPAA Security. An Ounce of Prevention is Worth a Pound of Cure HIPAA Security An Ounce of Prevention is Worth a Pound of Cure Presented by CJ Wolf, MD, COC, CPC, CHC, CCEP, CIA Healthicity Senior Compliance Executive Paul R. Hales, Attorney at Law Subject Matter Expert

More information

Data Compromise Notice Procedure Summary and Guide

Data Compromise Notice Procedure Summary and Guide Data Compromise Notice Procedure Summary and Guide Various federal and state laws require notification of the breach of security or compromise of personally identifiable data. No single federal law or

More information

NOTICE OF PRIVACY PRACTICES

NOTICE OF PRIVACY PRACTICES NOTICE OF PRIVACY PRACTICES Chmura Orthodontics ( Practice ) understands the important of keeping your personal information private. Personal information includes: your name, postal address, e-mail address,

More information

Inside the OCR Investigation/Audit Process 2018 PBI HEALTH LAW INSTITUTE TUESDAY, MARCH 13, 2017 GREGORY M. FLISZAR, J.D., PH.D.

Inside the OCR Investigation/Audit Process 2018 PBI HEALTH LAW INSTITUTE TUESDAY, MARCH 13, 2017 GREGORY M. FLISZAR, J.D., PH.D. Inside the OCR Investigation/Audit Process 2018 PBI HEALTH LAW INSTITUTE TUESDAY, MARCH 13, 2017 GREGORY M. FLISZAR, J.D., PH.D. HIPAA GENERAL RULE PHI may not be disclosed without patient authorization

More information

CYBERSECURITY IN THE POST ACUTE ARENA AGENDA

CYBERSECURITY IN THE POST ACUTE ARENA AGENDA CYBERSECURITY IN THE POST ACUTE ARENA AGENDA 2 Introductions 3 Assessing Your Organization 4 Prioritizing Your Review 5 206 Benchmarks and Breaches 6 Compliance 0 & Cybersecurity 0 7 Common Threats & Vulnerabilities

More information

Security and Privacy-Aware Cyber-Physical Systems: Legal Considerations. Christopher S. Yoo University of Pennsylvania July 12, 2018

Security and Privacy-Aware Cyber-Physical Systems: Legal Considerations. Christopher S. Yoo University of Pennsylvania July 12, 2018 Security and Privacy-Aware Cyber-Physical Systems: Legal Considerations Christopher S. Yoo University of Pennsylvania July 12, 2018 Overview of Research Tort and products liability for CPS Privacy and

More information

Critical HIPAA Privacy & Security Crossover Areas

Critical HIPAA Privacy & Security Crossover Areas Critical HIPAA Privacy & Security Crossover Areas Presented by HIPAA Solutions, LC Peter MacKoul, JD Senior Privacy SME Ken Hughes Senior Security SME HIPAA Solutions, LC 2016 1 Critical HIPAA Privacy

More information

Breach Notification Remember State Law

Breach Notification Remember State Law Breach Notification HITECH: First federal law mandating breach notification for health care industry Applies to covered entities, business associates, PHR vendors, and PHR service providers FTC regulates

More information

HIPAA 101: What All Doctors NEED To Know

HIPAA 101: What All Doctors NEED To Know HIPAA 101: What All Doctors NEED To Know 1 HIPAA Basics HIPAA: Health Insurance and Portability Accountability Act of 1996 Purpose: to protect confidential information through improved security and privacy

More information

T11: Incident Response Clinic Kieran Norton, Deloitte & Touche

T11: Incident Response Clinic Kieran Norton, Deloitte & Touche T11: Incident Response Clinic Kieran Norton, Deloitte & Touche Incident Response Clinic Kieran Norton Senior Manager, Deloitte First Things First Who am I? Who are you? Together we will: Review the current

More information

HIPAA Security Awareness Training

HIPAA Security Awareness Training HIPAA Security Awareness Training Spring 2015 DBHDS Vision: A life of possibilities for all Virginians What is HIPAA? HIPAA means: Health Insurance Portability and Accountability Act It is a set of regulations

More information

Privacy Breach Policy

Privacy Breach Policy 1. PURPOSE 1.1 The purpose of this policy is to guide NB-IRDT employees and approved users on how to proceed in the event of a privacy breach, and to demonstrate to stakeholders that a systematic procedure

More information

Request for Proposal HIPAA Security Risk and Vulnerability Assessment. May 1, First Choice Community Healthcare

Request for Proposal HIPAA Security Risk and Vulnerability Assessment. May 1, First Choice Community Healthcare Request for Proposal HIPAA Security Risk and Vulnerability Assessment May 1, 2016 First Choice Community Healthcare Timeline The following Timeline has been defined to efficiently solicit multiple competitive

More information

HIPAA Security Manual

HIPAA Security Manual 2010 HIPAA Security Manual Revised with HITECH ACT Amendments Authored by J. Kevin West, Esq. 2010 HALL, FARLEY, OBERRECHT & BLANTON, P.A. DISCLAIMER This Manual is designed to set forth general policies

More information

Remote Access to a Healthcare Facility and the IT professional s obligations under HIPAA and the HITECH Act

Remote Access to a Healthcare Facility and the IT professional s obligations under HIPAA and the HITECH Act Remote Access to a Healthcare Facility and the IT professional s obligations under HIPAA and the HITECH Act Are your authentication, access, and audit paradigms up to date? Table of Contents Synopsis...1

More information

Privacy Policy on the Responsibilities of Third Party Service Providers

Privacy Policy on the Responsibilities of Third Party Service Providers Privacy Policy on the Responsibilities of Third Party Service Providers Privacy Office Document ID: 2489 Version: 3.2 Owner: Chief Privacy Officer Sensitivity Level: Low Copyright Notice Copyright 2016,

More information

HIPAA in 2017: Hot Topics You Can t Ignore. Danika Brinda, PhD, RHIA, CHPS, HCISPP March 16, 2017

HIPAA in 2017: Hot Topics You Can t Ignore. Danika Brinda, PhD, RHIA, CHPS, HCISPP March 16, 2017 HIPAA in 2017: Hot Topics You Can t Ignore Danika Brinda, PhD, RHIA, CHPS, HCISPP March 16, 2017 Breach Notification State Law Privacy Rule Authorizations Polices and Procedures The Truth Is Have created

More information

EXHIBIT A. - HIPAA Security Assessment Template -

EXHIBIT A. - HIPAA Security Assessment Template - Department/Unit: Date: Person(s) Conducting Assessment: Title: 1. Administrative Safeguards: The HIPAA Security Rule defines administrative safeguards as, administrative actions, and policies and procedures,

More information

Policy. Policy Information. Purpose. Scope. Background

Policy. Policy Information. Purpose. Scope. Background Background Congress enacted HIPAA Privacy & Security Compliance Policy Policy Information Policy Owner: (TBD Possibly HIPAA Privacy and Security Official or Executive Director of University Ethics and

More information

HIPAA COMPLIANCE CALIFORNIA STATE UNIVERSITY, LOS ANGELES. Audit Report October 29, 2010

HIPAA COMPLIANCE CALIFORNIA STATE UNIVERSITY, LOS ANGELES. Audit Report October 29, 2010 HIPAA COMPLIANCE CALIFORNIA STATE UNIVERSITY, LOS ANGELES Audit Report 10-52 October 29, 2010 Members, Committee on Audit Henry Mendoza, Chair Raymond W. Holdsworth, Vice Chair Nicole M. Anderson Margaret

More information

Privacy Statement. Your privacy and trust are important to us and this Privacy Statement ( Statement ) provides important information

Privacy Statement. Your privacy and trust are important to us and this Privacy Statement ( Statement ) provides important information Privacy Statement Introduction Your privacy and trust are important to us and this Privacy Statement ( Statement ) provides important information about how IT Support (UK) Ltd handle personal information.

More information

Privacy & Information Security Protocol: Breach Notification & Mitigation

Privacy & Information Security Protocol: Breach Notification & Mitigation The VUMC Privacy Office coordinates compliance with the required notification steps and prepares the necessary notification and reporting documents. The business unit from which the breach occurred covers

More information

Virginia State University Policies Manual. Title: Information Security Program Policy: 6110

Virginia State University Policies Manual. Title: Information Security Program Policy: 6110 Purpose Virginia State University (VSU) uses information to perform the business services and functions necessary to fulfill its mission. VSU information is contained in many different mediums including

More information

This Policy has been prepared with due regard to the General Data Protection Regulation (EU Regulation 2016/679) ( GDPR ).

This Policy has been prepared with due regard to the General Data Protection Regulation (EU Regulation 2016/679) ( GDPR ). PRIVACY POLICY Data Protection Policy 1. Introduction This Data Protection Policy (this Policy ) sets out how Brital Foods Limited ( we, us, our ) handle the Personal Data we Process in the course of our

More information

Regulation P & GLBA Training

Regulation P & GLBA Training Regulation P & GLBA Training Overview Regulation P governs the treatment of nonpublic personal information about consumers by the financial institution. (Gramm-Leach-Bliley Act of 1999) The GLBA is composed

More information

IT SECURITY OFFICER. Department: Information Technology. Pay Range: Professional 18

IT SECURITY OFFICER. Department: Information Technology. Pay Range: Professional 18 Pierce County Classification Description IT SECURITY OFFICER Department: Information Technology Job Class #: 634900 Pay Range: Professional 18 FLSA: Exempt Represented: No Classification descriptions are

More information

What is HIPPA/PCI? Understanding HIPAA. Understanding PCI DSS

What is HIPPA/PCI? Understanding HIPAA. Understanding PCI DSS What is HIPPA/PCI? In this digital era, where every bit of information pertaining to individuals has gone digital and is stored in digital form somewhere or the other, there is a need protect the individuals

More information

Decrypting the Security Risk Assessment (SRA) Requirement for Meaningful Use

Decrypting the Security Risk Assessment (SRA) Requirement for Meaningful Use Click to edit Master title style Decrypting the Security Risk Assessment (SRA) Requirement for Meaningful Use Andy Petrovich, MHSA, MPH M-CEITA / Altarum Institute June 21, 2016 6/21/2016 1 1 Disclaimer

More information

Introduction CHAPTER 1

Introduction CHAPTER 1 CHAPTER 1 Introduction Data security breaches are an everyday occurrence. The news media constantly publicize data breaches, especially those involving retailers in which hackers steal the payment card

More information

Securing IT Infrastructure Improve information exchange and comply with HIPAA, HITECH, and ACA mandates

Securing IT Infrastructure Improve information exchange and comply with HIPAA, HITECH, and ACA mandates Securing IT Infrastructure Improve information exchange and comply with HIPAA, HITECH, and ACA mandates Ruby Raley, Director Healthcare Solutions Axway Agenda Topics: Using risk assessments to improve

More information

It applies to personal information for individuals that are external to us such as donors, clients and suppliers (you, your).

It applies to personal information for individuals that are external to us such as donors, clients and suppliers (you, your). Our Privacy Policy 1 Purpose Mission Australia is required by law to comply with the Privacy Act 1988 (Cth) (the Act), including the Australian Privacy Principles (APPs). We take our privacy obligations

More information