HIPAA Final Rule: Security Standards, General Rules & Administrative Safeguard Modifications

February 5, 2013.  Today, we cover the modifications to Security Standards:  General Rules, and Administrative Safeguards in the HIPAA Security Rule, as modified by the Final Rule:  Modifications to the HIPAA Privacy, Security, Enforcement, and Breach Notification Rules under the Health Information Technology for Economic and Clinical Health Act [HITECH Act] and the Genetic Information Nondiscrimination Act; Other Modifications of the HIPAA Rules, which was published in the Federal Register on January 25, 2013.  The effective date of the Final Rule is March 26, 2013, and covered entities and business associates must comply by September 23, 2013. Security Standards:  General Rules.  The five General Rules govern how the administrative, physical,…

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Five HIPAA Compliance Activities Your Organization Must Undertake

HIPAA Administrative Simplification was enacted on August 21, 1996 as Subtitle F of Title II of Public Law 104-191. The so-called HITECH Act “Omnibus” regulation that modifies HIPAA privacy and security provisions will be published in the Federal Register by the end of this summer, according to the head of HHS’ National Coordinator for Health Information Technology, Farzad Mostashari, M.D. Based on the timeline in the Notice of Proposed Rule Making, compliance by all covered entities and their business associates would be required 240 days after publication, most likely sometime in May 2013, assuming the end-of-summer deadline is met.  All covered entities and their business associates will be required to comply with provisions of…

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OCR’s Publicly Disclosed Large Breaches Now Top 20 Million Impacted Individuals

May 16, 2012.  The Department of Health and Human Services’ (HHS) HIPAA/HITECH Act privacy and security enforcement arm, Office for Civil Rights (OCR), is responsible under the HITECH Act to publicly disclose privacy and security breaches that affect 500 or more individuals on its Breach Notification Web site.  With the now reported Utah Department of Health hacking/IT incident breach occurring in the period March 10-April 2, 2012 and affecting a reported 780,000 individuals, the total number in 435 breaches reported since September 22, 2009, now totals 20,079,189 impacted individuals.  Of the total number of breaches where location of breached information is known (e.g., electronic or hard copy source), 72% of…

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OCR Penalizes Physician Practice for HIPAA Privacy and Security Rule Violations

April 18, 2012.  Late last week, the Office for Civil Rights (OCR) of the Department of Health and Human Services (HHS) executed a Resolution Agreement and included Corrective Action Plan (Appendix A) as a settlement for violations of HIPAA Privacy and Security Rules by a physician practice, Phoenix Cardiac Surgery, P.C., of Phoenix and Prescott, AZ. In its April 17, 2012, News Release, HHS stated: “The incident giving rise to OCR’s investigation was a report that the physician practice was posting clinical and surgical appointments for its patients on an Internet-based calendar that was publicly accessible. On further investigation, OCR found that Phoenix Cardiac Surgery had implemented few policies and…

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CMS Publishes Stage 2 Meaningful Use Incentive Program NPRM

On March 7, 2012, the Centers for Medicare & Medicaid Services (CMS) published in the Federal Register its 132-page notice of proposed rule making (NPRM):  Medicare and Medicaid Programs; Electronic Health Record Incentive Program–Stage 2.  Comments to the Department of Health and Human Services (HHS) may be made until 5 PM on May 7, 2012. The summary of the NPRM is included here: “This proposed rule would specify the Stage 2 criteria that eligible professionals (EPs), eligible hospitals, and critical access hospitals (CAHs) must meet in order to qualify for Medicare and/or Medicaid electronic health record (EHR) incentive payments.  In addition, it would specify payment adjustments under Medicare for covered…

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OCR Issues Draft Guidance on Security Risk Analysis

The Office for Civil Rights (OCR) of the Department of Health and Human Services  (HHS) issued on May 7, 2010, Security Rule Draft Guidance on Risk Analysis. This is the first in a “series of guidance documents [that] will assist organizations in identifying and implementing the most effective and appropriate administrative, physical, and technical safeguards to protect the confidentiality, integrity, and availability of electronic protected health information.  The materials will be updated annually, as appropriate.” This eight-page document is available online. The Draft Guidance on Risk makes the following key points: “The Security Rule does not prescribe a specific risk analysis methodology, recognizing that methods will vary dependent on the…

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Transmission Security Integrity Controls: What to Do and How to Do It

In our series on the HIPAA Administrative Simplification Security Rule, this is the first implementation specification for the Technical Safeguard Standard, Transmission Security.  This implementation specification is addressable. Addressable does not mean “optional.”  Rather, an addressable implementation specification means that a covered entity must use reasonable and appropriate measures to meet the standard.  As we noted in earlier postings on HIPAA.com, business associates of covered entities will be required to comply with the Security Rule safeguard standards, beginning February 17, 2010.  This requirement is one of the HITECH Act provisions of the American Recovery and Reinvestment Act (ARRA), signed by President Obama on February 17, 2009. What to Do Implement…

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Transmission Security: What This HIPAA Security Rule Technical Safeguard Standard Means

This is the fifth and last Technical Safeguard Standard of the HIPAA Administrative Simplification Security Rule.  It has two implementation specifications:  integrity controls; and encryption.  Each is addressable.  Addressable does not mean “optional.”  Rather, an addressable implementation specification means that a covered entity must use reasonable and appropriate measures to meet the standard.  As we have noted in earlier postings on HIPAA.com, business associates of covered entities will be required to comply with the Security Rule safeguard standards, beginning February 17, 2010.  This requirement is one of the HITECH Act provisions of the American Recovery and Reinvestment Act (ARRA), signed by President Obama on February 17, 2009. For compliance with…

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Person or Entity Authentication: What to Do and How to Do It

In our series on the HIPAA Administrative Simplification Security Rule, this is the fourth Technical Safeguard Standard.  There is not a separately described implementation specification.  Rather, this standard’s implementation specification is connoted in the language of the standard and is required.  As we have noted in earlier postings on HIPAA.com, business associates of covered entities will be required to comply with the Security Rule safeguard standards, beginning February 17, 2010.  This requirement is one of the HITECH Act provisions of the American Recovery and Reinvestment Act (ARRA), signed by President Obama on February 17, 2009. What to Do A covered entity is required to implement procedures to verify that a…

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Person or Entity Authentication: What This HIPAA Security Rule Technical Safeguard Standard Means

This is the fourth Technical Safeguard Standard of the HIPAA Administrative Simplification Security Rule.  There is not a separately described implementation specification.  Rather, this standard’s implementation specification is connoted in the language of the standard and is required.  As we have noted in earlier postings on HIPAA.com, business associates of covered entities will be required to comply with the Security Rule safeguard standards, beginning February 17, 2010.  This requirement is one of the HITECH Act provisions of the American Recovery and Reinvestment Act (ARRA), signed by President Obama on February 17, 2009. For compliance with this Technical Safeguard Standard, a covered entity is required to implement procedures to verify that…

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