Health
Insurance Portability & Accountability Act (HIPAA)
Title II
of HIPAA defines numerous offenses relating to health care and sets civil
and criminal penalties for them. It also creates several programs to control
fraud and abuse within the health care system.
However, the most significant provisions of Title II are its
Administrative Simplification (AS) rules.
The relevant rules to the Healthcare Industry are the Privacy Rule
and the Security Rule.
The Privacy Rule establishes regulations for the use and disclosure of
Protected Health Information (PHI). PHI is any information about health
status, provision of health care, or payment for health care that can be
linked to an individual. This is interpreted rather broadly and includes any
part of a patient’s
medical record or payment history.
A covered entity may disclose PHI to facilitate treatment, payment, or
health care operations or if the covered entity has obtained authorization
from the individual. However, when a covered entity discloses any PHI, it
must make a reasonable effort to disclose only the minimum necessary
information required to achieve its purpose.
The Privacy Rule gives individuals the right to request that a covered
entity correct any inaccurate PHI. It also requires covered entities to take
reasonable steps to ensure the confidentiality of communications with
individuals. For example, an individual can ask to be called at his or her
work number, instead of home or cell phone number.
The Privacy Rule requires covered entities to notify individuals of uses of
their PHI. Covered entities must also keep track of disclosures of PHI and
document privacy policies and procedures. They must appoint a Privacy
Official and a contact person responsible for receiving complaints and train
all members of their workforce in procedures regarding PHI.
The
Security Rule complements the Privacy Rule. While the privacy pertains to
all (PHI) protected heath information, including paper and Electronic. The
Security rule deals specifically with (EPHI) electronic protected health
information. It lays out three types of security safeguards required for
compliance: administrative, physical, and technical. For each of these
types, the Rule identifies various security standards, and for each
standard, it names both required and addressable implementation
specifications. Required specifications must be adopted and administered as
dictated by the Rule. Addressable specifications are more flexible.
Individual covered entities can evaluate their own situation and determine
the best way to implement addressable specifications. The standards and
specifications are as follows:
Administrative Safeguards
- policies and procedures designed to clearly show how the entity will
comply with the act
Covered entities (entities that must comply with HIPAA requirements) must
adopt a written set of privacy procedures and designate a privacy officer to
be responsible for developing and implementing all required policies and
procedures.
The policies and procedures must reference management oversight and
organizational buy-in to compliance with the documented security controls.
Procedures should clearly identify employees or classes of employees who
will have access to electronic protected health information (EPHI). Access
to EPHI must be restricted to only those employees who have a need for it to
complete their job function.
The procedures must address access authorization, establishment,
modification, and termination.
Entities must show that an appropriate ongoing training program regarding
the handling of PHI is provided to employees performing health plan
administrative functions.
Covered entities that out-source some of their business processes to a third
party must ensure that their vendors also have a framework in place to
comply with HIPAA requirements. Companies typically gain this assurance
through clauses in the contracts stating that the vendor will meet the same
data protection requirements that apply to the covered entity. Care must be
taken to determine if the vendor further out-sources any data handling
functions to other vendors and monitor whether appropriate contracts and
controls are in place.
A contingency plan should be in place for responding to emergencies. Covered
entities are responsible for backing up their data and having disaster
recovery procedures in place. The plan should document data priority and
failure analysis, testing activities, and change control procedures.
Internal audits play a key role in HIPAA compliance by reviewing operations
with the goal of identifying potential security violations. Policies and
procedures should specifically document the scope, frequency, and procedures
of audits. Audits should be both routine and event-based.
Procedures should document instructions for addressing and responding to
security breaches that are identified either during the audit or the normal
course of operations.
Physical Safeguards
- controlling physical access to protect against inappropriate access to
protected data.
Controls must govern the introduction and removal of hardware and software
from the network. (When equipment is retired it must be disposed of properly
to ensure that PHI is not compromised.)
Access to equipment containing health information should be carefully
controlled and monitored.
Access to hardware and software must be limited to properly authorized
individuals.
Required access controls consist of facility security plans, maintenance
records, and visitor sign-in and escorts.
Policies are required to address proper workstation use. Workstations should
be removed from high traffic areas and monitor screens should not be in
direct view of the public.
If the covered entities utilize contractors or agents, they too must be
fully trained on their physical access responsibilities.
Technical Safeguards
- controlling access to computer systems and enabling covered entities to
protect communications containing PHI transmitted electronically over open
networks from being intercepted by anyone other than the intended recipient.
Information systems housing PHI must be protected from intrusion. When
information flows over open networks, some form of encryption must be
utilized. If closed systems/networks are utilized, existing access controls
are considered sufficient and encryption is optional.
Each covered entity is responsible for ensuring that the data within its
systems has not been changed or erased in an unauthorized manner.
Data corroboration, including the use of check sum, double-keying, message
authentication, and digital signature may be used to ensure data integrity.
Covered entities must also authenticate entities it communicates with.
Authentication consists of corroborating that an entity is who it claims to
be. Examples of corroboration include: password systems, two or three-way
handshakes, telephone callback, and token systems.
Covered entities must make documentation of their HIPAA practices available
to the government to determine compliance.
In addition to policies and procedures and access records, information
technology documentation should also include a written record of all
configuration settings on the components of the network because these
components are complex, configurable, and always changing.
Documented risk analysis and risk management programs are required. Covered
entities must carefully consider the risks of their operations as they
implement systems to comply with the act. (The requirement of risk analysis
and risk management implies that the act’s security requirements are a
minimum standard and places responsibility on covered entities to take all
reasonable precautions necessary to prevent PHI from being used for
non-health purposes.)