Transcript Health Insurance Portability & Accountability Act (HIPAA)

Health Insurance
Portability & Accountability
Act (HIPAA) 1996
HITECH 2009
Introduction
Privacy Rule
Security Rule
Acknowledgments
Material is from:
 HIPAA Compliance, Carlene Dalgleish
 Legal Issues in Information Security, Joanna Lyn Grama
 Health Care Reform in the United States: HITECH Act and HIPAA
Privacy, Security, and Enforcement Issues, Amy E Kempfert,
Benjamin D Reed
Author: Susan J Lincke, PhD
Univ. of Wisconsin-Parkside
Contributor:
Misty Lowery
Reviewers:
Funded by National Science Foundation (NSF) Course, Curriculum and
Laboratory Improvement (CCLI) grant 0837574: Information
Security: Audit, Case Study, and Service Learning.
Any opinions, findings, and conclusions or recommendations
expressed in this material are those of the author(s) and/or
source(s) and do not necessarily reflect the views of the National
Science Foundation.
HIPAA


Introduced by Senators Edward Kennedy &
Nancy Kassebaum
Portability: Workers can continue health care
between different employers
 Group
insurance cannot reject, not renew, or charge
higher premiums of certain individuals
 Simplify administration by creating a health care
transaction standard

Accountability:
 Penalties
for non-compliance
 Tax provisions
HIPAA Titles



Title 1: Health Care Insurance Access, Portability, and
Renewability
Title 2: Preventing Health Care Fraud & Abuse,
Administrative Simplification, Medical Liability Reform
Title 3: Tax-related Health Provisions



Standardizes medical savings accounts
Title 4: Application and Enforcement of Group Health
Insurance Requirements
Title 5: Revenue Offsets

Defines how employers can deduct company-owned life
insurance premiums from income tax
Title 2 Has Three Rules
Transactions, Code Sets, and Identifiers:
Standards for electronic transmission
 Electronic
Data Interchange: Standardized
records for health care transactions
The Privacy Rule: Standard for Privacy of
Individually Identifiable Health Information
The Security Rule: Security Standard for
electronic patient health
Reasons for Legislation





Records of patients or insurance claims made publicly
available by accident
Email reminder to take Prozac sent to 600 (not blind
cc’d)
Woman fired from job after positive review but expensive
illness
35% of Fortune 500 companies admitted checking
medical records before hiring or promoting
People avoid using insurance when they have AIDS,
cancer, STD, substance abuse or mental illness
Medical Identity Theft:
When a person’s name and other parts of
his/her medical identity are stolen for the
purpose of getting medical services and
goods.
Medical Identity Theft:
Problems:
 Medical info is for wrong person
 Inaccurate
health records
 Wrong diagnosis
 Fatal treatments

Imposter claims health care
 Medical
Insurance Fraud
 Inaccurate Credit History: Bills sent elsewhere
Medical Identity Thieves:
Who can commit this crime?



Computer hackers
Members of organized crime rings
Health care providers (doctor’s, dentists, hospital employees)
2003: An employee at a cancer center stole the identity of a center
patient. The identity thief was sentenced to 16 mos. In prison and
ordered to pay restitution.
2006: A desk clerk at a Florida clinic stole the health info of over 1,000
patients. The clerk sold the data to another person. That person used
the information to submit $2.8M in fraudulent Medicare claims to the
U.S. government.
Business Challenges Facing the
Health Care Industry


Hospital computer systems contain notes
from hospital employees and primary care
physicians.
Health Insurance Companies collect and
compile patient data from different providers.
Organizations MUST maintain
the security of computer systems
that hold health data.
Breach Notification Laws
The Oregonian, May 2006
In one of Oregon’s largest security breaches, Providence
Health System disclosed that a burglar stole unencrypted
medical records on 365,000 patients kept on disks and
tapes left overnight in an employee’s van
State Laws, called Breach Notification Laws require CEs to
notify patients when their PHI has been breached
If data is encrypted and laptop is lost, notification is not
required
This often applies to any industry that uses personal
information, such as Social Security Numbers
HITECH: Health Information Technology for
Economic and Clinical Health Act (2009)
Breach Notification Rule
 Introduced notification requirements
 PHI shall be encrypted in a way that is
approved by HHS.
 PHI shall be shredded or destroyed and
disposed of properly.
 Specifies how CE/BA should notify
individuals and agencies if a breach of
information occurs
Criminal Penalties for HIPAA
$ Penalty
Imprisonment
Up to $50K
Up to one
year
Up to
$100K
Up to
$500K
Up to 5
years
Up to 10
years
Offense
Wrongful disclosure of
individually identifiable health
information
…committed under false
pretenses
… with intent to sell, achieve
personal gain, or cause
malicious harm
Then consider bad press, state audit, state law penalties, lost claims, …
HITECH Act (2009)
Each
Violation
Max $
Per Year
CE/BA exercised reasonable
diligence but did not learn about
violation
$100$50k
$1.5
Million
Violation is due to reasonable cause
$1k$50k
$1.5
Million
CE/BA demonstrated willful neglect
but corrected violation
$10k$50k
$1.5
Million
CE/BA demonstrated willful neglect
and took no corrective action
$50k
$1.5
Million
Penalties are prohibited if problem is corrected within 30 days and no willful neglect
Penalties pay for enforcement and redress for harm caused
Health Care Organization
Covered Entities (CE)
Health plan
(e.g., HMO, PPO)
Standard
bills/records
Health care
Clearinghouse
Standard
bills/records
Nonstandard
bills/records
Health Care Provider
(e.g., doctor, hospital)
Health Care Organization
Business Associates (BA)
Works
Covered
Entities (CE)
Health plan
for
Performs: Claims Processing
Transcription
Billing
Data Analysis
Independent organization
Work involves health info
Not bank or post office
Health care
Clearinghouse
Health Care Provider
Protected Health Information (PHI)
Health
Information
Relates to
Physical or
Mental health
or past/present/
future payment
Identifiers
Name
SSN
city or county
zip code
phone or fax
medical record #
fingerprint
If YOU had AIDS, how could such identifiers
Identify you?
Individually Identifiable
Health Information
Created or maintained by
CE or BA
Protected Health
Information
(PHI)
Covered by HIPAA
& HITECH
Treatment, Payment & Health Care
Operations (TPO)
Treatment
Payment
Provision & coordination
of health care among
health care providers,
including referral
Any activities
involved in
compensation
for health care:
billing, determining
coverage or eligibility
analyzing services
$
Health Care
Operations
Administrative
functions related
to health care:
financial or legal or
quality improvement,
training, certification,
case mgmt, business
planning
HIPAA Standard Transactions
Health plan
(e.g., HMO, PPO)
 Enrollment or Disenrollment into
Health Plan
 Health Plan Premium Payment
 Health Plan Eligibility Inquiry
 Certification & Authorization
of Referral
 Health Care Claim
 Health Care Claim Status Request
 Health Care
Claim Payment
Plan Sponsor
(Employer)
 Certification &
Authorization
of Referral
Health Care Provider
(e.g., doctor, hospital)
The Genetic Information
Nondiscrimination Act of 2008

Protects against some types of genetic
testing discrimination.
 Insurance
companies can’t make eligibility
decision based on genetic testing results.
 Insurance companies can’t base cost of
premiums on genetic testing results.
 Employers can’t hire, fire or make job
decisions based on the use genetic testing.
 Employers/Health Insurance Plans can not
requiring genetic testing.
The HIPAA
Privacy Rule
Privacy Rule: Develop Policies
CE/BAs shall:
 Develop policies, procedures, and standards for
how it will adhere to Privacy Rule. How will
CE/BA:
 use and disclose PHI?
 protect patient rights?



Regularly review policies and procedures
Update policies when new requirements emerge
Monitor that policies/procedures are consistently
applied throughout the organization
Privacy Rule:
No NonHealth Usage of PHI
The National Law Journal, May 30, 1994
A banker who also served on his county’s health board
cross-referenced customer accounts with patient
Information. He called due the mortgages of anyone
suffering from cancer.
Health information is not to be used for nonhealth
purposes, unless an individual gives explicit
permission
Privacy Rule:
Need-to-Know Access
Washington Post, March 1, 1995
The 13-year-old daughter of a hospital employee took a list of
patients’ names and phone numbers from the hospital when
visiting her mother at work. As a joke, she contacted patients
and told them they were diagnosed with HIV.
CE/BA Employees should have access only to what is
absolutely required as part of their jobs.




What individuals should have access to PHI?
What categories of PHI should individuals have access to?
What conditions are required for access?
How will Business Associates & Trading Partners be informed and
controlled?
Privacy Rule:
Protections against Marketing
Boston Globe, August 1, 2000
A patient at Brigham and Women’s Hospital in Boston
learned that employees had accessed her medical
record more than 200 times.
CE must obtain permission before sending any
marketing materials, with limited exceptions
Privacy Rule:
Establish Privacy Safeguards
Required
 Shut or locked doors
 Keep voice down
 Clear desk policy
 Privacy curtains
 Password protection
 Auto screen savers
 Locked cabinets
 Paper shredders
Not Required
 Soundproof rooms
 Redesign office space
 Private hospital rooms
(semiprivate ok)
 OK for doctors to talk to
nurses at nurse stations
Safeguards should be REASONABLE
Privacy Rule:
Employee Training & Accountability
New York Times, Jan. 19, 2002
Eli Lilly and Co. inadvertently revealed over 600 patient
e-mail addresses when it sent an all message to every
individual registered to receive reminders about taking
Prozac.


Each CE organization shall name one person who is
accountable for Privacy Rule compliance
Each employee, volunteer, contractor shall be trained in
privacy policies and procedures

Full and Part-time
Privacy Rule: Individual Privacy
Rights
Patients have the Right to:








See or obtain copies of medical information (except for
psychotherapy notes)
Request correction to health record
Receive a Notice of Privacy Practices
Request restrictions as to who can see PHI
Request specific method of contact for sake of privacy
Know who has accessed PHI
File a complaint if their rights have been violated
Allow and withdraw authorizations for use and disclosure
CE must:
 Respond to requests within 30 days
 May extend delay with notice for another 30 days
 Keep records of how PHI is disclosed
Notice of Privacy Practices
Privacy
 NPP must be available when asked for
 NPP must be displayed prominently in the office
 Health Plan must provide upon enrollment
 Health Provider must provide on first service delivery
 Both must request written acknowledgment of receipt of
NPP
 After change, revised NPP must be issued to clients
within 60 days
Electronic
 Must be displayed prominently on web page
 Must be emailed to customers after a change in NPP
Required & Permitted Disclosures
Required Disclosure:
 Patient


or personal representative, e.g., parent, next of kin
Office of Civil Rights Enforcement: Investigates potential
violations to Privacy Rule
Permitted Disclosure:
 Minimum-Necessary PHI may be disclosed without
authorization for: judicial proceedings, coroner/funeral,
organ donation, approved research, military-related
situations, government-provided benefits, worker’s
compensation, domestic violence or abuse, some law
enforcement activities
 ID must be verified by proof of identity/badge and
documentation
More Disclosures
Routine Disclosure
 Disclosures that happen periodically should be addressed in
policies, procedures, forms
 E.g.: Referral to another provider, school immunization, report
communicable disease, medical transcription, births, deaths & other
vital statistics
Non-routine Disclosure
 CEs shall have reasonable criteria to review requests for non-routine
PHI disclosures
 E.g., Research disclosures
Incidental Disclosure
 CEs shall have reasonable safeguards
 E.g. Patient overhears advice given to another patient
Accidental Disclosure
 Computer is stolen with PHI
Disclosures must be tracked for THREE years
Disclosures Requiring
Authorization



Research project (special conditions may allow)
Person outside health care system
Employer

However, employer may require authorization for drug test
before hiring
Other insurance companies
 Health care provider not involved in patient’s health care
 Insurance company not paying patient’s claims
 Lawyer
Patient should get copy of authorization

Sample Authorization Form
Disclosure Authorization Form
Description of Information:_____________________________________
Patient making authorized disclosure____________________________
Person receiving information:__________________________________
Purpose of the disclosure:
Authorization Expiration Date:________________
Patient Signature__________________________ Date:____________
A form to revoke authorization must be completed to terminate authorization.
Must be retained by CE for 6 years
Implementing ‘Minimum Necessary’
Minimum necessary: Just enough info to
accomplish the main purpose
 E.g.,
Send prescription for glasses to optician, not
medical history

Data Classification
 Sensitivity
of information
 Type of treatment required

Questions to Answer
 What
parts of record can each user type access?
 How will we constrain access to implement view?
Business Associates (BA)
Must also be responsible with PHI
Accreditation
Consulting
Actuarial
Not Business
Associates
Janitorial
Electrical
Phone
Vending
Copy
Conduit: Mail
Financial Institution:
Banks
Business Associate Contract
(BAC)
CEs must request BA to sign a BAC:
 BA will not disclose PHI
 BA is liable for damage due to disclosure or misuse
 BA will use safeguards to prevent misuse
 BA will report any security incident or violation of
agreement
 BA will destroy or protect PHI upon termination of
contract
 CE can terminate contract if violation occurs
 CE will provide BA copies of policies, procedures and
materials for safeguarding
 Etc.
BAs are equally liable as CEs, under HITECH
Act
HITECH: Health Information
Technology for Economic and Clinical
Health Act (2009)
BA’s must follow the HIPAA Security Rule.
 BA’s are held to the same standard as
CE’s.
 Health & Human Services (HHS) can:

 require
BA’s to comply with HIPAA.
 enforce penalties on noncompliant BA’s.
Violation of HIPAA Privacy
Rule:
WTHR Investigation Leads to Record $2.25M HIPAA Settlement,
Indianapolis, IN, 2006:
Reported that CVS was “throwing sensitive personal information in the
trash” (e.g.: unredacted pill bottles, prescription instruction sheets,
pharmacy receipts with credit card information and health insurance
account numbers.
After this, other CVS pharmacies were investigated and it was found
that they also were improperly disposing of PHI.
To see the above article, go to:
http://www.wthr.com/global/Category.asp?c=83157
The HIPAA
Security Rule
+
Security Rule Enforces
Privacy Rule on Computers
Privacy Rule
With or w/o computer
Protect PHI
Security Rule
With computer
Protect EPHI
Minimum Necessary
Authentication &
Access Control
Accounting of Disclosures
Unique Login Credentials
Authentication
Track modifications to EPHI:
Who did what when?
Security Vocabulary
Asset: Diamonds
Threat: Theft
Vulnerability: Open
door or windows
Threat agent: Burglar
Owner: Those
accountable or who
value the asset
Risk: Danger to assets
Security Rule Assures…
Security Services
Authentication
 Access Control
 Data confidentiality
 Data integrity
 Data backup & recovery
 Nonrepudiation = Cannot say it wasn’t you
who sent or received data
 Risk Management

Risk Management
Risk assessment
 Policy & Procedures Maintenance
 Security Program Enforcement

 Audit
logs, vulnerability assessments, audit
for procedure adherence and control
effectiveness
 Patches are applied to software
 Data is available, confidential, & integrity is
protected
Security Rule Standards
Comprehensive
Technology Neutral
Scalable
Administrative
Controls
Security
Rule
Small
or
Large
Physical Controls
Technical Controls
Look to Best Practices
for Technology Answers
e.g. NIST
Security
Rule
Three Areas of Safeguards
Administrative: Administrative policies, procedures, and actions
to implement and maintain security controls to protect EPHI, including
risk mgmt, access control, contingency plans, incident response.
Security
Rule
Physical: Protection of the physical access to terminals, laptops,
servers, backup tapes, CDs, memory, including viewing,
access, maintenance and disposal.
Technical: Protection using technology tools to protect EPHI,
including logs, encryption, authentication
Policies & Procedures
Policies and Procedures MUST BE:
 Retained for 6 years after date of creation
or last effect
 Available to workers responsible for them
 Must be updated regularly accommodating
changes in environment & operations
Security Rule Standard
This is recommended…
Address this in some way…
Implement equivalent alternative
measure….
If it doesn’t apply, document well
why not…
DO IT!
We do this instead:
…..
Administrative:
Security Mgmt Process
Risk Analysis: Conduct an accurate and thorough assessment
of the potential risks and vulnerabilities to the CIA of EPHI held
by the CE.
R
Risk Mgmt: Implement security measures sufficient to reduce
risks and vulnerabilities to a reasonable and appropriate level to
comply with the Security Rule
R
Sanction Policy: Apply appropriate penalties against workforce
members who fail to comply with the entity’s security policies
and procedures
R
Info System Activity Review: Implement procedures to
regularly review records of IS activity, such as audit logs,
access reports, and security incident tracking reports
R
Security Mgmt Implications
We will need an IT person
to regularly check logs to
be sure our system was not
broken into
The Sanction
policy basically
requires we all
sign a
confidentiality
agreement and if
someone breaks
the rule, they
could be fired.
Risk assessment
must be ‘accurate
and thorough’ –
that will be a
challenge!
And all are Rs…
Security Mgmt
Process
Administrative:
Workforce Security
Authorization and/or Supervision: Implement
procedures for the authorization and/or supervision of
workforce members who work with EPHI or in
locations where it might be accessed
Workforce Clearance Procedure: Implement
procedures to determine that the access of a
workforce member to EPHI is appropriate
A
A
Termination Procedures: Implement procedures for A
terminating access to EPHI when the employment of a
workforce member ends…
Workforce Security Implications
They are asking for checks
and balances with
supervision or
authorization
.We must have
procedures to
allocate
authorization,
periodically
check
authorization, and
procedures to
terminate
someone
Workforce
Security
We are a three
person operation,
can we get away
with not doing this?
Must we document
our situation?
These are As.
Administrative:
Information Access Mgmt
Isolating Health Care Clearinghouse (CH) Function: If a
health care CH is part of a larger organization, the CH operation
must implement policies and procedures that protect the EPHI of
the CH from unauthorized access by the larger organization
R
Access Authorization: Implement policies and procedure for
granting access to EPHI – e.g., through access to a workstation,
transaction, program, process, or other mechanism
A
Access Establishment & Modification: Implement policies and
procedures that, based upon the entity’s access authorization
policies, establish, document, review, and modify a user’s right
of access to a workstation, transaction, program or process.
A
Info Access Mgmt Implications
Isn’t this the same as the
previous rule?
It is an
implementation:
We must define a
data owner for
each major
process
.And then our IT
people must define
how they will grant
access based upon
the data owner’s
decisions.
Info Access
Mgmt
Administrative:
Security Awareness & Training
Security Reminders: Provide periodic security
updates to members of the workforce
A
Protection from Malicious Software: Implement
procedures for guarding against, detecting, and
reporting malicious software
A
Login Monitoring: Implement procedures for
A
monitoring login attempts and reporting discrepancies
Password Mgmt: Implement procedures for
creating, changing and safeguarding passwords
What do you think these mean?
A
Administrative:
Contingency Plan
Data Backup Plan: Establish and implement procedures to create
and maintain retrievable exact copies of EPHI
R
Disaster Recovery Plan: Establish … procedures to restore any
loss of data
R
Emergency Mode Operation Plan: The emergency mode
operation plan requires CEs to establish … procedures to enable
continuation of critical business processes, while maintaining the
security of EPHI while operating in emergency mode
R
Testing & Revision Procedure: Implement procedures for periodic
testing and revision of contingency plans.
A
Applications & Data Criticality Analysis: Assess the relative
criticality of specific applications and data in support of other
contingency plan components.
A
Administrative:
One-Line Safeguards
Assigned Security Responsibility: Identify the
R
security official who is responsible for the
development and implementation of the policies and
procedures required by this rule for the entity.
Security Incident Procedures: Implement policies & R
procedures to address security incidents. Identify
and respond to suspected or known security
incidents; mitigate … harmful effects of security
incidents that are known to the CE; and document
security incidents and their outcomes.
Administrative:
More One-Line Safeguards
Evaluation: Perform a periodic technical and nontechical
evaluation, based initially upon the standards implemented
under this rule and subsequently, in response to
environmental or operations changes affecting the security
of EPHI, that establishes the extent to which an entity’s
security policies and procedures meet the requirements of
this subpart
R
BA Contracts and Other Arrangements: A BA [may]
create, receive, maintain, or transmit EPHI on the CE’s
behalf only if the CE obtains satisfactory assurances that
the BA will appropriately safeguard the information.
R
Info Access Mgmt Implications
According to Evaluation, we
must self-test or be certified on
a regular basis, to be sure we
follow the Security Rule
That makes sense
when technology
changes, but I
guess we have to
do it periodically as
well, since the
world changes.
We need to know
who, what, when,
where, why for
incident response.
Evaluation
Who shall we name
as our Security
Manager?
Physical Safeguards:
Facility Access Controls
Facility Access Controls: Implement
policies and procedures to limit physical
access to electronic info systems and areas
where sensitive paper documents are stored
and any facilities in which they are housed,
while ensuring authorized access
Contingency Operations
Facility Security Plan
Access Control & Validation Procedures
Maintenance Records
A
A
A
A
Physical Safeguards:
Facility Access Control



How will physical access be restricted to
sensitive paper documents, terminals, server,
backup copies, laptops, contingency operations
in copy, view, or modify forms?
How are visitors controlled from accessing
PHI/EPHI?
When repairs occur (to facility or systems) how
will PHI/EPHI be safeguarded?
Physical Safeguards: Workstations
Workstation Use: Implement policies and
R
procedures that specify the proper functions to be
performed, the manner in which those functions are
to be performed, and the physical attributes of the
surroundings of a specific workstation or class of
workstation that can be used to access EPHI
Workstation Security: Implement physical
R
safeguards for all workstations that can be used to
access EPHI, to restrict access to authorized users
Workstation Use and Security





What functions will be performed on which
workstations?
How will workstation access be limited when the
user leaves their station?
How will theft of laptops be prevented?
How will the workstations be positioned?
What other physical safeguards (locked rooms,
hoods) will be implemented to prevent shoulder
surfing?
Physical Safeguards:
Device & Media Controls
Device and Media Controls: Implement policies and
procedures that govern the receipt and removal of
hardware and electronic media and devices that
contain EPHI into and out of a worksite or facility, and
the movement of these items within the worksite or
facility.
Disposal
Media Reuse
Accountability
Data Backup and Storage
R
R
A
A
Device & Media Controls

How will media be erased or damaged before
disposal or reuse?
 Reformatting
disk may not be adequate even for
reuse


How, when and where has EPHI been moved or
transferred? Documentation is necessary
How is a backup made and where/how stored?
Technical Safeguards:
Access Control
Access Control: Implement technical policies and
procedures for electronic info systems that maintain
EPHI. These policies and procedures should contain
access protocols that will establish and enforce the
entity’s other access policies, and allow access only to
those persons or software programs that have been
granted access rights
Unique User Identification
R
Emergency Access Procedure
Automatic Logoff
Encryption and Decryption
R
A
A
Technical Safeguards:
Access Control





How is each user uniquely identified to the
system?
How does authentication occur?
In an emergency, what backup methods are
used for authentication?
How does automatic logoff occur after a period
of inactivity?
Which data is encrypted in storage and/or
transmission?
Technical Safeguards:
Transmission Security
Transmission Security: Implement technical
security measures to guard against
unauthorized access to EPHI that is being
transmitted over an electronic communications
network
Integrity Controls
A
Encryption
A
Technical Safeguards:
Transmission Security
How are we sure that data is not modified
or lost during transmission?
 What encryption techniques are used to
protect the security of EPHI transmitted
over a public network?

Other Technical Safeguards
Audit Controls: Implement hardware, software, and/or R
procedural mechanisms that record and examine
activity in information systems that contain or use EPHI
Integrity: Implement policies and procedures to
protect EPHI at rest, meaning stored on organizational
systems and applications, from improper alteration or
destruction.
Person or Entity Authentication: Implement
procedures to verify that a person or entity seeking
access to EPHI is the one claimed
A
R
Other Technical Safeguards





For which devices will the logs be monitored?
What log events should be archived for security
purposes?
How will potential attacks found in logs be recorded,
reported, and acted upon?
What techniques will be used to ensure stored data has
not been modified (hashes, message digests?)
What authentication mechanisms will be used to assure
that approved entities (people or systems) are accessing
EPHI?
Question
An example of a vulnerability is
1. Theft
2. Burglar
3. Open door
4. Diamonds
Question
1.
2.
3.
4.
Protected Health Information is:
SSN, medical information
Name, SSN, medical information
Name, address, SSN, phone, medical
information
Medical information stored in a computer
Question
The Security Rule requires that:
1. Logs are monitored
2. An intrusion detection system is
implemented
3. Cabinets containing PHI must be locked
4. Walls must be soundproof and all
terminals outside of waiting room
Question
The Privacy Rule requires that:
1. Logs are monitored
2. An intrusion detection system is
implemented
3. Cabinets containing PHI must be locked
4. Walls must be soundproof and all
terminals outside of the waiting room
Question
The Addressable option for the Security Rule means:
1. Smaller organizations need not implement if they can
justify it would be too expensive
2. HIPAA discusses alternative means to accomplish this,
and the organization must select one
3. The CE must document how they accomplish this
provision
4. This provision must be implemented or addressed in
some way, although alternative implementations are
allowed
To Study:





Define HIPAA, Privacy Rule, Security Rule, CE,
PHI.
Define threat, vulnerability, threat agent
Describe what Privacy Rule covers at a high
level
Describe what Security Rule covers at a high
level
Describe the difference between Required and
Addressable for the Security Rule.
Not Covered in this Presentation
Some specialized material is not being covered as
part of this presentation, including:
 Hybrid Entities: Part Covered, Part Not
 Organized Health Care Arrangement (OHCA):
Group of doctors
 Jointly Administered Govt. Program
 Trading Partner: CEs exchange electronic
transactions without clearinghouse
COBRA

The Consolidated Omnibus Budget
Reconciliation Act of 1986.
This allows some types of employees (and
their families) to continue health coverage
when they change/lose a job for a
maximum of 18 mos.