May I see your comprehensive security policy please?
May I see your comprehensive security policy please?
Huh? What’s that?
Lack of compliance with the HIPAA security standards is common in county and municipal government agencies even though many of these organizations have covered entities (CE) under their umbrellas. For some reason, almost everyone got the memo on required compliance with HIPAA privacy rules in 2003, but many organizations missed the subsequent memo on required compliance with security rules by April of 2005.
Nearly 14 years have passed since the security rule was published, and I have no explanation for the compliance lacuna that exists today. If you are an executive, manager or provide IT services for a CE, your security policy should be as well-worn as your kids’ Harry Potter books.
If someone (i.e. an auditor) asks about your compliance program, you should be able to succinctly summarize it and immediately provide documentation of your compliance activities. If this doesn’t describe your organization, you are not alone and there is no time like to present to begin the process.
Compliance isn’t a one-time, passive event and there are routine steps you must take ensure the CIA (confidentiality, integrity and availability) of your clients’ protected health information (PHI).
Denial and disbelief
Denial and disbelief are the first two stumbling blocks I encounter when informing managers in government agencies that they are not in compliance with HIPAA. Sickening yellow clouds of realization dawn over a period of several weeks while I continue to email copies of the Code of Federal Regulations (CFR) to the relevant parties. The attorney is generally the first to comprehend the magnitude of the situation.
Holistic information security
I talk about security policies rather than HIPAA policies. Something that is also common in municipal government is a lack of information security policies based on some generally accepted standard or framework for information security. You can and should address HIPAA security requirements and your overarching organizational information security requirements together.
Form a governance committee
Developing your security policy isn’t an IT project; it is part of an Information Governance program. A cross-functional team including representation from several organizational entities must be part of the process for developing your information security policies. Here are the roles I generally request to be part of the policy development team:
1. Executive owner
2. Legal
3. HR
4. Information technology
5. Line of business units
6. Records management
7. Risk management, privacy and information security officer roles (Many municipal governments do not employ these functional roles, but they will once they have developed their policy).
Read the regulations!
I am a big believer in always working from primary sources. I encourage you to embark upon your HIPAA journey by reading the full text of the regulations. In the table below, I have hyperlinked them for your convenience. When I write policies for clients, I work directly from the regulation with their policy or governance committee so that everyone understands the process and the final result. Even so, clients will often argue about something that is projected on the wall right in front of them. I link every client policy to the corresponding HIPAA requirement.
Primary sources for compliance – educate yourself
| HIPAA Compliance | ||
|---|---|---|
| HIPAA Privacy Rule | 45 CFR Parts 160 and 164 Standards for Privacy of Individually Identifiable Health Information. | Final Rule – December 28, 2000 |
| HIPAA Security Rule | 45 CFR Parts 160, 162, 164. | Final Rule – February 2003 |
| HIPAA Combined Regulation Text | HIPAA Administrative Simplification. | Unofficial version amended through March 2013 combining the privacy and security rules. |
| HITECH Act Enforcement | HITECH Act interim final rule includes penalties for non-compliance. | October 30, 2009 |
| NIST Special Publication 800-53 | Security and Privacy Controls for Federal Information Systems and Organizations | Revision 4, April 2013 |
| Privacy Rule Resources | HHS.GOV resources | |
| Guide to Privacy and Security of Electronic Health Information | Office of National Coordinator for Health Information Technology | Version 2.0 April 2015 |
| NIST HIPAA Security Rule Toolkit | Downloads and tools from NIST for assessment, etc. | |
| NIST Special Publication 800-66 | An Introductory Resource Guide for Implementing the Health Insurance Portability and Accountability Act (HIPAA) Security Rule | October 2008 |
| Security Risk Assessment Tool | HealthIT.Gov | Executable tool – paper copy available too. |
Compliance Matrix
In a previous article on the subject, I provided a sample, high-level compliance matrix for a security policy aligned with HIPAA.
Caveat emptor
Vendors often market products as being “HIPAA compliant.” If you have read the regulations above, you now know that there is no such thing. The HIPAA security rule is technology-neutral, and any reference to compliance would be to your organization’s policy rather than to the rule itself.
Get to work!
If you are now nauseous because you realize that you are not even remotely in compliance, that’s a good thing. Use that feeling to quickly get to work to protect your organizational information assets.
© Copyright Jeffrey Morgan, 2016
This article firs appeared on CIO.COM at http://www.cio.com/article/3134484/government/may-i-see-your-comprehensive-security-policy-please.html
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