Health information security & compliance Charles Nwasor, Xcellent Technologies

The New Healthcare Paradigm Agenda HIPAA 1 2 The New Healthcare Paradigm Internal Compliance 3 Conclusion 4

HIPAA 1

HIPAA – Overview Sets standards to assure the Confidentiality, Integrity, and Availability of PHI Health Insurance Portability & Accountability Act (HIPAA) Privacy – individuals’ rights of privacy and standards Security – security of ePHI Breach Notification – reporting breach information Limits the use and disclosure of confidential information: Protected Health Information (PHI) Electronic Protected Health Information (ePHI)

HIPAA – PHI PHI and Personally Identifiable Information Any information (verbal, electronic, or written) that relates to a person’s physical or mental health or payment information Name Postal Address All elements of Date Telephone Number Fax Number Email Address URL IP Address Social Security Number Account Numbers License Number Medical Record Number Health Plan Number Device Identifier Vehicle Identifier Biometric Identifier Full-face Photos Any other unique identifying number Genetic information

HIPAA – CIA Triad Confidentiality – keeping information from unauthorized access Integrity – safeguarding against unauthorized modification Availability – assuring the constant availability of information

HIPAA – Privacy Rule Establishes rights of privacy and standards for disclosure Permitted Disclosures Personal Representatives Treatment, Payment and Healthcare Operations Written Authorization/Verbal Consent De-identified Data Required Disclosures Public Health Activities Law Enforcement Verification Requirements Notice of Privacy Practices

HIPAA – Security Rule Requires control measures to safeguard the confidentiality, integrity and availability of electronic Protected Health Information (ePHI) Organizational Requirements – Business Associate Agreements (BAAs) Security Standards Administrative Physical Technical Security Management Process Information Access Management Security Awareness and Training

HIPAA – Breach Notification Rule Requires notifications to authorities and/or patients when unsecured PHI has been breached Defines Breach as the inappropriate use or disclosure that compromises the security and privacy of PHI Exceptions Unintentional Acquisition by a workforce member Inadvertent Disclosure between workforce members Recipient can not reasonably retain the information Unsecured PHI – is PHI that has not been rendered unreadable or indecipherable to unauthorized persons

The New Healthcare Paradigm 2 The New Healthcare Paradigm

The New Healthcare Paradigm

Internal Compliance 3

Internal Compliance Framework Assess Risk Security Risk Assessment Plan Corrective Action Prioritize Controls Create & Implement Control Measures Remediate

Internal Compliance Framework Information Security Policy & Technical Controls Acceptable Use Access controls & Physical Security Secure Software & Malicious Code Security Incident Management Sanctions Breach Notification Workforce Security Security Awareness and Training Proper Conduct and Authorized Disclosures

Internal Compliance Framework

Impacts of Non-Compliance Regulatory Fines Lawsuits and Liability Loss of Business Professional Sanctions

Current Examples Hospice of North Idaho - $50,000 Massachusetts Eye and Ear Associates Inc. - $1.5 Million River Falls Medical Clinic – 2,400 Patient Records stolen Shands Jacksonville Clinic – 261 Patient Records photographed Goldthwait Associates, a Billing Service Provider - $140,000 Phoenix Cardiac Surgery, P.C. - $100,000

Conclusion 4

Assuring the Privacy and Security of Patients’ Information is a vital component of providing healthcare.

Questions ----- Meeting Notes (12/21/12 13:43) ----- Review the system (Technical, Business, Implementation and Training Review Contract Pressed the company on Modernizing Medicine EMA Investigate the 4 Products

Xcellent Technologies 43155 Main Street Suite 2210-D Novi, MI 48375 (248) 956.0538 info@xcellenttechnologies.com http://www.xcellenttechnologies.com