1. Health information security & compliance
Charles Nwasor,
Xcellent Technologies

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

3. HIPAA 1

4. 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)

5. 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
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

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

7. 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

8. 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

9. 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

10. The New Healthcare Paradigm2
The New Healthcare Paradigm

11. The New Healthcare Paradigm

12. Internal Compliance 3

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

14. 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

15. Internal Compliance Framework

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

17. 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

18. Conclusion 4

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

20. 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

21. Xcellent Technologies
43155 Main Street Suite 2210-D Novi, MI 48375
(248)