HIPAA Security Meeting Compliance

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HEALTH AFFAIRS                                                                                   Management

      HIPAA Security: Meeting Compliance

                           TRICARE Annual Conference

                Samuel P. Jenkins, Privacy Officer
          Chairman of HIPAA Security Implementation IPT
                 TRICARE Management Activity

                                         January 2005

      This document contains proprietary information and will be handled within Government regulations.
                It is intended solely for the use and information of the Military Health System.
Presentation Objectives

• Upon completion of this presentation you will
  be able to:
  – Summarize the HIPAA Security Rule content and
    structure and the process for implementing the
  – Describe the MHS HIPAA Security implementation
  – Identify what you need to do to ensure compliance
    with the HIPAA Security Rule

Where Does This Fit In?

                       Health Insurance Portability and Accountability Act of 1996

          Title I                                   Title II                           Title III                Title IV                   Title V
Health Care Access,                Preventing
                                   Health Care
                                                     Medical     Administrative
                                                                                     Tax-Related              Group                       Revenue


  Portability, and                 Fraud and
                                                                                       Health               Health Plan
   Renewability                                                                       Provision            Requirements

        Preventing                                   Medical                         Administrative
        Health Care                                  Liability                       Simplification
         Fraud and                                   Reform

         Electronic                              Unique                           Code sets for       Privacy              Security
                                                 Identifiers for                  Health Care                               Administrative Safeguards
         Data Exchange                           • Providers                                                                Physical Safeguards
                                                 • Employers                      Plans                                     Technical Safeguards

Source: National Institute of Standards and Technology (NIST)

Applicability of the HIPAA Security Rule


Providers who use a
covered transaction         MTFs, DTFs, and clinics

Health plans                  TRICARE Health Plan

Healthcare                  Companies that perform
clearinghouses                 electronic billing on
                                   behalf of MTFs

Business                             Managed care
associates                      support contractors
                              and other contractors

Purpose of the HIPAA Security Rule

• To adopt national standards for safeguards to
  protect the confidentiality, integrity, and
  availability of Electronic Protected Health
  Information (EPHI)

Privacy vs Security

             Privacy                  Security
•   HIPAA 1996             •   HIPAA 1996
•   Covered entities       •   Covered entities
•   April, 14 2003         •   April 21, 2005
•   PHI                    •   EPHI
•   Uses and Disclosures   •   Safeguards
•   Confidentiality        •   Confidentiality, Integrity,
•   OCR                        and Availability
                           •   CMS


• HIPAA Security Rule contains standards and
  implementation specifications
   – Standards are required
   – Three categories of standards or safeguards:
      • Administrative
      • Physical
      • Technical
   – Standards state what to do, but not how to do it
   – Most standards have implementation specifications

Implementation Specifications

• Implementation specifications support specific standards
• Provide instructions to assist meeting the standards
• Meeting all the implementation specifications does not
  automatically equate to meeting the standard
• In some cases, a standard itself provides sufficient
  information for implementation, in which case there is not
  a distinct implementation specification
• May be “required” or “addressable”


• Required means that covered entities must carry out the
  implementation specification at their facility
• For compliance with required implementation
                                    Conduct Risk

         Document relevant   Yes                       No      Implement and
            policies and                                    document corrective
                                   Specification met
            procedures                                            actions
           and implement

                                                            Document relevant
                                                               policies and
                                                              and implement
• Addressable means that covered entities must carry out
  the implementation specification if no other security
  measure meets the implementation specifications and it is
  reasonable and appropriate

• For DoD, only three implementation specifications are


    • For compliance with addressable implementation

                                                                    Implementation               Standard met
                 Addressable       No                       No                          No
Conduct Risk                             Is it reasonable             Specification                 without
  Analysis                              and appropriate?            reasonable and              Implementation
                                                                      appropriate?               Specification?

                        Yes                       Yes                       Yes                          Yes

                                          Develop and               Develop and                Document rationale
               Document relevant
                                        document relevant        document alternative        for not developing new
                  policies and
                                           policies and              policies and                  policies and
                                           procedures                procedures                    procedures
                and implement
                                          and implement             and implement

Administrative Safeguards

• Administrative actions, and policies and procedures,
  to manage the selection, development,
  implementation, and maintenance of security
  measures to protect EPHI and to manage the
  conduct of the covered entity’s workforce in relation
  to the protection of that information

Administrative Safeguards

• Standards
   –   Security Management Process
   –   Assigned Security Responsibility
   –   Workforce Security
   –   Information Access Management
   –   Security Awareness and Training
   –   Security Incident Procedures
   –   Contingency Plan
   –   Evaluation
   –   Business Associate Contracts and Other Arrangements

Standard: Security Management Process

• Implement policies and procedures to prevent, detect,
  contain, and correct security violations

• Implementation Specifications:
    – Risk analysis
    – Risk management
    – Sanction policy
    – Information system activity review

Standard: Assigned Security
• Identify the security official who is responsible for the
  development and implementation of the policies and
  procedures required by this subpart for the entity

• Implementation Specifications
    – None

Standard: Workforce Security

• Implement policies and procedures to ensure that all
  members of its workforce have appropriate access to
  EPHI and to prevent those workforce members who do
  not have access from obtaining access to EPHI

• Implementation Specifications:
    – Authorization and/or supervision
    – Workforce clearance procedures
    – Termination procedures

Standard: Information Access
• Implement policies and procedures for authorizing access
  to EPHI that are consistent with the applicable

• Implementation Specifications:
    – Isolating health care clearinghouse functions
    – Access authorization
    – Access establishment and modification

Standard: Security Awareness and
• Implement a security awareness and training program for
  all members of its workforce (including management)

• Implementation Specifications:
    – Security reminders
    – Protection from malicious software
    – Log-in monitoring
    – Password management

Standard: Security Incident Procedures

• Implement policies and procedures to address security

• Implementation Specifications:
    – Response and reporting

Standard: Contingency Plan

• Establish (and implement as needed) policies and
  procedures for responding to an emergency or other
  occurrence (for example, fire, vandalism, system failure,
  and natural disaster) that damages systems that contain

• Implementation Specifications:
    – Data backup plan
    – Disaster recovery plan
    – Emergency mode operation plan
    – Testing and revision procedures
    – Applications and data criticality analysis
Standard: Evaluation

• Perform a periodic technical and non-technical evaluation,
  based initially upon the standards implemented under this
  rule and subsequently, in response to environmental or
  operational changes affecting the security of EPHI, that
  establishes the extent to which an entity’s security policies
  and procedures meet the requirements

• Implementation Specifications
    – None

Standard: Business Associate
Contracts and Other Arrangements
• A covered entity may permit a business associate to
  create, receive, maintain, or transmit EPHI on the covered
  entity’s behalf only if the covered entity obtains
  satisfactory assurances that the business associate
  appropriately safeguards the information

• Implementation Specifications:
    – Written contract or other arrangement

Physical Safeguards

• Physical measures, policies, and procedures to protect a
  covered entity’s electronic information systems and
  related buildings and equipment, from natural and
  environmental hazards, and unauthorized intrusion

Physical Safeguards

• Standards
   –   Facility access controls
   –   Workstation use
   –   Workstation security
   –   Device and media controls

Standard: Facility Access Controls

• Implement policies and procedures to limit physical access
  to its electronic information systems and the facility or
  facilities in which they are housed, while ensuring that
  properly authorized access is allowed

• Implementation Specifications:
   – Contingency operations
   – Facility security plan
   – Access control and validation procedures
   – Maintenance records

Standard: Workstation Use

• Implement policies and 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 access EPHI

• Implementation Specifications
   – None

Standard: Workstation Security
• Implement physical safeguards for all workstations that
  access EPHI, to restrict access to authorized users

• Implementation Specifications
   – None

Standard: Device and Media Controls

• Implement policies and procedures that govern the receipt
  and removal of hardware and electronic media that
  contain EPHI into and out of a facility, and the movement
  of these items within the facility

• Implementation Specifications:
   – Disposal
   – Media re-use
   – Accountability
   – Data backup and storage

Technical Safeguards

• Technical safeguards are the technology, as well as the
  policies and procedures for its use, that protect EPHI and
  control access to it. The technical safeguards are
  designed to protect EPHI being created, processed,
  stored, or transmitted

Technical Safeguards

• Standards
   –   Access controls
   –   Audit controls
   –   Integrity
   –   Person or entity authentication
   –   Transmission security

Standard: Access Control

• Implement technical policies and procedures for electronic
  information systems that maintain EPHI to allow access
  only to those persons or software programs that have
  been granted access rights

• Implementation Specifications:
   – Unique user identification
   – Emergency access procedure
   – Automatic logoff (A)
   – Encryption and decryption (A)

Standard: Audit Controls

• Implement hardware, software, and/or procedural
  mechanisms that record and examine activity in
  information systems that contain or use EPHI

• Implementation Specifications
   – None

Standard: Integrity

• Implement policies and procedures to protect EPHI from
  improper alteration or destruction

• Implementation Specifications:
   – Mechanism to authenticate EPHI

Standard: Person or Entity
• Implement procedures to verify that a person or entity
  seeking access to EPHI is the one claimed

• Implementation Specifications
   – None

Standard: Transmission Security

• Implement technical security measures to guard against
  unauthorized access to EPHI that is being transmitted
  over an electronic communications network

• Implementation Specifications:
   – Integrity controls
   – Encryption (A)

Standard: Policies and Procedures

• Implement reasonable and appropriate policies and
  procedures to comply with the standards, implementation
  specifications, or other requirements

• Implementation Specifications
   – None

Standard: Documentation

• Maintain the policies and procedures implemented to
  comply with this subpart in written (which may be
  electronic) form; and if an action, activity or assessment is
  required by this subpart to be documented, maintain a
  written (which may be electronic) record of the action,
  activity, or assessment

• Implementation Specifications
   – Time limit: retain applicable documentation of policies,
     procedures, actions, activities, assessments for 6 years
   – Availability: make documentation available to involved
   – Updates: update documentation when changes affect
     security of EPHI
How to Establish and Maintain
• To correctly implement the security standards, each
  covered entity must:
    –   Assess potential risks and vulnerabilities to EPHI
    –   Develop, implement, and maintain appropriate security
        measures given those risks
    –   Document those measures and keep them current

        Implementing HIPAA Security is meant to be
                   flexible and scalable

HIPAA Implementation Life Cycle

Process – Risk Analysis

• Risk Analysis is the key to
   – Understanding what must be protected
   – Identifying potential risks and vulnerabilities
   – Initiating Risk Management

Process – Risk Management

• Risk Management, which includes risk analysis, is the
  process of
   – Assessing risk
   – Mitigating risk
   – Monitoring risk

• Important: risk management is a continuing process – not
  a one time event

Process – Risk Management
Relevance to HIPAA
• Risk analysis determines the following key components to
  establishing HIPAA Security compliance:
   – The security risks involved in your organization’s operations
   – The degree of response to security risks
   – Whether the addressable implementation specifications are
     reasonable and appropriate
   – Security measures to apply within your particular security

• Your ability to assess your state of compliance is greatly
  improved with risk analysis and a process for managing
  the data

Tools and Resources

• Tools include those provided by TMA
   – HIPAA BASICS™ Compliance Tool
   – HIPAA Training Tool (LMS)
• Available Resources
   – Training
   – Website
      • Policies and Guidance
      • Information Papers
      • Forms
      • Briefings
   – Privacymail@tma.osd.mil
   – Service Representatives

Roles and Responsibilities

• Successful compliance with HIPAA Security requires
  clearly defined and assigned roles and responsibilities to
   – Accountability
   – Responsibility
   – Applicability

Roles and Responsibilities

• HIPAA Security Rule requirement for the appointment of a
  security official
   – Assignment letter for Security Officer
      • Roles and responsibilities
          – Policy Implementation, Oversight, Auditing and
          – Education, Training and Communication
          – Integration Activities

Roles and Responsibilities

• Other individuals who are part of the compliance initiative
   –   Commander
   –   Chief Information Officer (CIO)
   –   Privacy Officer
   –   Physical Security Officer
   –   Information Security Manager/Officer
   –   MTF Analysis and Implementation Team (MISRT)
   –   Incident response team

Roles and Responsibilities

• Roles and responsibilities exist throughout the
  organization, including individuals who are
   –   Full-time employees
   –   Senior management
   –   Part-time employees
   –   Contractors
   –   Vendors

Oversight and Compliance (1 of 4)

• Compliance is established and maintained by
  implementing business practices including
   –   Measuring success
   –   Identifying areas of improvement
   –   Preparations and contingencies
   –   Communication

Oversight and Compliance (2 of 4)

• Methodologies
   – Initial requirements
       • Reports that provide information on compliance within
          organizations and across the enterprise
       • Metrics to gauge compliance performance and monitor the
          progress of HIPAA privacy and security programs

Oversight and Compliance (3 of 4)

• Increasing level of detail
   – Program Reviews to ensure that information being reported on
     HIPAA compliance is accurate and complete
   – POA&M used to identify and monitor privacy and security-
     related programmatic and system-level weaknesses
   – Metrics to demonstrate the maturity of the organization’s
     HIPAA programs

Oversight and Compliance (4 of 4)

• Compliance Assurance requirements for the MHS (including
  reporting standards) are currently under development by HIPAA
  Security Integrated Process Team (IPT)
   – Operations Subcommittee is the primary work group for this

Proposed Reporting Requirements (1 of 2)

 • Reports will be at multiple levels of the organization
    – TRICARE Health Plan (MHS)
       • Includes TMA, Army, Navy, Air Force, and the Coast Guard
       • Results will be provided to ASD(HA)
    – Service Medical Components/TMA
       • Included entities are at the discretion of the Services and
          TMA management
       • Results of the reports to be provided to the MHS on a
          quarterly/annual basis or as requested
    – Military Treatment Facilities
       • Includes clinics and satellite facilities

Proposed Reporting Requirements (2 of 2)

• Type and frequency:
   – Training Reports
      • Monthly or as needed to verify compliance
   – Compliance Reports
      • Baseline for HIPAA Security and then monthly during the
        implementation phase (December 2004 - TBD)
      • Phased decrease to quarterly report for HIPAA Security
        Compliance after May 2005

Tools for Compliance Reporting

• TMA has provided 2 centrally funded and managed tools to
  facilitate compliance reporting efforts across the MHS
   – Training Tool
      • Plateau’s Learning Management System (LMS)
   – Compliance Tool
      • Strategic Management Systems, Inc HIPAA BASICS TM


• Title 45, Code of Federal Regulations, “Health Insurance
  Reform: Security Standards; Final Rule,” Parts 160, 162 and
  164, current edition

•   www.tricare.osd.mil/tmaprivacy/HIPAA.cfm

• privacymail@tma.osd.mil for subject matter questions

• hipaasupport@tma.osd.mil for tool related questions

• Service HIPAA security representatives

Our Commitment

The TRICARE Management Activity (TMA)
Privacy Office is committed to ensuring the
privacy and security of patient information    TRICARE

at every level as we deliver the best         Management

medical care possible to those we serve.