Security management process is the foundation for compliance with HIPAA Security Rule

Security management process can be an organization’s biggest strength or biggest weakness, and most organizations lack one or all of the components that establish a security management process. In a Health Care Compliance Association (HCCA) webinar entitled, “Is Your Security Management Process Your Biggest Risk?” presenters Kezai Cook-Robinson and Ahmad M. Sabbarini of Ernst & Young LLP emphasized that a security management process is the foundation for an organization’s compliance with the Health Insurance Portability and Accountability Act’s (HIPAA) (P.L. 104-191) Security Rule.

Under 45 C.F.R. Sec. 164.308(a)(1) a covered entity or business associate is required to implement policies and procedures to prevent, detect, contain, and correct security violations. This process requires covered entities and business associates to implement standards and required implementation specifications and to implement, when appropriate and reasonable, addressable implementation specifications through risk analysis, risk management, sanction policy, and information system activity review.

Risk analysis

Covered entities and business associates must conduct an accurate and thorough assessment of the potential risks and vulnerabilities to the confidentiality, integrity, and availability of electronic protected health information held by the covered entity or business associate. This means, said the presenters, that covered entities and business associates must conduct an enterprise-wide risk analysis and develop a current, comprehensive, and thorough risk analysis of security risks and vulnerabilities to include the electronic personal health information (e-PHI) created, received, maintained, or transmitted by the organizations’ facilities and applications. This should be done periodically (calendar-based) and in response to events (event-based triggers).

As part of the risk analysis, organizations should conduct a comprehensive inventory of e-PHI. Assets can be grouped into a common grouping for purposes of the inventory—for example, if work stations have the same number and type of e-PHI, they can be grouped into one asset category. In addition, to save time and money, organizations should start with lists that have already created from financial statements and privacy compliance activities.

Risk management

Covered entities and business associates should establish and implement an organization-wide risk management plan to address and mitigate any security risks and vulnerabilities found in the risk analysis. It should include a process and timeline for an organization’s implementation, evaluation, and revision of its risk remediation activities. The presenters noted that the higher the risk, the more robust controls are needed.

Sanctions policy and information system activity review

The security management process also requires covered entities and business associates to apply appropriate sanctions against workforce members who fail to comply with security policies and procedures and to implement procedures to regularly review records of information system activity, such as audit logs, access reports, and security incident tracking reports.

Documentation

“Document, document, document,” said Cook-Robinson, because “it does not exist unless it’s in writing.” She advised that covered entities and business associates document and keep as records the analyses, decision making, and rationale for overall risk assessments, as well as individual risk analyses for implemented safeguards.

NIST guidelines

Cook-Robinson and Sabbarini also advised organizations to align as necessary with the guidelines and frameworks that HHS leverages, including the National Institute of Standards and Technology (NIST) Framework for Improving Critical Infrastructure Cybersecurity (CSF) and NIST 800-30.

AMA preparing to tackle questions surrounding physician-patient texting

Regulators are serious about privacy and violations of the Health Insurance Portability and Accountability Act (HIPAA) (P.L. 104-191), and crackdowns keep providers on their toes. The evolution of technology provides innovative and efficient ways to practice medicine and communicate with patients, but this evolution brings with it new obstacles that can easily trip up a provider who is not paying close attention. At the end of a long day, a tired doctor might send a quick text to a mother who does not want to bring in her sick child if over-the-counter medicines will do the trick, trying to be as accommodating as possible and truly caring for the patient’s well-being. Both mother and doctor will be relieved that an unnecessary trip was avoided, but is this type of communication appropriate?

The American Medical Association (AMA) provides guidelines for providers on issues just like this one, and the AMA House of Delegates will consider expanding its advice on email communications to include text messaging at a June meeting. Although the AMA maintains that a face-to-face meeting is the foundation of a physician’s relationship with a patient, it recognizes that patients and physicians may prefer text message communications in various settings.

Considerations when texting

As expected, the AMA’s first basic standard of engagement to consider is HIPAA. The Board of Trustees (BOT) recommends discussing obligations under HIPAA’s Security Rule with both information technology (IT) staff and legal counsel. This rule requires that entities transmitting electronic protected health information (ePHI) ensure that these transmissions are confidential and secure. The AMA provides an educational tool to assist providers in achieving compliance with the rule, and HHS offers advice on protecting ePHI when using cell phones.

Providers should keep in mind potential differences in communication with patients, as opposed to colleagues. While doctors and nurses in the same office may think nothing of texting one another, a patient needs to consent to communication. Current guidance indicates that a patient’s initiation of a text conversation may serve as consent, but some providers might obtain written consent that acknowledges risks in such transmissions. Patients should be reminded that security is not guaranteed and that privacy can be breached as easily as someone they know using their phone and seeing a text.

Boundaries

In addition to consent and security issues, the AMA raises several points more along the lines of etiquette but that must be approached within the patient-physician relationship framework. A physician should establish boundaries with patients, such as establishing reasonable response times and appropriate times of day for texting. Additionally, extensive conversations are not recommended, and if a patient requests a lengthy explanation the physician should request that the patient come into the office.

When texting, the AMA recommends keeping a formal tone, cordial but refraining from using jokes, emoticons, or emotionally charged or sarcastic speech. The recommendations even extend to ending texts with the physician’s full name and business affiliation, accompanied by a request to acknowledge receipt of the message. Although it may seem obvious, the AMA also reiterates refraining using identifying information such as name or Social Security number and keeping text records.