Defining a Process for Gathering Information Pertaining to a HIPAA Compliance Audit

March 16, 2024March 16, 2024 Discipline: Computer science
Introduction
It’s important for health care companies to understand the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and its privacy and security rules. The act applies not only to doctors and hospitals but to all health care providers and researchers who are able to share patient information that’s classified as private. HIPAA was designed to protect the consumer, not 
the health care providers. It’s important to understand HIPAA’s primary aspects and how it impacts and defines an audit scope.
In this homework assignment, you will gather information about the health care industry that addresses the requirements a health care organization must comply with. You will relate the HIPAA Privacy and Security rules to  National  Institute of Standards and Technology (NIST) standards and encryption technologies to ensure confidentiality of  electronic protected health information 
(ePHI) transmission. You will evaluate HIPAA requirements, identify what ePHI data consists of and apply HIPAA Privacy and Security rules to  ensure confidentiality, integrity,  and 
availability.  Finally, you will relate the security requirements for protected health information (PHI) to an overall privacy and security strategy for a health care organization. 
Learning Objectives
Upon completing this lab, you will be able to:
  • Relate the Health Insurance Portability and Accountability Act (HIPAA) Privacy and Security Rules to NIST standards and encryption technologies to ensure the confidentiality of ePHI transmission.
  • Evaluate the requirements for a health care organization to become compliant with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
  • Identify what ePHI data consists of and apply HIPAA privacy and security rules to ensure its confidentiality, integrity, and availability.
  • Relate the security requirements for protected health information (PHI) to an overall privacy and security strategy for a health care organization.
  • Draft an  executive summary that defines a process for obtaining and addressing HIPAA 
    compliance for a health care organization.
Consider the following scenario:
Your manager has asked you to identify information and resources in the health care industry that address the laws, rules, and guidelines your health care organization needs to follow. Your health care organization is to have an audit, so you need to gather information for the upcoming audit, which will be more stringent than any that has been done before. The health care organization that employs you believes it is necessary to conduct a review of its HIPAA compliance (or lack of compliance) and put the gathered information into a report to show all the requirements the organization faces. Your manager has asked you to perform this function, knowing that your work has been above reproach. He expects a summary of the HIPAA requirements the organization needs to comply with and any financial regulatory acts for which it might also be held liable.  You will need to dig deep into the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Rule and Security Rule. You can use resources from HHS.gov, the U.S. Department of Health and Human Services’ Web site, to evaluate the HIPAA Privacy and Security rules. 
Scope Creep: Your job is to define the audit’s scope and objectives prior to the audit. As you start this assignment, be sure you know what the audit goals are, and then define what the audit scope includes and does not include. Every experienced auditor knows that an audit without a properly defined scope and goals is an audit at risk of “scope creep” or an ever-increasing effort beyond what is necessary.
  1. On your local computer, open a new Internet browser window.
  2. In the  address box of  your  Internet browser, type the URL: http://www.himss.org/  and press Enter  to open the Healthcare Information and Management Systems Society 
    (HIMSS) Web site.  Review the Web site.
  3. At the top of the HIMSS Web site, click the About HIMSS link.
  4. On the left side of the HIMSS Web site, click on the FAQs link. Review the information you find. Note: Reading through the history of HIMSS will provide insight on how HIMSS progressed.  This history is available by clicking on the left sidebar link titled “History of HIMSS.”
  5. Then, in the SEARCH box in the upper right corner of the screen, type the words Health Information Technology and press Enter.  Review the information you find.
  6. In the address box of your Internet browser, type the URL https://csrc.nist.gov/csrc/media/events/hipaa-2010-safeguarding-health-information-buil/documents/2-3-logging-auditing-mcmillan-cynergistek.pdf and press Enter to open the Web site.
  7. Review the following sections:
    1. Logging & Audit Requirements
    2. Privacy vs. Security
    3. Challenges  & Barriers
  8. In  the  address box of  your  Internet browser, type the URL https://www.healthit.gov/topic/health-it-resources/guide-privacy-security-electronic-health-information and press Enter to 
    open the Web site.
  9. Browse  the  Privacy and Security section  of The Office of the National Coordinator for Health  Information Technology and   review  the available information and resources 
    provided. Note: The Privacy and Security section of the Office of the National Coordinator for Health Information Technology Web page also provides students with both the historical rationale behind HIPAA as well as valuable toolkits for conducting assessments and employing best practices.
  10. In the address box of your Internet browser, type the URL www.HHS.gov and press Enter to open the Web site.
  11. Using the search box in the upper right corner of the web page, search the Health and Human Services Web site for information on HIPAA’s main points and requirements. Note: 
    The HIPAA Security Information Series is an educational series that provides information about all of HIPAA’s administrative, physical, and technical safeguards, as well as HIPAA’s main requirements. You can access this information through Health IT’s Privacy  and Security  section,  which you visited in  step 13, by typing the URL http://www.hhs.gov/hipaa/for-professionals/security/guidance/index.html
  12. In the address box of your Internet browser, type the URL: https://www.hhs.gov/hipaa/for-professionals/privacy/laws-regulations/index.html, and press Enter to open the Web site. Review the HIPAA Security Rule. Note: Privacy Rule Versus Security Rule Unlike the HIPAA Privacy Rule, the Security Rule applies only to electronic protected health information (ePHI). Both the Privacy Rule and the Security Rule seek to ensure information confidentiality, but the Security Rule makes specific use of administrative, technical, and physical safeguards to protect any electronic form.
HIPAA’s Final Rule: It wasn’t until 2006 that HIPAA’s Final Rule was enacted. The Final Rule focuses on the enforcement of HIPAA.  The final rule, called the enforcement rule, was created as a result of violations and noncompliance.  The Enforcement Rule details investigation procedures as well as penalties and procedures with which to deal with HIPAA violations. 

Overview
In this homework assignment, you gathered information about the health care industry that addresses the requirements a health care organization must comply with. You related the HIPAA Privacy and Security Rules to National Institute of Standards and Technology (NIST) standards and encryption technologies to ensure the confidentiality of electronic protected health information (ePHI) transmission. You evaluated HIPAA requirements, identified what ePHI data consists of, and applied HIPAA privacy and security rules to ensure confidentiality, integrity, and availability. Finally, you related the security requirements for protected health information (PHI) to an overall privacy and security strategy for a health care organization.
Please answer the following questions:
  1. What are the four parts of the administrative simplification requirements of HIPAA?
  2. Name three factors used to determine whether you need to comply with HIPAA.
  3. What are the three categories of entities affected by the HIPAA Medical Privacy Regulations?
  4. What would business associates of covered entities consist of as it pertains to HIPAA’s regulation?
  5. Who/what is covered by the HIPAA Privacy Rule? Give some examples.
  6. What information is protected under HIPAA?
  7. Describe the basic principles and required disclosures of HIPAA.
  8. Is a health information organization (HIO) covered by the HIPAA Privacy Rule?
  9. Does the HIPAA Privacy Rule inhibit electronic health information exchange across different states or jurisdictions?
  10. How should a covered entity respond to any HIPAA Privacy Rule violation by a health information organization (HIO) acting as its business associate?
  11. True or false: As a patient, your doctor must have you sign a HIPAA Consent and Release Form to share your ePHI or PHI with insurance providers who pay your medical bills. This is part of the HIPAA Privacy Rule.
  12. After the patient provides consent and permission to the medical practice or covered entity, what agreement is needed between the medical practice and its downstream medical insurance claims processor or downstream medical specialist that requires the patient’s ePHI?
  13. Why is security awareness training for all employees within a health care organization a major component of HIPAA compliance?
  14. Under the HIPAA Security Rule, it is a requirement for a health care organization to have a security incident response plan and team to handle potential security incidents and breaches. Why is this a requirement?
  15. True or false: It is a requirement for a health care organization to secure the transmission of ePHI through the public Internet.

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