We have talked in the past about the Office for Civil Rights conducting a minimum of a 12 month look back for data security/ HIPAA compliance efforts. If an organization suffers a breach, with proper documentation fines may be waived. This is becoming known as “Recognized Security Practices”. Every organization will have different documentation based on their network configuration and how data flows in and out of your information systems. This isn’t really anything new since data security requirements have been in place since the Security Rule was enacted. There have been updates over the last few years, and they are making some new revisions requiring covered entities and business associates to document their efforts now more than ever. NIST SP800-66 Rev. 2
This includes ensuring your policies and procedures are documented and followed by your staff. Our online system makes this task must easier by enabling the HIPAA compliance officer to download and share certain policies for employees to review. Plus, the confidentiality and acceptable use agreement that is signed via DocuSign demonstrates you have advised your employees they must follow your policies and procedures.
Another part of this documentation should be reports from your IT department/vendor. Again, depending on how you access ePHI (electronic protected health information), reports will vary from practice to practice. Some suggested reports are:
- Managed devices. You can use this as your inventory list instead of completing the list in your package. However, we still recommend documenting which devices have been used to access and/or store ePHI.
- In the report above, this may contain operating systems, patches / updates that have been applied, IP addresses, User ID, and a device name. All of this is useful information, and if the report does not contain this information, you need to look for another report.
- Software lists are very important since you can see if any employee has downloaded unauthorized software or if a computer has been compromised.
- Device health reports typically include information on anti-virus, last log in, some record failed logins, or that is in a different report. These are must have reports.
- Access logs may be located within the software the IT vendor utilizes to manage your network, within your domain controller, and within your EHR/PM software. These reports must be reviewed to ensure employees are only accessing ePHI based on their job function and to look for outside intrusions.
- Backup reports should demonstrate when backups are performed and to ensure they are successful.
- Summary reports are useful, but you must make sure you review them, and they can be lengthy.
There are times when certain devices cannot be updated or upgraded due to the nature of the equipment and the cost to do so. This would not necessarily be a violation if you demonstrate other means to protect your system. For example, either removing the outdated equipment from internet access or placing it on a separate network so it would not be accessible by other drives that contain ePHI. Your IT vendor should be able to guide you through the proper process based on your particular network.
Annual audits by a third party are highly recommended unless your IT vendor specializes in network security. Often, these two types of companies work well together. The IT vendor handles the day-to-day operations, and the network security companies hardens the systems.
Some organizations complain that this costs too much money. Trust me, this is much less expensive than a data breach. Plus, if you plan on obtaining cyber liability insurance, carriers are now asking detailed questions about data security and compliance efforts. If you do have a data breach and you do not have “qualified documentation”, your claim could be denied. Of course, the term “qualified documentation” is open to interpretation. They do have an outlandish wish list from what I have seen. Although I have always been a proponent of this insurance, I am starting to believe unless you already have a policy, you may not be able to obtain one. If you do apply now, you will need to have HEAVY data security in place. Which you should have anyway!
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