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Breach Prevention: Developing Best Practices from OCR Audits and Enforcement Activities

AHIMA held its 11th Annual Privacy and Security Institute on October 7-8, 2017 in Los Angeles, concurrent with the national convention. As a sponsor of the event, MRO held a breach prevention session titled “Developing Best Practices from OCR Audits and Enforcement Activities.” During the presentation, Rita Bowen and I reviewed the current Office for Civil Rights (OCR) audit and enforcement landscape and provided best practice guidance based on audit and enforcement outcomes.

We discussed some of the biggest cases to date including nine resolution agreements totaling over $17M collected by the OCR. The top five compliance issues (in order of frequency) included (1) impermissible use and disclosures, (2) lack of safeguards, (3) lack of patient access to health information, (4) releasing the minimum necessary, and (5) lack of administrative safeguards to electronic Protected Health Information (PHI). Below are five best practices for breach prevention, as well as a video interview where I recap the presentation.

Video Recap: AHIMA Privacy and Security Institute

 

Five Best Practices for Breach Prevention

1) Create a patient data protection committee.
This committee should oversee the organization’s patient privacy compliance program and conduct quarterly risk analyses and assessments. Serving as the incident response team, each committee member should review policies and procedures annually. In addition to these responsibilities, a patient data protection committee should perform mock HIPAA audits using Phase 2 protocols from the OCR.

2) Provide ongoing education and training for workforce members.
Many breaches are caused by unintentional actions taken by workforce members who are not familiar with the proper policies and procedures for Protected Health Information disclosure management. To avoid this from happening, organizations should provide formal training at least once a year to ensure compliance with applicable federal and state law. Provide reminders of policies and procedures through emails, posters, and patient privacy awareness activities.

Some free helpful tools include:
OCR’s website
OCR’s YouTube channel
AHIMA’s Body of Knowledge

3) Implement HIPAA’s security rules for administrative, physical and technical safeguards.
Make sure your organization’s risk analysis is current and complete. This is the key to avoiding any potential threats and vulnerabilities. Utilize technologies that strengthen your compliance program and access monitoring software. For HHS guidance on technical safeguards, visit their website.

4) Test the effectiveness of your compliance program.
This can be done a few ways. Through internal, external and penetration audits. Through social engineering, which involves fake phishing emails, fake phone calls and checking desks for exposed passwords. And lastly, through mock breach exercises.

5) Assess your Business Associates’ compliance.
With proper due diligence and periodic vendor assessments, healthcare providers can safeguard their organizations against breach by way of their BAs. Additionally, Business Associate Agreements (BAAs) can ensure HIPAA compliance, and hold subcontractors liable for potential violations.

Complete the form below to download MRO’s eBook on breach prevention “Tips and Best Practices to Safeguard your Healthcare Organization.”

DOWNLOAD MRO’S eBook “Preventing a Breach: Tips and Best Practices to Safeguard your Healthcare Organization.”

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AHIMA Convention Reflections: Business Associate Management and Best Practices for Risk Analysis

At the 2017 AHIMA National Convention and Exhibit, Rita Bowen, MA, RHIA, CHPS, CHPC, SSGB, and I co-presented a session titled “Essentials for Business Associate Management: Due Diligence and Ongoing Risk Analysis.” In this presentation, we discussed ways to manage risk associated with Business Associates (BAs) for Covered Entities (CEs).

Rita and I reviewed industry trends around the renewed focus on vendor relationships and compliance, and the Office for Civil Rights’ (OCR) increased scrutiny of BAs. We covered many key components of thorough due diligence when evaluating BAs, and the necessary ongoing risk analysis once partnered.

The audience learned best practices that they can incorporate into their risk assessment process, which will make Business Associate management more bearable. Below is a video interview where I recap the presentation.

Video Recap: Managing Risk Associated with Business Associates for Covered Entities

 

Video Transcript

Anthony: I am Anthony Murray, Vice President of Information Technology for MRO.

Question: Tell us a little bit more about your presentation and the topic of BA Management.

Anthony: Today, Rita Bowen and myself presented on managing risks associated with Business Associates for Covered Entities. I think primarily what we were trying to drive home was a consistent approach to assessing risk when doing business with Business Associates within the Covered Entity space. It is a broad and deep topic. We covered a lot of different ways and concepts, so hopefully they came away with some ideas that they can incorporate into their risk assessment process to hopefully make their dealing with BAAs (Business Associate Agreements) a little bit more bearable.

Question: What best practices did you discuss during your presentation?

Anthony: We talked a lot about access controls, understanding the governance that’s in place, and trying to read the maturity scales of the Business Associates. What it really boiled down to was hopefully distilling down and understanding the services that the vendor is providing and associating the appropriate risk level to them. Based on the risk level, you hope to identify how deep into the privacy and security controls that they have in place are important to you as a company.

Question: What is MRO doing to address this topic?

Anthony: MRO is doing a number of things to help address this topic. One, is we have ongoing certifications to help augment what our CEs are going to do to assess us from a risk perspective. So, we’re trying to achieve things like HITRUST and perform our SSAE 16 and SOC type 2 audits. In addition, we also employ a number of very transparent controls that we talk about from the very onset of our relationship with our clients. How we manage access controls, how we report incidences and privacy threats all the way down to even giving access to our end user ongoing training seminars.

Question: What are some of the biggest trends and themes you’ve noticed at this year’s convention?

Anthony: I actually think this was one of the bigger topics between cyber and general privacy concerns with some of the changes in legislation. What you’re seeing is a continued focus on the business associates and risk they present. We saw a lot of good traction that we’re getting the paper work done when it comes to managing your business associates, but continuing to develop and look at the threat profile of the BAs continues to be a hot topic here.

Question: What is your favorite part about AHIMA?

Anthony: My favorite part of AHIMA is being around people who are all sharing the same struggles, challenges and opportunities that I’m facing. As a Business Associate, I’m confronted with CEs and other other agencies like ourselves that provide services to these hospitals all dealing with the same problems and being able to come together as a community and discuss it is just so reassuring that we’re not left out on an island.

To download slides from MRO’s Business Associate Management presentation, complete the form below.

DOWNLOAD MRO’S BUSINESS ASSOCIATE MANAGEMENT PRESENTATION

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