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Resource Overview

Conducting an SRA in accordance with HIPAA policy is a complex task, especially for small to medium providers such as community health centers. The HIPAA Security Rule mandates security standards to safeguard electronic Protected Health Information (ePHI) maintained by electronic health record (EHR) technology, with detailed attention to how ePHI is stored, accessed, transmitted, and audited. This rule is different from the HIPAA Privacy Rule, which requires safeguards to protect the privacy of PHI and sets limits and conditions on it use and disclosure. Meaningful Use supports the HIPAA Security Rule. In order to successfully attest to Meaningful Use, providers must conduct a security risk assessment (SRA), implement updates as needed, and correctly identify security deficiencies. By conducting an SRA regularly, providers can identify and document potential threats and vulnerabilities related to data security, and develop a plan of action to mitigate them.

Security vulnerabilities must be addressed before the SRA can be considered complete. Providers must document the process and steps taken to mitigate risks in three main areas: administration, physical environment, and technical hardware and software. The following set of resources provide education, strategies and tools for conducting SRA.

Security Risk Analysis Resources
Health Center Security & Compliance System Implementation Guide
Adam Kehler (OBS) & Nathan Botts (HITEQ)
/ Categories: EHR Selection and Implementation, EHR Implementation, Privacy and Security, Privacy & Security Best Practices, Security Risk Analysis

Health Center Security & Compliance System Implementation Guide

January 2019

There are ever-increasing cybersecurity guidelines and protection measures that Health Centers must navigate and digest. Newer and rurally located Health Centers can especially benefit from guidance and decision support that assists them in determining how to implement systems in a manner that meets compliance requirements and doesn’t expose information to undue security risk. Identifying and managing these types of risk can be especially important when procuring new Health IT (e.g. EHRs, Medical Devices, Data Warehouses) for the Health Center. This toolkit provides a framework for Health Centers to evaluate compliance and security concerns as they purchase, adopt, and implement technology solutions.

Every time a Health Center adopts and implements newly procured technology, they could be exposing themselves to compliance gaps and security risks. Often these topics are addressed after the solution is implemented and are an after-thought. Unfortunately, the later in the adoption process that security is considered, the costlier it becomes to address as it may require redesign or reconfiguration of software, systems, and processes.

Especially important for covered entities, like Health Centers, is for this process to meet the regulations outlined within HIPAA. Throughout this document, the related HIPAA requirements are highlighted within each section so as to better understand where this process sits within broader security risk assessment (SRA) practices. In the Appendix of this guide is an EHR/Health IT Systems checklist that can be used as an implementation interview guide when procuring new resources.

This guide can help organizations identify security concerns and design the appropriate solution starting at the design and vendor-selection phase, thereby increasing the likelihood that security will be considered fully throughout the implementation process.

Download the full toolkit below, which includes the following sections:

  • System overview
  • Information classification and inventory
  • Business Associate Agreements and Contracts
  • Risk Analysis
  • Identity management
  • Encryption
  • Auditing and logging
  • Contingency planning
  • Workstation requirements
  • Patching
  • Security testing
  • Vendor and developer access
  • Physical security
  • Network segmentation

Documents to download

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Intended AudienceHealth Center IT Staff and Leadership

Acknowledgements

This resource collection was cultivated and developed by the HITEQ team with valuable suggestions and contributions from HITEQ Project collaborators.

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