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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
I Provide SUD Services in an FQHC: Does Part 2 Apply to Me?
HITEQ Center
/ Categories: Privacy and Security, HIPAA

I Provide SUD Services in an FQHC: Does Part 2 Apply to Me?

A Decision Tree from the Legal Action Center

This decision tree, developed through funding from the  Substance Abuse and Mental Health Services Administration (SAMHSA) helps organizations determine if Part 2 of CFR 42 applies to them.

It should be noted that FQHCs will always be designated as “federally assisted” due to certified status as Medicaid providers and/or federal funding. Under 42 CFR Part 2 (hereafter referred to as “Part 2”), a patient can revoke consent to one or more parties named in a multi-party consent form while leaving the rest of the consent in effect. In a non-Health Information Exchange (HIE) environment, this can be accomplished simply by the Part 2 program indicating on the consent form or in the patient’s record that consent has been revoked with respect to one or more named parties. In an HIE environment, the revocation with respect to one or more parties should be clearly communicated to the Health Information Organization (HIO) as well as noted in the patient’s record by the Part 2 program.

Documents to download

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Intended Audiencehealth center staff

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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