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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
Payment Reform Readiness Assessment Tool

Payment Reform Readiness Assessment Tool

The readiness assessment tool allows health centers to systematically self-assess their current state of readiness for engagement in value-based payment initiatives and identify opportunities to improve or maintain readiness. The tool includes a series of statements and scaled response choices for health center leadership and management staff to respond to. The tool is organized into three domains:

  • Organizational leadership to pursue and guide payment reform eff orts (including leadership in the development of partnerships);
  • Change management and service delivery transformation with the ability to make robust use of data and information to support payment reform eff orts (and related delivery system redesign); and
  • Financial and operational analysis required for the successful participation in payment reform initiatives.

Additional resources are available at https://www.nachc.org/focus-areas/policy-matters/medicaid-and-medicare/payment-and-delivery-reform/ 

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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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