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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
Section IV - Acknowledgements
Nathan Botts
/ Categories: Archived

Section IV - Acknowledgements

Guide to Improving Care Processes and Outcomes in FQHCs

Origins and Ongoing Refinement of this Guide: The content in this resource is drawn from and builds on widely used CDS/QI tools and strategies that have evolved over the past decade. The HITEQ Center plans to continue refining this Guide based on input from users like you, so please consider sharing your feedback through the comment form.

  • The content in this Guide is an adapted and expanded version of care process improvement guidance on healthit.gov. That original material was developed by Jerome Osheroff, MD, TMIT Consulting, LLC in collaboration with ONC and Deloitte, and this version on HITEQ was also developed by Osheroff/TMIT in collaboration with JSI and others.
     
  • Guide Reviewers (Individuals below each provided helpful feedback on an earlier draft of this guide; those marked with * provided particularly detailed feedback that led to substantial enhancements):
    • Sheila Allen, MPH; Chief Compliance and Quality Officer, HealthNet, Inc.
    • *Daren Anderson, MD; Director of the Weitzman Institute and VP/Chief Quality Officer of Community Health Center, Inc
    • Sasha East, MD; Internal Medicine Resident, Robert Wood Johnson University Hospital
    • Renu George, MD; Internal Medicine Resident, Robert Wood Johnson University Hospital
    • *Meg Meador, MPH, C-PHI;  NACHC Director of Clinical Integration and Education
    • *Jillian Maccini, MBA; Consultant, JSI
    • Laura Methvin, MD; Internal Medicine Resident, Robert Wood Johnson University Hospital
    • Alan Mitchell; Program Director, Performance Improvement, Primary Care Development Corporation (PCDC)
    • * Nivedita Mohanty, MD; Director of Evidence-based Practice, Alliance of Chicago
    • Rick Reifenberg MD, FAAP, FACP, Associate Medical Director, HealthNet Inc.
       
  • Refinements to material on this page to enhance its use and usefulness are planned based on user feedback (HITEQinfo@jsi.com).
     
  • Recommended citation for this Guide [provided by JSI/HITEQ]
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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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