Episode 6 - HIPAA Compliant IT

In this episode we discuss technology support requirements under HIPAA and why professional, HIPAA compliant IT services are an important part of managing your security compliance.

The Security Rule has so many specific technical things to consider it really requires professional technology services to handle it properly.  We discuss why that is needed and what to expect from a HIPAA Compliant IT company. 

Glossary

A managed service provider (MSP) is a third-party contractor that is under contract (usually a monthly fee) to provide on-going technology support to other organizations.

Links

FindHealthcareIT

HIPAAforMSPS.com

Kardon Compliance

 

Notes

 

Check out the latest episode!

Without Documentation It Didn't Happen

In this episode we discuss the importance of documentation for your HIPAA compliance program.  You can be doing everything right but without documentation there is now way for you to show anyone else that is the case.  If you can't prove it then you aren't doing it as far as OCR is concerned. 

Glossary

A managed service provider (MSP) is a third-party contractor that is under contract (usually a monthly fee) to provide on-going technology support to other organizations.

Links

FindHealthcareIT

HIPAAforMSPS.com

KardonCompliance.com

ComplyAssistant.com

Notes

• OCR says "don't just tell me you are compliant, show me you are"
• What do you need to document
  • Policies and Procedures, including archive history
  • Risk Analysis and Risk Assessment
  • Training for workforce (who, what, where, when)
  • Risk Mitigation project plans
  • Issue/Incident details
  • BAAs and BA Due Diligence
  • Activity monitoring reports and logs
  • Audit plans and results
  • Assessment plans and results
  • Inventories of software, hardware, etc
  • Breach response plans and documentation
• Spreadsheets and documents in folders or document management tools
• Compliance Management tools

Check out the latest episode!

How Do You Eat An Elephant?

In this episode we discuss how to take the first steps to building a "culture of compliance" in your organization. Every project has to start somewhere but where do you start with something as big and complicated as HIPAA? Well.... Just like the joke goes "How do you eat an elephant?" "One bite at a time."

How do you break HIPAA Compliance into bite sized pieces and get your project moving? We have some tips for you.

 

Glossary

 

A culture of compliance is when an organization establishes standards, rules, and policies that aren't simply distributed to the workforce. The organization as a whole takes their compliance serious at a personal level. Each person agrees to abide by the standards, rules, and policies set forth and holds themselves accountable to each other for doing so. This culture can only be accomplished if it is done from the CEO all the way down the organization to the volunteers and/or temporary employees.

 

Links

Posts From Donna's Blog SmallProviderHIPAA.com

How do you create a culture of HIPAA compliance?

HIPAA Documentation AKA Telling Your Compliance Story

How long will it take to get HIPAA compliant?

Simple HIPAA Checklist – Well Sort of

5 Tips to Just Get Your Risk Analysis Done

Please, Just Do My HIPAA For Me!

 

Notes

• What is a culture of compliance?
• What are the parts I need to build a culture of compliance?
  • Established and supported by Senior Mgmt
  • Integrated into all training and education done for the workforce
  • Programs are designed to reward compliance
  • Sanctions are applied equally to all levels for failure to comply
  • All technology is reviewed and managed with compliance in mind
  • Every decision, project, addition, and subtraction to the business includes considerations for compliance
• How can you really break HIPAA into small bites?
  • Documentation management plan
  • Business Associates
  • Privacy
  • Security
  • Breach
• How to motivate myself to take the first bite of the elephant?
  • Every single week start with one task that must be completed
    • Policy or procedure reviewed
    • BA evaluated and audited
    • Procedure audited
    • Training class attended
  • Allocate time to complete a task each week
    • It isn't something you do last, it should be something that is as important as completing you accounting reports, payroll, accounts receivable management, etc.
    • Build the habit or assign it to someone who has the time to apply to getting it done.
  • Build on what you started
    • HIPAA compliance is never "done"

Check out the latest episode!

Business Associates

In this episode we discuss the definition of a Business Associate.  How do you find your Business Associates and what should your process for managing them include.

Glossary

A managed service provider (MSP) is a third-party contractor that is under contract (usually a monthly fee) to provide on-going technology support to other organizations.

 

Notice of Privacy Practices (NPP) is the document CEs provide to patients when they begin treatment or coverage.  It is the document that defines the CEs Privacy, Security, and Breach Rule commitments to the patient.  

 

Links

WEDI BA Decision Tree

WEDI Business Associates & HITECH Deep Dive

 FindHealthcareIT

 HIPAAforMSPS.com

 Kardon Compliance

 

Notes

1. Anyone that CReMaTs PHI on behalf of a CE or another BA 

    Another way to think of it Produced, Received, Saved, Transferred

2. Upstream and Downstream BAs

3. BAAs and what they really mean

4. What are BAs supposed to do?  

•  Security Rule, 
•  Breach Plan, 
•  Portions of the Privacy rule.  
•  OCR - do what CEs are required to do.

5. BA Due Diligence

6. Finding them in your organization.  

•    1099s, 
•    subcontractors, 
•    software vendors.

7. Don't go crazy making everyone a BA - Incidental exposure applies for electricians and others.

Check out the latest episode!

Sue for HIPAA Negligence? No way. Way!

Takeaways: HIPAA keeps getting more important to the business for CEs and BAs but who is going to have to learn the hard way for your office to take note?

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Business Associate Agreement – Yours, Mine, or Ours?

Click to read: Business Associate Agreement – Yours, Mine, or Ours?

HIPAA One and Done has Gone the Way of the Dodo

Click to read: HIPAA One and Done has Gone the Way of the Dodo