HIPAA Security – Required or Addressable

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By Jay Masci

Compliance deadline for the HIPAA Security Rule, finalized and published February 20, is February 21, 2005. If you were required to comply with the Privacy Rule or Electronic Trasactions and Code Sets Rule, you are a "covered entity" and must also comply with the Security Rule.

The Department of Health and Human Services (DHHS) provides flexibility to covered entities by stating whether a specification is "required" or "addressable."

If the specification is "required," the covered entity must implement the specification as stated in the Security Rule.

If the specification is "addressable" then the covered entity must:

1. Assess whether the specification is a reasonable and appropriate safeguard in its environment and is likely to contribute to protecting the entity's electronic protected health information.

2. Implement the specification or document why it would not be reasonable and appropriate and implement an equivalent alternative measure if reasonable and appropriate.

Implementation Specifications
(R)=Required, (A)=Addressable

Administrative Safeguards

Standards

Security Management Process  

  • Risk Analysis (R)
  • Risk Management (R)
  • Sanction Policy (R)
  • Information System Activity Review (R)

Assigned Security Responsibility (R)

Workforce Security  

  • Authorization and/or Supervision (A)
  • Workforce Clearance Procedure (A)
  • Termination Procedures (A)

Information Access Management  

  • Isolating Health Care Clearinghouse Function (R)
  • Access Authorization (A)
  • Access Establishment and Modification (A)

Security Awareness and Training  

  • Security Reminders (A)
  • Protection from Malicious Software (A)
  • Log-in Monitoring (A)
  • Password Management (A)

Security Incident Procedures

  •  Response and Reporting (R)

Contingency Plan

  • Data Backup Plan (R)
  • Disaster Recovery Plan (R)
  • Emergency Mode Operation Plan (R)
  • Testing and Revision Procedure (A)
  • Applications and Data Criticality Analysis (A)

Evaluation (R)

Business Associate Contracts and Other Arrangement

  •  Written Contract or Other Arrangement (R) 


Physical Safeguards

Standards 

Facility Access Controls

  • Contingency Operations (A)
  • Facility Security Plan (A)
  • Access Control and Validation Procedures (A)
  • Maintenance Records (A)

Workstation Use (R)

Workstation Security (R)

Device and Media Controls

  •  Disposal (R)
  •  Media Re-use (R)
  •  Accountability (A)
  •  Data Backup and Storage (A)


Technical Safeguards

Standards  

Access Control

  •  Unique User Identification (R)
  •  Emergency Access Procedure (R)
  •  Automatic Logoff (A)
  •  Encryption and Decryption (A)

Audit Controls (R)

Integrity

  •  Mechanism to Authenticate Electronic PHI (A)

Person or Entity Authentication (R)

Transmission Security

  •  Integrity Controls (A)
  •  Encryption (A)


Organizational Safeguards

Standards  

Business Associate Contracts or Other Arrangements (R)

Group Health Plans (R)

Policies and Procedures (R)

Documentation

  • Time Limit (R)
  • Availability (R)
  • Updates (R)

This article is informational only and does not constitute the rendering of legal, financial, or other professional advice or recommendations by Provaliant or individual members. If you require legal advice, you should consult with an attorney.

Jay Masci is the principal consultant of Provaliant, which provides IT consulting services including HIPAA compliance and customized training. Visit www.provaliant.com or contact Provaliant at 480.952.0656.