July 1, 2016
Briefings on HIPAA

HIPAA audits

Phase 2 audit protocol

As Phase 2 of the HIPAA audit program begins, covered entities (CE) and business associates (BA) will be watching their email for an audit letter from OCR. Of those chosen for audit, most will be selected for a desk audit. They'll have 10 days after receipt of the email to gather requested documents for OCR's auditors.

But how will CEs and BAs know they are collecting the right information? A careful reading of the updated Phase 2 audit protocol (www.hhs.gov/hipaa/for-professionals/compliance-enforcement/audit/protocol/index.html) will help guide CEs and BAs. But if the protocol isn't read carefully, and in full, important documents could easily be left out, leading to inaccurate audit reports and even a visit from OCR's investigators.

The Phase 2 audit protocol expands the Phase 1 compliance areas to reflect changes made by the 2013 HIPAA omnibus final rule. The updated audit protocol also includes information for BAs, which were not audited during Phase 1 but will be in the current round of audits. The protocol contains a description of the audit areas, general instructions and definitions, and a keyword-searchable table.

Phase 2 audits will be conducted in three rounds. The first two rounds will consist of desk audits of specific audit targets, while the third round will be comprehensive audits. Round one audits will target CEs and round two audits will target BAs.

Round one CE audit targets will target:

  • Security: risk analysis and risk management
  • Breach: content and timeliness of notifications
  • Privacy: notice and access


The round two BA audits will target:

  • Security: risk analysis and risk management
  • Breach: breach reporting to covered entities


July 1, 2016
Briefings on HIPAA

Protecting patients' identities

Medical identity theft: Part 1

Editor's note: This is part one of a series about medical identity theft. Look for part two in an upcoming issue of BOH.

Privacy and security officers are sitting on a hoard of valuable data: medical identity information. Social Security numbers. Medicare, Medicaid, and other insurer numbers. Credit card and bank account information. This data can fetch a high price on the black market, and medical identity theft costs patients, providers, and insurers millions of dollars a year. The lure of medical identity information makes healthcare organizations an appealing target for criminals, from large operations launching sophisticated hacking schemes to smaller groups running tried and true fraud scams.

A 2015 study conducted by the Ponemon Institute and sponsored by the Medical Identity Fraud Alliance (MIFA), the Fifth Annual Study on Medical Identity Theft, found that medical identity fraud nearly doubled between 2010 and 2014. More than 2.3 million adults were victims of medical identity theft and fraud in 2014 alone. The average cost per victim was $13,500 and the combined out-of-pocket cost was approximately $20 billion. But the financial impact is only the tip of the iceberg. Medical identity theft can result in physical harm to a patient if the medical record is altered to include another person's information such as allergies, disease status, or blood type.

Healthcare organizations often absorb some of the costs, and if the stolen PHI was used to commit Medicare or Medicaid fraud, they could be investigated by the OIG.

The stakes are high but by raising awareness and championing education and robust security programs, privacy and security officers can help their organizations stay one step ahead of criminals.

July 1, 2016
Briefings on HIPAA

Risk analysis

Creating and conducting an organizationwide risk analysis: Part 2

Editor's note: This is part two of a series about implementing an organizationwide risk analysis. See the May 2016 issue of BOH for part one.

Performing a regular organizationwide risk analysis is a basic HIPAA requirement and also simply good business practice. Beyond checking off an item on the HIPAA compliance list, a risk analysis will help an organization identify and rank security weaknesses, efficiently use resources to address them, and ultimately protect the security and integrity of an organization's data, including PHI, financial, and business operations information. Yet in a world of competing demands and limited resources, a risk analysis may be put off until it's too late. Even if one is completed, security officers may encounter obstacles when trying to act on the results of the risk analysis.

The purpose of a risk analysis is to develop a strategic plan of action that addresses and corrects vulnerabilities, and shouldn't be used to simply create a report on the current state of security, says Kate Borten, CISSP, CISM, HCISPP, founder of The Marblehead Group in Marblehead, Massachusetts. "Only when an organization performs periodic and as-needed risk assessments, and then mitigates significant risks, can the ISO [information security officer] and leadership have the confidence that their security program is functioning and adequate," she says.

A risk analysis is one of several activities that is part of a risk management program, says Rick Ensenbach, CISSP-ISSMP, CISA, CISM, CCSFP, manager of risk advisory and forensic services at Wipfli, LLP, in Eau Claire, Wisconsin. The risk management program is about managing risks to the organization (i.e., business mission, image, reputation, and patient safety and privacy), organizational assets, and workforce. An organization can't mitigate risks it isn't aware of and doesn't understand.

Risks are first identified, then analyzed and evaluated based on what action is needed, Ensenbach says. They also must be monitored on an ongoing basis, a vital step that if missed can undermine an otherwise solid risk management program.

July 1, 2016
Briefings on HIPAA

Product watch

Maize Analytics audit log tool

by Chris Apgar, CISSP

Information systems activity review is a fancy way of saying you need to monitor your network and your applications including who is looking at and manipulating your patient information. That can be an expensive, or even almost impossible, proposition when it comes to regular monitoring of access to patient information stored in electronic health records (EHR). Two of the well-known automated audit logging tools on the market, FairWarning and Iatric, are well outside the budget for small- to medium-sized covered entities (CE). The manual option, checking audit logs by hand, is slow and ineffective.

July 1, 2016
Briefings on HIPAA


by Mary D. Brandt, MBA, RHIA, CHE, CHPS

Q: Is it permissible to take pictures of patients for identification purposes as a part of the registration process? Do the patients need to sign a consent form before their picture can be taken?


A: It is permissible to take pictures of patients for identification purposes if the patient agrees to it. Since the Privacy Rule considers full-face photographs to be a patient identifier, it is a good practice to get the patient's written consent to take a photograph and file it with the patient's electronic record. The patient should be allowed to opt out of the photograph if he or she chooses.

Editor's note

Brandt is a healthcare consultant specializing in healthcare regulatory compliance and operations improvement. She is also an advisory board member for BOH. This information does not constitute legal advice. Consult legal counsel for answers to specific privacy and security questions. Opinions expressed are those of the author and do not represent HCPro or ACDIS. Email your HIPAA questions to Associate Editor Nicole Votta at nvotta@hcpro.com.

July 1, 2016
Briefings on HIPAA

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