The intent of quality and safety programs is to evaluate and monitor performance and to improve results. Organizations develop annual quality and safety plans with measurable objectives that departments adopt and include as integral aspects of their performance improvement plans.
In my experience, most organizations in the health-care industry?both covered entities and business associates?have taken the steps to put policies, business processes, and training programs in place to help ensure compliance with the HIPAA Security Rule. Still, there's a gaping hole in many healthcare compliance and security programs: a lack of technical security testing of Web applications, mobile applications, and network systems.
Q: I am familiar with the HIPAA Security Rule requiring information system review audits. Are there any HIPAA Privacy Rule requirements?other than to perform audits?that require the examination of inappropriate access for an alleged breach? Currently, our security team performs monthly information system review audits and issues reports to leadership on a quarterly basis. Will this suffice, or are there audits that the privacy team should perform as well?
Privacy and information security programs in healthcare organizations have developed and matured to meet the requirements of HIPAA and other federal and state laws. In some organizations, providers and managers struggle to keep pace with the changes. Expanded focus on EHR technology and new threats to the security of personally identifiable information (e.g., healthcare, financial, educational, employment) will further affect privacy and information security programs in the future.
Although numerous privacy and security laws apply to healthcare entities, HIPAA rules and requirements tend to receive the most emphasis?and generate the most angst. The terms HIPAA-compliant vendor, HIPAA cop, and HIPAA disciplinary action are anathema to experienced and serious privacy and information security professionals. HIPAA, as has been noted, represents the floor of requirements intended to protect the privacy and security of patient information. More stringent privacy requirements have existed at the state and national levels for several years before the HIPAA Privacy Rule was implemented (e.g., state medical records laws and requirements). Notably, many organizations implement policies and procedures that are more stringent than that required by HIPAA. Some of this is due to misinformation or misunderstanding of the HIPAA rules.
