Q: I was recently hired for a position at a long-term care facility. Upon getting acclimated, I learned that the facility has completed handwritten logs for every fax that was sent out since 2003. This document is referred to as the HIPAA fax log and contains the date the fax was sent, to whom it was sent, by whom it was sent, the number of pages, and whether a cover sheet with confidentiality statement was included. I would like to do away with this form since fax machines can generate their own logs. However, if this is a necessary process then I would like to follow official guidelines and update the facility's policies and procedures accordingly. Does the HIPAA Privacy or Security Rule require these logs? If so, what information must we include?
At this point, there are no federally recognized HIPAA certification standards for covered entities (CE) and business associates (BA). However, that doesn't mean there are no good assessment tools out there to gauge information security and regulatory compliance. The Health Information Trust Alliance (HITRUST) published its first common security framework (CSF) in March 2009 with the goal of focusing on information security as a core pillar of the broad adoption of health information systems and exchanges.
Q: My facility no longer registers patients under aliases, but will allow them to opt out of the patient directory. However, opting out of the registry will not exclude our patients from the operating room (OR) list. At one time, the facility's CEO received the daily OR list with full patient names so he could visit board members, donors, or others whom he knows at our facility. HIM changed this practice so that patients' names would not be on the OR schedule provided to the CEO. The CEO took this matter to the hospital attorney, who said the names could be included because the use of PHI by the CEO to determine whether and when a patient visit is appropriate is permitted by HIPAA as it is part of healthcare operations. Is it a violation of HIPAA for the CEO to use PHI to track patients in this manner?
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.
Albert Einstein once said "The difference between stupidity and genius is that genius has its limits." To paraphrase Einstein, the difference between security and compliance is that compliance has its limits. With each high-profile breach that makes headlines, organizations likely question the link between compliance and security, wondering whether the two are one and the same.
