Following in the footsteps of its bestselling predecessor, The Practical Guide to HIPAA Privacy and Security Compliance, Second Edition is a one-stop, up-to-date resource on Health Insurance Portability and Accountability Act (HIPAA) privacy and security, including details on the HITECH Act, the 2013 Omnibus Rule, and the pending rules. Updated and revised with several new sections, this edition defines what HIPAA is, what it requires, and what you need to do to achieve compliance.
The book provides an easy-to-understand overview of HIPAA privacy and security rules and compliance tasks. Supplying authoritative insights into real-world HIPAA privacy and security issues, it summarizes the analysis, training, and technology needed to properly plan and implement privacy and security policies, training, and an overall program to manage information risks. Instead of focusing on technical jargon, the book spells out what your organization must do to achieve and maintain compliance requirements on an ongoing basis.
Table of Contents
Introduction to HIPAA
How HIPAA Came to Be
What HIPAA Covers
Current State of HIPAA Compliance
Overview of the Omnibus Rule Updates
What the HITECH Act Covers
Pending Proposed Rules
Organizations That Must Comply with HIPAA
Organizations That Must Comply with the HITECH Act
HIPAA Penalties and Enforcement
Insight into the Electronic Transactions and Code
Related Regulations, Laws, Standards, and Guidance
ARRA and the HITECH Act
Preparing for HIPAA, HITECH , and Other Compliance Changes
Creating the Mind-Set
It Is Up to You
HIPAA Cost Considerations
Privacy Implementation Costs
Privacy Ongoing Maintenance Costs
Costs Related to Providing Access to PHI
Privacy Officer Costs
Security Implementation Costs
Security Ongoing Maintenance Costs
Security Officer Costs
Relationship between Security and Privacy
Privacy Rule and Security Rule Overlaps
HIPAA PRIVACY RULE
HIPAA Privacy Rule Requirements Overview
Uses and Disclosures
Incidental Uses and Disclosures
Minimum Necessary Requirement
Notice of Privacy Practices for PHI
Individual Rights to Request Privacy Protection for PHI
Individual Access to PHI
Amendment of PHI
Accounting Disclosures of PHI
PHI Restrictions Requests
Compliance Dates and Penalties
Performing a Privacy Rule Gap Analysis and Risk Analysis
Gap Analysis and Risk Analysis
Writing Effective Privacy Policies
Notice of Privacy Practices
Organizational Privacy Policies
What Is Contrary?
Exceptions to Preemption
Crafting a Privacy Implementation Plan
Some Points to Keep in Mind
Privacy Rule Compliance Checklist
HIPAA SECURITY RULE
Security Rule Requirements Overview
Introduction to the Security Rule
General Rules for Security Rule Compliance
Insight into the Security Rule
Other Organizational Requirements
Reasons to Get Started on Security Rule Initiatives
Performing a Security Rule Risk Analysis
Risk Analysis Requirements According to HIPAA
Risk Analysis Essentials
Stepping through the Process
Managing Risks Going Forward
Writing Effective Information Security Policies
Introduction to Security Policies
Critical Elements of Security Policies
Sample Security Policy Framework
Security Policies You May Need for HIPAA Security Rule Compliance
Managing Your Security Policies
Crafting a Security Implementation Plan
Some Points to Keep in Mind
Security Rule Compliance Checklist
COVERED ENTITY ISSUES
Health-Care Provider Issues
Fees for Record Review
Health-Care Clearinghouse Issues
Health Plan Issues
What Is a Health Plan?
What Is a Small Health Plan?
Health Plan Requirements
Notice of Privacy Practices
Types of Insurance Plans Excluded from HIPAA
Government and Law Enforcement
"Small" and "Large" Employers
Enforcement and Penalties
Business Associate Issues
Is Your Organization a Business Associate?
Business Associate Requirements
What You Can Expect to See or Hear from Covered Entities
Common Business Associate Weaknesses
Issues to Consider
HIPAA TECHNOLOGY CONSIDERATIONS
Building a HIPAA-Compliant Technology Infrastructure
Areas of Technology to Focus On
Looking Deeper into Specific Technologies
Additional Technology Considerations
Crafting Security Incident Procedures and Contingency Plans
Handling Security Incidents
Security Incident Procedure Essentials
Basics of Contingency Planning
Outsourcing Information Technology Services
Reasons to Consider Outsourcing
What Functions to Outsource
What to Look For in Outsourcing Firms
Common Outsourcing Mistakes
MANAGING ONGOING HIPAA COMPLIANCE
HIPAA Training, Education, and Awareness
Creating an Effective Awareness Program
Identify Awareness and Training Groups
Training Design and Development
Document Training and Awareness Activities
Performing Ongoing HIPAA Compliance Reviews and Audits
Ongoing Cost of Compliance
Making Audits Work
Appendix A: Enforcement and Sanctions
Appendix B: HIPAA Glossary
Appendix C: Model Incident and Privacy Response Procedures
Appendix D: HIPAA Resources
Kevin Beaver is an independent information security consultant, writer, professional speaker, and expert witness with Atlanta, Georgia based Principle Logic, LLC. He has worked in IT since 1989 and specializes in performing information security assessments for corporations, security product vendors, independent software developers, universities, government agencies, and nonprofit organizations. Before starting his information security consulting practice in 2001, Kevin served in various information technology and security roles for several health care, e-commerce, financial, and educational institutions.
Kevin has appeared on CNN as an information security expert and has been quoted in The Wall Street Journal, Entrepreneur, Fortune Small Business, Men’s Health, Women’s Health, Woman’s Day, and Inc. Magazine. His work has also been referenced by the PCI Security Standards Council in their PCI DSS Wireless Guidelines. He has given and participated in hundreds of highly rated presentations, panel discussions, seminars, and webcasts on information security and compliance.
Kevin has authored or coauthored 11 information security books, including Hacking For Dummies and Hacking Wireless Networks For Dummies (Wiley) as well as Implementation Strategies for Fulfilling and Maintaining IT Compliance (Realtimepublishers.com). He has written dozens of whitepapers and hundreds of articles and guest blog posts, and he is a regular contributor to SearchSecurity.com, SearchEnterpriseDesktop.com, SearchWindowsServer.com, and Security Technology Executive magazine.
Kevin is the creator and producer of the Security On Wheels audiobooks, which provide security learning for IT professionals on the go (http://www.securityonwheels.com) and its associated blog (http:// www.securityonwheels.com/blog). He also covers information security and related matters on Twitter (@kevinbeaver) and YouTube (PrincipleLogic). He earned his bachelor’s degree in computer engineering technology from Southern College of Technology and his master’s degree in management of technology from Georgia Tech. He obtained his CISSP certification in 2001 and also holds MCSE, Master CNE, and IT Project+ certifications.
Kevin can be reached through his website (http://www.principlelogic.com) and invites you to connect to him via LinkedIn (http://www.linkedin.com/in/kevinbeaver).
Rebecca Herold has over 25 years of information privacy, security, and compliance expertise. She is CEO of Privacy Professor® and is a partner for Compliance Helper®. She has led the NIST SGIP Smart Grid Privacy Subgroup since June 2009. She has been an adjunct professor for the Norwich University Master of Science in Information Security and Assurance (MSISA) program since 2005. She has written 17 books and hundreds of published articles. She has been invited to speak at a wide variety of events throughout the United States, and in other worldwide locations such as Melbourne, Australia; Bogotá, Colombia; and Naas, County Kildare, Ireland.
Rebecca is widely recognized and respected, and has been providing information privacy, security, and compliance services, tools, and products to organizations in an extensive range of industries for over two decades. Just a few of her awards and recognitions include the following:
- Rebecca was ranked #2 in the "Top 25 Female Infosec Leaders to Follow on Twitter" in 2014 by Information Security Buzz.
- Rebecca was named to the ISACA International Privacy Task Force in 2013.
- Rebecca was named on Tripwire’s list of "InfoSec’s Rising Stars and Hidden Gems: The Top 15 Educators" in July 2013.
- Rebecca was ranked #5 in the "Top 25 Female Infosec Leaders to Follow on Twiter" in 2013 by Information Security Buzz.
- Rebecca has been named one of the "Best Privacy Advisers in the World" multiple times in recent years by Computerworld magazine, most recently ranking third in the world in the last rankings provided.
- In 2012, Rebecca was named one of the most influential people and groups in online privacy by Techopedia.com.
- In 2012, Rebecca was named a Privacy by Design Ambassador by the Ontario, Canada Data Privacy Commissioner.
Rebecca is a partner for the Compliance Helper services for health-care organizations and their business associates to meet their HIPAA, HITECH, and other legal requirements. She is a member of the IAPP Certification Advisory Board, and is an instructor for the IAPP’s CIPM, CIPP/IT, CIPP/US, and CIPP foundations classes.
Rebecca currently serves on multiple advisory boards for security, privacy, and high-tech technology organizations. She is frequently interviewed and quoted in diverse broadcasts and publications such as IAPP Privacy Advisor, BNA Privacy & Security Law Report, Wired, Popular Science, Computerworld, IEEE’s Security and Privacy Journal, NPR, and many others. She regularly appears on the Des Moines, Iowa-based Great Day morning television program on KCWI to discuss and provide advice for information security and privacy topics.
Rebecca was born and raised in Missouri and has degrees in math, computer science, and education. She has lived in Iowa on a farm with her family for the past couple of decades, where they raise corn, soy beans, and sunflowers, and make hay. They are currently renovating a house that is over 100 years. See more about Rebecca, her work, services, and products at:
- The Privacy Professor (http://www.privacyguidance.com and http://www.privacyprofessor.org)
- Co-Owner, CPO, and CISO, SIMBUS (http://www.hipaacompliance.org)
- Partner, Compliance Helper (http://www.compliancehelper.com)
- Adjunct Professor for the Norwich University Master of Science in Information Security and Assurance (MSISA) program (http://infoassurance.norwich.edu/)
- Twitter ID: PrivacyProf (http://twitter.com/PrivacyProf)
Praise for the New Edition:
The HIPAA regulations are transforming how providers and insurers think about the individually identifiable health information they create and receive every minute of every day. ... There is a potential for serious harm to service levels and even to patient health if misunderstandings as to the dictates of these regulations choke off the exchange of patient-health information. This guide is a good step toward erasing many of those misunderstandings. I commend the authors for their fine efforts at translating a difficult subject into practical terms.
—Mark Lutes, Chairman, Epstein Becker Green, Washington, DC
Praise for the Bestselling First Edition:
The book's main strength is its abundant and varied content. It thoroughly describes the main provisions of HIPAA's security and privacy requirements using actual language from the legislation interspersed with the authors' commentary. This format…helpfully guides readers through the labyrinthine HIPAA requirements.
—Scott Forbes, Microsoft
Rebecca and Kevin have compiled a wealth of knowledge in an easy-to-read, conversational style. This book is packed with useful facts and practical tips that grabs and keeps your attention as though you are listening to the authors in your own living room. The astute reader will keep a pad of paper and a pile of 'sticky notes' handy. You will no doubt come back to this valuable resource over and over again!
Michael J. Corby, CCP, CISSP, President and CEO, M. Corby & Associates, Inc.
This is a very comprehensive view of HIPAA privacy and security compliance which provides a pragmatic, step by step methodology for understanding and complying with the regulation. The practical checklists, the quizzes which
can be used in HIPAA awareness programs, and the pointers to valuable resources are all added benefits.
Micki Krause, CISSP, Chief Information Security Officer, Pacific Life Insurance