One of the Meaningful Use(MU) core objectives for eligible professionals, eligible hospitals and critical access hospitals is to conduct through technical risk analysis of EHR and ePHI systems. The primary objective of the risk analysis is to identify the key vulnerabilities in the ePHI and EHR systems and plan on mitigating the risks by fixing, transferring or accepting risks. Attestation of the risk analysis is required every year to CMS for incentive payments. EHR 2.0 risk analysis services ensures you identify the key technical risks in your areas. Why risk analysis? HIPAA and meaningful risk analysis is the first step in healthcare practice’s security rule compliance efforts. Risk analysis is an ongoing process that should provide the practice with a detailed understanding of the risks to the confidentiality, integrity, and availability of e-PHI. The key questions asked during a risk analysis are: Have you identified the e-PHI within your organization? This includes e-PHI that you create, receive, maintain or transmit. What are the external sources of e-PHI? For example, do vendors or consultants create, receive, maintain or transmit e-PHI? What are the human, natural, and environmental threats to information systems that contain e-PHI? What is the scope of the risk analysis? The scope of risk analysis that the HIPAA security rule encompasses includes the potential risks and vulnerabilities to the confidentiality, availability and integrity of all e-PHI that an organization creates, receives, maintains, or transmits. This includes e-PHI in all forms of electronic media, such as hard drives, floppy disks, CDs, DVDs, smart cards or other storage devices, personal digital assistants, transmission media, or portable electronic media. Electronic media includes a single workstation as well as complex networks connected between multiple locations. Thus, an organization’s risk analysis should take into account all of its e-PHI, regardless of the particular electronic medium in which it is created, received, maintained or transmitted or the source or location of its e-PHI. How to inventory ePHI systems? An healthcare organization must identify where the e-PHI is stored, received, maintained or transmitted. An organization could gather relevant data by: reviewing past and/or existing projects; performing interviews; reviewing documentation; or using other data gathering techniques. The data on e-PHI gathered using these methods must be documented. Learn more about our services at http://ehr20.com/services/risk-analysis-for-meaningful-use/

1. Meaningful Use Risk
Analysis

2. Who are we
EHR 2.0 Mission: To assist healthcare
organizations develop and implement
practices to secure IT systems and comply
with HIPAA/HITECH regulations.
 Education
 Consulting
 Toolkit(Tools, Best Practices & Checklist)
Goal: To make compliance an enjoyable
and painless experience

3. Webinar Objective
Understand and Perform Meaningful Use
Risk Analysis that satisfies CMS
incentive and attestation requirement.
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4. Glossary
1. HHS, CMS:
2. NIST:
3. Threats and Vulnerabilities:
4. Findings:
5. Risk Analysis:
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5. The American Recovery and
Reinvestment Act of 2009 and HITECH
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6. HITECH Act
The Health Information Technology for Economic and
Clinical Health (“HITECH”) provisions of the
American Recovery and Reinvestment Act of 2009
(“ARRA”, also referred to as the “Stimulus Bill”) codify and
expand on many of the requirements contained in the
Health Insurance Portability and Accountability Act of 1996
(“HIPAA”) and its regulations to protect the privacy and
security of protected health information (“PHI”).
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7. HITECH
HITECH modifications to HIPAA including:
 Creating incentives for developing a meaningful use of
electronic health records
 Changing the liability and responsibilities of Business
Associates
 Redefining what a breach is
 Creating stricter notification standards
 Tightening enforcement
 Raising the penalties for a violation
 Creating new code and transaction sets (HIPAA 5010,
ICD10) 7

8. CMS Meaningful Use Incentives
For Eligible Professionals 8

9. For Eligible Professionals
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10. For Eligible Hospital & CAH
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11. HIPAA Titles - Overview
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12. HIPAA Security Rule
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13. Information Security Model
Confidentiality
Limiting information access and
disclosure to authorized users (the right
people)
Integrity
Trustworthiness of information
resources (no inappropriate changes)
Availability
Availability of information resources (at
the right time)
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14. PHI
Health
Information
Individually
Identifiable
Health
Information
PHI
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15. ePHI – 18 Elements
Elements Examples
Name Max Bialystock
1355 Seasonal Lane
Address (all geographic subdivisions smaller than state,
including street address, city, county, or ZIP code)
Dates related to an individual Birth, death, admission, discharge
212 555 1234, home, office, mobile etc.,
Telephone numbers
212 555 1234
Fax number
Email address LeonT@Hotmail.com, personal, official
Social Security number 239-68-9807
Medical record number 189-88876
Health plan beneficiary number 123-ir-2222-98
Account number 333389
Certificate/license number 3908763 NY
Any vehicle or other device serial number SZV4016
Device identifiers or serial numbers Unique Medical Devices
Web URL www.rickymartin.com
Internet Protocol (IP) address numbers 19.180.240.15
Finger or voice prints finger.jpg
Photographic images mypicture.jpg
Any other characteristic that could uniquely 15
identify the individual

16. HIPAA Security –Administrative
safeguard (§164.308)
(A) Risk analysis (Required)
Conduct an accurate and thorough assessment of the
potential risks and vulnerabilities to the confidentiality,
integrity, and availability of electronic protected health
a(1) Security information held by the covered entity.
(B) Risk management (Required)
Management Implement security measures sufficient to reduce risks
and vulnerabilities to a reasonable and appropriate level
Process to comply with §164.306(a).
Implement policies and (C) Sanction policy (Required)
procedures to prevent,
detect, contain, and Apply appropriate sanctions against workforce members
correct security who fail to comply with the security policies and
violations. procedures of the covered entity.
(D) Information system activity review (Required)
Implement procedures to regularly review records of
information system activity, such as audit logs, access
reports, and security incident tracking reports.

17. Infrastructure
 Computers
 Storage Devices
 Networking devices (Routers,
Switches & Wireless)
 Medical Devices
 Scanners, fax and
Any device that photocopiers
electronically stores or  VoIP
transmits information  Smart-phones, Tablets (ipad,
using a software
PDAs)
program 17
 Cloud-based services

18. Trends in Healthcare IT
Informatics Collaboration
Mobile EHR
Computing HIE
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19. Handheld Usage in Healthcare
• 25% usage with providers
• Another 21% expected to use
• 38% physicians use medical
apps
• 70% think it is a high priority
• 1/3 use hand-held for accessing EMR/EHR
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compTIA 2011 Survey

20. EMR and EHR systems
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21. Health Information Exchange (HIE)
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22. Social Media
 How does your practice use it?
 How do your employees use it?
 Do you have policies?
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23. Cloud-based services
 Public Cloud
 EHR Applications
HIPAA regulations  Private-label e-mail
remain barriers to full
cloud adoption
 Private Cloud
 Archiving of Images
 File Sharing
Cloud Computing is taking
all batch processing, and  On-line Backups
farming it out to a huge
central or virtualized
 Hybrid 23
computers.

24. Informatics
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25. Risk Assessment Methodology
Flowchart(NIST)
Step 3: Step 5: Step 7: Step 8:
Step 1: System Step 2: Threat Step 4: Step 6:
Vulnerability Likelihood Risk Control
Characterization Identification Control Analysis Impact Analysis
Identification determination Determination Recommendation
Current controls
Mission impact Recommended
Reports from and planned Likelihood of
Hardware, analysis, asset controls
previous risk controls Threat source threat
Software, criticality
assessments, motivation, assessment, exploitation,
System any audit threat capacity, data criticality, magnitude of
Interfaces, Data History of comments, Nature of data sensitivity impact,
and Information, system attack, security List of current vulnerability, adequacy of
People and Data from requirements, and planned current controls planned or
System mission intelligence security test controls current controls
agencies results
Impact rating
Risk and
List of potential Likelihood rating Associated risk
System vulnerabilities levels
boundary,
functions,
criticality and
sensitivity
Threat
Statement

26. Risk Analysis - Example
Risk Description
Risk Description /Threat and Probability Conse- Risk Risk
Potential Loss of Loss quence Score Value
ePHI located on Desk top in an 4 4 16 High
employees office is not routinely
backed up.
Risk = Loss of PHI
(Identified in Gap Analysis)

27. Sample Risk Analysis Template
Likelihood
High Medium Low
High Unencrypted Lack of auditing on Missing security
laptop ePHI EHR systems patches on web server
hosting patient
information
Impact
Medium Unsecured Outdated anti-virus External hard drives
wireless network software not being backed up
in doctor’s office
Sales presentation Web server backup Weak password on
Low on USB thumb tape not stored in a internal document
drive secured location server
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28. Risk Management- Steps
 Develop and implement a risk management plan
 Implement security measures
 Evaluate and maintain security measures
 Risk transfer, reduction, acceptance

29. Sanction Policy
Acceptable Use of PHI
- Minimum Necessary
- Sanction Exemptions
Disciplinary Actions
Sample sanction policy:
https://docs.google.com/document/d/1KSMZtdp9O
AHILfTAKWdCkUR6jv6vl9mGIDYvv-5gQ1o/edit

30. Information System Security Review -
Example
 Review of Security Incidents Response reports
 System user privileges grants and changes logs
 User-level system access logs, if available
 User level system activity logs, if available
 User level transaction log reports, if available
 Exception reports
 The required level of system activity logging and
reporting capabilities, and the actual scope

31. Top 5 Recommendations
1. Ensure encryption on all protected health information
in storage and transit.(at least de-identification)
2. Implement a mobile device security program.
3. Strengthen information security user awareness and
training programs.
4. Ensure that business associate due diligence includes
clearly written contract, a periodic review of
implemented controls.
5. Minimize sensitive data capture, storage and sharing.
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32. Meaningful Use Stage 2 and Stage 3
Security Requirements
 Security Risk Analysis with encryption
assessment
 Secure Messaging for ambulatory practices
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33. Effective Management of Security and
Compliance
Find out where your
business is weak
Determine the
Re-evaluate on a
compliance and
periodic and
security needs &
consistent basis
gaps
Implement the right Put reasonable
technologies & policies and
processes to help business processes 33
with enforcement in place

34. HIPAA Security Checklist
Overview
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35. Key Takeaways
 Risk Analysis is foundation for an effective security
program
 ePHI elements drives risk analysis scope
 There is no silver bullet for risk management. It is a
journey of continuous assessment and improvement
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36. Additional Resources
 NIST - Risk Management Guide for Information
Technology Systems SP800-30
 Small Practice Security Guide
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37. How can you help us?
 Follow-us on social media
facebook.com/ehr20 (Like)
linkedin.com/company/ehr-2-0 (Follow us)
https://twitter.com/#!/EHR_20 (Follow)
 Next Webinar on Business Associate Assessment( 3/21)
 http://ehr20.com/services/
We sincerely appreciate your referrals! 37

38. Thank you!!
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