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Are You Ready for Stage 2 HIPAA Audits?

Posted on June 27, 2016 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

Many organizations probably didn’t even realize that OCR (HHS’ department in charge of HIPAA) had put in place HIPAA audits since the pilot program only audited 115 covered entities. That’s likely to change for a lot more healthcare organizations (including business associates) as Stage 2 HIPAA Audits are rolled out. Is your organization ready for a HIPAA Audit?

After spending about 2 months scouring the Stage 2 HIPAA Audit prototol, HIPAA One put together a great comparison of the simplicity of stage 1 HIPAA audits versus stage 2 HIPAA audits:

What it was – Phase 1 of the OCR’s Privacy, Security and Breach Notification Audit Program:
  1. HITECH added Breach Notification to HIPAA and endorsed the OCR‘s Audit Program.
  2. Contained 169 total protocols.
  3. Pilot program included 115 covered entities.
What it is now – the HIPAA Audit Program-Phase 2:
  1. OCR is implementing Phase 2 to include both CEs and business associates (every covered entity and business associate is eligible for an audit)
  2. Provides an opportunity for the OCR to identify best practices, risks and issues before they result in bigger problems (e.g. resulting in a breach) through the expanded random audit program.
  3. 180 Enhanced protocols (groups of instructions) which contain the following updates:
    1. Privacy – 708 updates (individual lines of instructions)
      1. Most notable changes are more policies and procedures surrounding the HIPAA Privacy Officer as well as some changes for Health Plans and Business Associates.
    2. Security – 880 updates (individual lines of instructions)
      1. Most notable changes are that Health Plans must have assurances from their plan sponsors and all companies now have to get proof of HIPAA compliance from their business associates, vendors and subcontractors.

That’s a lot of changes that are going to impact a lot of organizations. How many organizations have spent the time seeing which of these changes are going to impact their organization? I’m sure the answer to that is not many since “ignorance is bliss” is the mantra of many healthcare organizations when it comes to HIPAA compliance.

Particularly interesting is that HIPAA One points out that many of the checklists, books, commercial compliance software, and even ONC’s own SRA tool are likely outdated for these new changes to the HIPAA audit protocol. They’re probably right, so make sure whatever tool you’re using to do a HIPAA SRA takes into account the new HIPAA audit protocol.

Just so we’re clear, there actually hasn’t been a change to the HIPAA Omnibus update in 2013. However, the HIPAA audit protocol clarifies how the HIPAA law will be interpreted during an audit. That means that many of the gray areas in the law have been clarified through the audit protocol.

In HIPAA One’s blog post, they outline some important next steps for healthcare organizations. I won’t replicate it here, but go and check it out if you’re a HIPAA compliance officer for your organization or forward it to your HIPAA compliance officer if you’re not. The first suggestion is a really key one since you want to make sure you’re getting your HIPAA audit emails from OCR.

It’s taken HHS and OCR a while to roll out the full HIPAA audit program. However, it’s fully functioning now and I expect 2016 will be a real wake-up call for many organizations that aren’t prepared for a HIPAA audit. Plus, many others will be woken up when their friends fail their HIPAA audit.

Is your organization ready for a HIPAA audit?

Full Disclosure: HIPAA One is an advertiser on Healthcare Scene.

Windows XP Won’t Be HIPAA Compliant April 8, 2014

Posted on December 12, 2013 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

As was announced by Microsoft a long time ago, support for Windows XP is ending on April 8, 2014. For most of us, we don’t think this is a big deal and are asking, “Do people still use Windows XP?” However, IT support people in healthcare realize the answer to that question is yes, and far too much.

With Microsoft choosing to end its support for Windows XP, I wondered what the HIPAA implications were for those who aren’t able to move off Windows XP before April 8. Is using Windows XP when it’s no longer supported a HIPAA violation? I reached out to Mac McMillan, CEO & Co-Founder of CynergisTek for the answer:

Windows XP is definitely an issue. In fact, OCR has been very clear that unsupported systems are NOT compliant. They cited this routinely during the audits last year whenever identified.

Unsupported systems by definition are insecure and pose a risk not only to the data they hold, but the network they reside on as well.

Unfortunately, while the risk they pose is black and white, replacing them is not always that simple. For smaller organizations the cost of refreshing technology as often as it goes out of service can be a real challenge. And then there are those legacy applications that require an older version to operate properly.

Mac’s final comment is very interesting. In healthcare, there are still a number of software systems that only work on Windows XP. We’re not talking about the major enterprise systems in an organization. Those will be fine. The problem is the hundreds of other software a healthcare organization has to support. Some of those could be an issue for organizations.

Outside of these systems, it’s just a major undertaking to move from Windows XP to a new O/S. If you’ve been reading our blogs, Will Weider warned us of this issue back in July 2012. As Will said in that interview, “We will spend more time and money (about $5M) on this [updating Windows XP] than we spent working on Stage 1 of Meaningful Use.” I expect many organizations haven’t made this investment.

Did your HIPAA compliance officer already warn you of this? Do you even have a HIPAA compliance officer? There are a lot of online HIPAA Compliance training courses out there that more organizations should consider. For example, the designated compliance officer might want to consider the Certified HIPAA Security Professional (CHSP) course and the rest of the staff the HIPAA Workforce Certificate for Professionals (HWCP) course. There’s really not much excuse for an organization not to be HIPAA compliant. Plus, if they’re not HIPAA compliant it puts them at risk of not meeting the meaningful use security requirements. The meaningful use risk assessment should have caught this right?

I’m always amazed at the lack of understanding of HIPAA and HIPAA compliance I see in organizations. It’s often more lip service than actual action. I think that will come back to bite many in the coming years. One of those bites will likely be organizations with unsupported Windows XP machines.