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Instructor : Jim Sheldon Dean
Product Id : 20050PACK

Overview: The session will present how to use risk analysis techniques to help make good compliance decisions that are defensible and sensible. For many compliance questions, careful consideration of the likelihood of the issue being a problem, and the potential impact if it is a problem, can help provide understanding of how to prioritize and compare risk issues and make day-to-day decisions.

This session will cover the requirements for risk analysis and assessment in the HIPAA rules and provide a framework for analysis of risks for compliance with HIPAA Security Rule requirements (in §164.308(a)(1)) and the new breach determination requirements in the updated HIPAA Breach Notification Rule, and show how the two are related in a good compliance program. We will show how to go about assessing your risks and organizing your compliance plan, and show how having that information makes it easier to assess risks in the event of a breach.

For the Security Rule, we will explain what is called for in the rule and show a way to approach the work in an organized way that saves effort and produces meaningful results, with examples of how to conduct the risk analysis, and sample documents and templates provided. For the updated Breach Notification Rule, we will explain how the new process differs from the old "harm standard" that has been removed from the rule. If none of the defined exceptions for notification apply, the breach is reportable unless you can show, by a risk analysis, that there is a "low probability of compromise." The risk analysis must include at least four factors: 1) what the data is, how well identified is it, and how sensitive it is, 2) to whom the data was improperly disclosed, 3) whether or not the information was actually viewed or accessed, and 4) how the breach was mitigated. Issues with any one of the four factors can require reporting the breach. We will explain how to consider these factors.

The session will also include information on HIPAA Audits and how to be prepared to show that you have the right policies and procedures in place and are using them. To withstand random audits and investigations of non-compliance that may result from a breach report or complaint, thorough documentation of compliance-related activity is required. We will explain how to document your compliance using the HIPAA Audit Protocol as a guide, so you can be sure to avoid trouble if HHS ask questions about your compliance.

Areas Covered in the Session:
  • Identification of requirements for Risk Analysis in HIPAA Privacy, Security, and Breach Notification, and Meaningful Use Rules
  • Presentation of methods for identifying and evaluating risks
  • Techniques for organizing issues and prioritizing risk mitigation
  • How a thorough Risk Analysis satisfies many requirements in HIPAA at once
  • The difference between a HIPAA Risk Analysis and a Meaningful Use Risk Analysis
  • The Four Factors to consider in a Risk Assessment for determing whether or not to report a breach
  • Evaluating and comparing risks and risk mitigation methods
  • Policy versus Technology - both can bring compliance, but both must be audited by you

Who Will Benefit:
  • Compliance director
  • CEO
  • CFO
  • Privacy Officer
  • Security Officer
  • Information Systems Manager
  • HIPAA Officer
  • Chief Information Officer
  • Health Information Manager
  • Healthcare Counsel/lawyer
  • Office Manager
Jim Sheldon-Dean is the founder and director of compliance services at Lewis Creek Systems, LLC, a Vermont-based consulting firm founded in 1982, providing information privacy and security regulatory compliance services to a wide variety of health care entities.

Sheldon-Dean serves on the HIMSS Information Systems Security Workgroup, has co-chaired the Workgroup for Electronic Data Interchange Privacy and Security Workgroup, and is a recipient of the WEDI 2011 Award of Merit. He is a frequent speaker regarding HIPAA and information privacy and security compliance issues at seminars and conferences, including speaking engagements at numerous regional and national healthcare association conferences and conventions and the annual NIST/OCR HIPAA Security Conference in Washington, D.C.

Sheldon-Dean has more than 30 years of experience in policy analysis and implementation, business process analysis, information systems and software development. His experience includes leading the development of health care related Web sites; award-winning, best-selling commercial utility software; and mission-critical, fault-tolerant communications satellite control systems. In addition, he has eight years of experience doing hands-on medical work as a Vermont certified volunteer emergency medical technician. Sheldon-Dean received his B.S. degree, summa cum laude, from the University of Vermont and his master’s degree from the Massachusetts Institute of Technology.
Instructor : Jim Sheldon Dean
Product Id : 20050PACK

Overview: It seems everyone is moving to a new smart phone and wants to use it in all the incredible ways it can be used, including for health care purposes. New health care apps are being released all the time, and even good old e-mail is being used more and more to communicate, by providers and patients alike.

In order to integrate the use of mobile technology into patient communications, it is essential to perform the proper steps in an information security compliance process to evaluate and address the risks of using the technology. This session will describe the information security compliance process, how it works, and how it can help you decide how to integrate mobile technology into your organization in a compliant way. The process, including the use of information security risk analysis, will be explained, and the policies needed to support the process will be described.
But the process must also include consideration of various patient access requirements in the HIPAA Privacy Rule. There are new requirements to provide patients electronic access of electronically held PHI which raise new questions of how that access will be provided and how the information will be protected during and after access. And there has long been a HIPAA requirement for covered entities to do their best to meet the requests of their patients for particular modes of communication, and using a mobile device is no exception.

The stakes are high – any improper exposure of PHI may result in an official breach that must be reported to the individual and to the US Department of Health and Human Services, at great cost and with the potential to bring fines and other enforcement actions if a violation of rules is involved. Likewise, complaints by a patient if they are not afforded the access they desire can bring about HHS inquiries and enforcement actions, so it is essential to find the right balance of access and control.
HHS compliance audit activity and enforcement penalties are both increased, especially in instances of willful neglect of compliance, if, for instance, your organization hasn't adopted the complete suite of policies and procedures needed for compliance, or hasn’t adequately considered the impact of mobile devices on your compliance. Given that mobile devices are a leading source of breaches of PHI, it is essential to consider these devices and how their use affects the privacy and security of PHI; not doing so is inviting enforcement action by HHS.

The session will discuss the requirements, the risks, and the issues of the increasing use of mobile devices for patient communications and provide a road map for how to use them safely and effectively, to increase the quality of health care and patient satisfaction.

Areas Covered in the Session:
  • Find out the ways that patients want to use their mobile technology to communicate with providers, and the ways providers want to use their mobile technology to enable better patient care.
  • Learn what are the risks of using mobile technology, what can go wrong, and what can result when it does.
  • Find out about HIPAA requirements for access and patient preferences, as well as the requirements to protect PHI.
  • Learn how to use an information security management process to evaluate risks and make decisions about how best to protect PHI and meet patient needs and desires.
  • Find out what policies and procedures you should have in place for dealing with mobile devices and any new technology.
  • Learn about the training and education that must take place to ensure your staff uses mobile devices properly and does not risk exposure of PHI.
  • Find out the steps that must be followed in the event of a breach of PHI.
  • Learn about how the HIPAA audit and enforcement activities are now being increased and what you need to do to survive a HIPAA audit.

Who Will Benefit:
  • Compliance Director
  • CEO
  • CFO
  • Privacy Officer
  • Security Officer
  • Information Systems Manager
  • HIPAA Officer
  • Chief Information Officer
  • Health Information Manager
  • Healthcare Counsel/lawyer
  • Office Manager
Jim Sheldon-Dean is the founder and director of compliance services at Lewis Creek Systems, LLC, a Vermont-based consulting firm founded in 1982, providing information privacy and security regulatory compliance services to a wide variety of health care entities.

Sheldon-Dean serves on the HIMSS Information Systems Security Workgroup, has co-chaired the Workgroup for Electronic Data Interchange Privacy and Security Workgroup, and is a recipient of the WEDI 2011 Award of Merit. He is a frequent speaker regarding HIPAA and information privacy and security compliance issues at seminars and conferences, including speaking engagements at numerous regional and national healthcare association conferences and conventions and the annual NIST/OCR HIPAA Security Conference in Washington, D.C.

Sheldon-Dean has more than 30 years of experience in policy analysis and implementation, business process analysis, information systems and software development. His experience includes leading the development of health care related Web sites; award-winning, best-selling commercial utility software; and mission-critical, fault-tolerant communications satellite control systems. In addition, he has eight years of experience doing hands-on medical work as a Vermont certified volunteer emergency medical technician. Sheldon-Dean received his B.S. degree, summa cum laude, from the University of Vermont and his master’s degree from the Massachusetts Institute of Technology.
Instructor : Jim Sheldon Dean
Product Id : 20050PACK

Overview: This session will focus on the rights of individuals to communicate in the manner they desire, and how a medical office can decide what is an acceptable process for communications with individuals. The session will explain how to discuss communications options with individuals so that you can best meet their needs and desires, while preserving their rights under the rules.

  • With the new HIPAA random audit program now getting under way, and increases in enforcement actions following breaches, now is the time to ensure your organization is in compliance with the regulations and meeting the e-mail and texting communication needs and desires of its providers and patients. You need the proper privacy protections for health information, and the necessary documented policies and procedures, as well as documentation of any actions taken pursuant to your policies and procedures. Your policies and procedures will probably need major revisions to maintain compliance in areas such as individual access of records, accounting of disclosures, and breach notification. And, of course, you will need to train your staff in all the new policies and procedures.
  • E-mail has long been a staple of people's lives, but as we move into the new digital age, it seems everyone is moving to a new smart phone and wants to use it in all the incredible ways it can be used for health care purposes, including the use of e-mail and texting. Doctors are finding that texting is far more flexible, convenient, and effective than paging, and patients want to be able to use short message texting for handling of appointments, updates, and the like, where even e-mail or the telephone would seem inconvenient.
  • In order to integrate the use of e-mail and texting into patient communications, it is essential to perform the proper steps in an information security compliance process to evaluate and address the risks of using the technology. This session will describe the information security compliance process, how it works, and how it can help you decide how to integrate e-mail and texting into your organization in a compliant way. The process, including the use of information security risk analysis, will be explained, and the policies needed to support the process will be described.
  • But the process must also include consideration of various patient access requirements in the HIPAA Privacy Rule. There are new requirements to provide patients electronic access of electronically held PHI which raise new questions of how that access will be provided and how the information will be protected during and after access. And there has long been a HIPAA requirement for covered entities to do their best to meet the requests of their patients for particular modes of communication, and using e-mail or texting is no exception.
  • The stakes are high - any improper exposure of PHI may result in an official breach that must be reported to the individual and to the US Department of Health and Human Services, at great cost and with the potential to bring fines and other enforcement actions if a violation of rules is involved. Likewise, complaints by a patient if they are not afforded the access they desire can bring about HHS inquiries and enforcement actions, so it is essential to find the right balance of access and control.
  • HHS compliance audit activity and enforcement penalties are both increased, especially in instances of willful neglect of compliance, if, for instance, your organization hasn't adopted the complete suite of policies and procedures needed for compliance, or hasn’t adequately considered the impact of e-mail or texting on your compliance.
  • The session will discuss the requirements, the risks, and the issues of the increasing use of e-mail and texting for patient and provider communications and provide a road map for how to use them safely and effectively, to increase the quality of health care and patient satisfaction. In addition, the session will discuss how to be prepared for the eventuality that there is a breach, so that compliance can be assured.

Why should you attend:
  • The HIPAA Omnibus Update rules contain numerous changes to HIPAA Privacy, Security, and Breach Notification rules that affect communication with patients and clients of health care services, who often ask to communicate with health care offices via e-mail or text message. Many of the policies and procedures in place at every health care-related organization will need to be reviewed and updated to meet the new requirements. Organizations need to understand the various ways that health care communications can take place, and how patient communications fit in with the HIPAA rules. They need to design and implement a patient communication policy and plan, and train their staff on it, or they may face significant new fines for noncompliance.
  • E-mail and texting present new challenges to health care providers, as there are simultaneously new requirements to share information with patients, and a new enforcement effort to ensure the privacy and security of Protected Health Information (PHI). Meeting both challenges requires careful consideration of all the regulations and technologies, as well as patient preferences and work flow.
  • Most HIPAA covered entities now face difficult choices between compliance and ease of communication. Most organizations haven’t updated their information security risk analysis or policies and procedures and run the risk of breaches, rule violations, and fines in the event of mishandling of PHI using these new technologies.

Areas Covered in the Session:
  • Find out the ways that patients want to use their e-mail and texting to communicate with providers, and the ways providers want to use e-mail and texting to enable better patient care
  • Learn what are the risks of using e-mail and texting, what can go wrong, and what can result when it does
  • Find out about HIPAA requirements for access and patient preferences, as well as the requirements to protect PHI
  • Learn how to use an information security management process to evaluate risks and make decisions about how best to protect PHI and meet patient needs and desires
  • Find out what policies and procedures you should have in place for dealing with e-mail and texting, as well as any new technology
  • Learn about the training and education that must take place to ensure your staff uses e-mail and texting properly and does not risk exposure of PHI
  • Find out the steps that must be followed in the event of a breach of PHI
  • Learn about how the HIPAA audit and enforcement activities are now being increased and what you need to do to survive a HIPAA audit

Who Will Benefit:
  • Compliance Director
  • CEO
  • CFO
  • Privacy Officer
  • Security Officer
  • Information Systems Manager
  • HIPAA Officer
  • Chief Information Officer
  • Health Information Manager
  • Healthcare Counsel/lawyer
  • Office Manager
Jim Sheldon-Dean is the founder and director of compliance services at Lewis Creek Systems, LLC, a Vermont-based consulting firm founded in 1982, providing information privacy and security regulatory compliance services to a wide variety of health care entities.

Sheldon-Dean serves on the HIMSS Information Systems Security Workgroup, has co-chaired the Workgroup for Electronic Data Interchange Privacy and Security Workgroup, and is a recipient of the WEDI 2011 Award of Merit. He is a frequent speaker regarding HIPAA and information privacy and security compliance issues at seminars and conferences, including speaking engagements at numerous regional and national healthcare association conferences and conventions and the annual NIST/OCR HIPAA Security Conference in Washington, D.C.

Sheldon-Dean has more than 30 years of experience in policy analysis and implementation, business process analysis, information systems and software development. His experience includes leading the development of health care related Web sites; award-winning, best-selling commercial utility software; and mission-critical, fault-tolerant communications satellite control systems. In addition, he has eight years of experience doing hands-on medical work as a Vermont certified volunteer emergency medical technician. Sheldon-Dean received his B.S. degree, summa cum laude, from the University of Vermont and his master’s degree from the Massachusetts Institute of Technology.