{"id":428,"date":"2013-03-18T11:00:32","date_gmt":"2013-03-18T15:00:32","guid":{"rendered":"http:\/\/www.eclipsepracticemanagementsoftware.com\/blog\/?p=428"},"modified":"2014-07-08T15:10:50","modified_gmt":"2014-07-08T19:10:50","slug":"meaningful-use-audits","status":"publish","type":"post","link":"https:\/\/eclipsepracticemanagementsoftware.com\/blog\/2013\/03\/18\/meaningful-use-audits\/","title":{"rendered":"Meaningful Use Audits"},"content":{"rendered":"<p>The rumors began the moment the law (ARRA) was passed in 2009, intensified as testing protocols were created, and continued through the implementation process. Some physicians simply couldn\u2019t get past those rumors, and decided to avoid the cash incentives provided by the Meaningful Use program. An unfortunate choice. However,\u00a0if you received incentive payments, the audit program is here. And with it, some unexpected confusion.\u00a0 The audit process is not difficult. The most important items that an auditor may initially request include proof that you owned the certified technology you purchased during the attestation period ,\u00a0a copy of the report you printed from your certified EHR, some screenshots, etc.\u00a0But those items certainly aren\u2019t confusing, and as an ECLIPSE user, you knew from your HELP to save such reports rather than discard them. So, where does the confusion lie? Just a few short years ago, it\u2019s likely that you attended one or more seminars with regard to maintaining HIPAA compliance within your facility. Perhaps you received C.E. credits. Perhaps your staff attended. You learned some of the protocols you were expected to follow to ensure protection of Patient History Information (PHI). You also learned that this was an ongoing process. It\u2019s likely you appointed a <em>HIPAA Compliance Officer<\/em> within your practice and created a <em>HIPAA Compliance Manual<\/em> at that time. Your HIPAA Compliance Manual might have contained wording to the effect of:<\/p>\n<blockquote><p>Risk Analysis and Management: Little Ferry Chiropractic Center (LFCC) conducts thorough assessments of the potential risks and vulnerabilities to the confidentiality, integrity, and availability of electronic protected health information held in its computer systems on a regular basis. When LFCC\u2019s Compliance Officer believes\u00a0risks exist, the Compliance Officer addresses each risk and completes a mitigation report. LFCC\u00a0has implemented security measures to reduce risks and vulnerabilities to a reasonable and appropriate level to comply with the HIPAA Security Rule. These measures are described in detail\u2026<\/p><\/blockquote>\n<p>In other words, you\u2019ve been doing risk assessments for years now. During attestation, for item #15, you attested that you have\u2026<\/p>\n<blockquote><p>conducted a review or security analysis per 45 CFR 164.308(a)(1) and have implemented security updates as necessary, corrected security deficiencies as part of your risk management process.<\/p><\/blockquote>\n<p>Now that we\u2019ve established that you\u2019ve been doing this all along\u2026\u00a0\u00a0let\u2019s visit some of the protocols you\u2019ve certainly implemented &amp; checked in your office:<\/p>\n<ul>\n<li>\u00a0It\u2019s likely that you purchased, maintain a subscription to, and routinely check software from companies like Symantec to prevent malware (e.g. viruses) from entering your system.<\/li>\n<li>You routinely remind employees not to leave Post-It notes on a computer monitor with user names &amp; passwords. And your HIPAA Compliance Officer checks this from time to time.<\/li>\n<li>If there\u2019s a door between your waiting room and\u00a0front desk, you\u2019ve ensured that\u00a0door is always locked from the waiting room side. If your front desk and charts are accessible from the waiting room, you\u2019ve established a procedure that ensures all employees log out when they leave the desk and\/or a protocol that ensures the front desk is always attended by at least one staff member.<\/li>\n<li>Within your software you\u2019ve assigned appropriate permissions based on job title to limit access to PHI as appropriate.<\/li>\n<li>Perhaps you\u2019ve called the HELP Desk to discuss potential security vulnerabilities and how to address them.<\/li>\n<li>You\u2019ve ensured appropriate Windows\u00a0 permissions on your computers or network to limit access.<\/li>\n<li>You password protected your routers if you have a network. And if you have a wireless network in your office, you\u2019ve also setup appropriate encryption protocols so your data can\u2019t be intercepted.<\/li>\n<li>You\u2019ve established backup procedures in the event of a hardware failure or natural disaster.<\/li>\n<li>If you routinely email PHI, you password protect &amp; encrypt attachments prior to sending.<\/li>\n<\/ul>\n<p>This is just a short list of many items routinely implemented &amp; addressed\u00a0in your practice as part of HIPAA\u00a0compliance. During the audit process, if you\u2019re asked to provide proof of your security risk assessment, simply provide appropriate pages from your HIPAA manual, along with the\u00a0steps that are part of your daily\/weekly\/monthly routine (and were likely repeated at the time of attestation). You should have a signed, dated copy that corresponds to your attestation period.<\/p>\n<p>Here are some\u00a0related links:<\/p>\n<ul>\n<li><span style=\"color: #666699;\"><a href=\"http:\/\/www.healthit.gov\/providers-professionals\/security-risk-assessment\"><span style=\"color: #666699;\">HealthIT.gov Security Risk Assessment Tools<\/span><\/a><\/span><\/li>\n<li><span style=\"color: #666699;\"><a href=\"http:\/\/www.cms.gov\/Regulations-and-Guidance\/Legislation\/EHRIncentivePrograms\/Downloads\/SecurityRiskAssessment_FactSheet_Updated20131122.pdf\"><span style=\"color: #666699;\">CMS Security Assessment Fact Sheet<\/span><\/a><\/span><\/li>\n<li><span style=\"color: #666699;\"><a href=\"http:\/\/www.hhs.gov\/ocr\/privacy\/hipaa\/administrative\/securityrule\/riskassessment.pdf\"><span style=\"color: #666699;\">DHHS Security Risk Assessment<\/span><\/a><\/span><\/li>\n<li><span style=\"color: #666699;\"><a href=\"http:\/\/www.hhs.gov\/ocr\/privacy\/hipaa\/administrative\/securityrule\/smallprovider.pdf\"><span style=\"color: #666699;\">DHHS Security Risk Assessment Small Provider\u2019s Guide<\/span><\/a><\/span><\/li>\n<\/ul>\n<p>And some samples:<\/p>\n<ul>\n<li><a href=\"http:\/\/scap.nist.gov\/hipaa\/\">NIST Toolkit<\/a><\/li>\n<li><a href=\"http:\/\/www.himss.org\/ResourceLibrary\/ResourceDetail.aspx?ItemNumber=21449\">HIMSS Resource Details<\/a><\/li>\n<li><a href=\"http:\/\/hipaacow.org\/resources\/hipaa-cow-documents\/risk-toolkit\/\">HIPAACOW Toolkit<\/a><\/li>\n<\/ul>\n","protected":false},"excerpt":{"rendered":"<p>The rumors began the moment the law (ARRA) was passed in 2009, intensified as testing protocols were created, and continued through the implementation process. Some physicians simply couldn\u2019t get past those rumors, and decided to avoid the cash incentives provided &hellip; <a href=\"https:\/\/eclipsepracticemanagementsoftware.com\/blog\/2013\/03\/18\/meaningful-use-audits\/\">Continue reading <span class=\"meta-nav\">&rarr;<\/span><\/a><\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"closed","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"jetpack_post_was_ever_published":false,"_jetpack_newsletter_access":"","_jetpack_dont_email_post_to_subs":false,"_jetpack_newsletter_tier_id":0,"_jetpack_memberships_contains_paywalled_content":false,"_jetpack_memberships_contains_paid_content":false,"footnotes":"","jetpack_publicize_message":"","jetpack_publicize_feature_enabled":true,"jetpack_social_post_already_shared":true,"jetpack_social_options":{"image_generator_settings":{"template":"highway","default_image_id":0,"font":"","enabled":false},"version":2}},"categories":[7,3],"tags":[14,17],"class_list":["post-428","post","type-post","status-publish","format-standard","hentry","category-audit","category-meaningfuluse","tag-chiropractic-audits","tag-chiropractic-meaningful-use"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v26.6 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>Meaningful Use Audits - ECLIPSE Blog<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/eclipsepracticemanagementsoftware.com\/blog\/2013\/03\/18\/meaningful-use-audits\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Meaningful Use Audits - ECLIPSE Blog\" \/>\n<meta property=\"og:description\" content=\"The rumors began the moment the law (ARRA) was passed in 2009, intensified as testing protocols were created, and continued through the implementation process. Some physicians simply couldn\u2019t get past those rumors, and decided to avoid the cash incentives provided &hellip; Continue reading &rarr;\" \/>\n<meta property=\"og:url\" content=\"https:\/\/eclipsepracticemanagementsoftware.com\/blog\/2013\/03\/18\/meaningful-use-audits\/\" \/>\n<meta property=\"og:site_name\" content=\"ECLIPSE Blog\" \/>\n<meta property=\"article:published_time\" content=\"2013-03-18T15:00:32+00:00\" \/>\n<meta property=\"article:modified_time\" content=\"2014-07-08T19:10:50+00:00\" \/>\n<meta name=\"author\" content=\"Mike Norworth\" \/>\n<meta name=\"twitter:card\" content=\"summary_large_image\" \/>\n<meta name=\"twitter:label1\" content=\"Written by\" \/>\n\t<meta name=\"twitter:data1\" content=\"Mike Norworth\" \/>\n\t<meta name=\"twitter:label2\" content=\"Est. reading time\" \/>\n\t<meta name=\"twitter:data2\" content=\"4 minutes\" \/>\n<script type=\"application\/ld+json\" class=\"yoast-schema-graph\">{\"@context\":\"https:\/\/schema.org\",\"@graph\":[{\"@type\":\"WebPage\",\"@id\":\"https:\/\/eclipsepracticemanagementsoftware.com\/blog\/2013\/03\/18\/meaningful-use-audits\/\",\"url\":\"https:\/\/eclipsepracticemanagementsoftware.com\/blog\/2013\/03\/18\/meaningful-use-audits\/\",\"name\":\"Meaningful Use Audits - ECLIPSE Blog\",\"isPartOf\":{\"@id\":\"https:\/\/eclipsepracticemanagementsoftware.com\/blog\/#website\"},\"datePublished\":\"2013-03-18T15:00:32+00:00\",\"dateModified\":\"2014-07-08T19:10:50+00:00\",\"author\":{\"@id\":\"https:\/\/eclipsepracticemanagementsoftware.com\/blog\/#\/schema\/person\/77b0ff03a4cb25079e40a98746886c81\"},\"breadcrumb\":{\"@id\":\"https:\/\/eclipsepracticemanagementsoftware.com\/blog\/2013\/03\/18\/meaningful-use-audits\/#breadcrumb\"},\"inLanguage\":\"en-US\",\"potentialAction\":[{\"@type\":\"ReadAction\",\"target\":[\"https:\/\/eclipsepracticemanagementsoftware.com\/blog\/2013\/03\/18\/meaningful-use-audits\/\"]}]},{\"@type\":\"BreadcrumbList\",\"@id\":\"https:\/\/eclipsepracticemanagementsoftware.com\/blog\/2013\/03\/18\/meaningful-use-audits\/#breadcrumb\",\"itemListElement\":[{\"@type\":\"ListItem\",\"position\":1,\"name\":\"Home\",\"item\":\"https:\/\/eclipsepracticemanagementsoftware.com\/blog\/\"},{\"@type\":\"ListItem\",\"position\":2,\"name\":\"Meaningful Use Audits\"}]},{\"@type\":\"WebSite\",\"@id\":\"https:\/\/eclipsepracticemanagementsoftware.com\/blog\/#website\",\"url\":\"https:\/\/eclipsepracticemanagementsoftware.com\/blog\/\",\"name\":\"ECLIPSE Blog\",\"description\":\"Direct from the developers... 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