HIPAA Breach Evaluation and Reporting –
What Qualifies as a Reportable Breach and How to Report It
- The definition of a Breach under HIPAA
- Evaluating the Privacy violation
- Reviewing the exceptions to the definition of a breach
- What is good enough encryption according to the rules
- Performing the Risk Analysis to determine the necessity to report
- Ransomware and Breaches – When to Report
- Avoiding Breaches
- The most common causes of breaches
- Reporting breaches to HHS and the individuals
- Reporting breaches to the press and other agencies
- Documenting your analysis and decisions
Breaches of Protected Health Information are becoming more and more common, and can be a result of a variety of circumstances, from words spoken too loudly in a public setting, to a lost thumb drive full of medical records, to files being held for ransom by hackers.
Any violation of the HIPAA Privacy Rule may be a reportable breach under the HIPAA Breach Notification rules, requiring notification of individuals and HHS when information security is breached. Any incident involving a HIPAA issue must be evaluated to see if it is reportable, and any decisions or actions must be fully documented.
- Compliance director
- 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.
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