Privacy & Security
Security Guidelines of Administrative Simplication
Administrative Procedures: Documented formal practices to manage the selection and execution of security measures to protect data and the conduct of personnel in relation to the protection of data.
Sanction and Security policy: Termination Procedures – locks changed, removal from access lists and user account(s) Training – User ed. concerning virus protection and password management
Physical Safeguards: The protection of physical computer systems and related buildings an equipment form fire and other natural and environmental hazards, as well as from intrusion. Physical safeguards also cover the use of locks, keys, and administrative measures used to control access to computer systems and facilities.
Technical Security Services: Include the processes that are put into place to protect and to control and monitor information access.
Technical Security Mechanisms: Include the processes that are put into place to prevent unauthorized access to data that is transmitted over a communications network.
Privacy Guidelines of Administrative Simplification*
The Privacy Rule provides the first comprehensive Federal protection for the privacy of health information and is carefully balanced to provide strong privacy protections that do not interfere with patient access to, or the quality of, healthcare delivery.
Incidental Uses and Disclosures (45CFR 164.502(a))
An incidental use of disclosure is a secondary use of disclosure that cannot be reasonably be prevented, is limited in nature, and that occurs as a result of another use or disclosure that is permitted by the Rule. An incidental use or disclosure is NOT permitted if it is a by-product of an underlying use or disclosure, which violates the Privacy Rule.
Minimum Necessary (45CFR 164.502(b), 164.514(d))
The Privacy Rule requires covered entities to take reasonable steps to limit the use or disclosure of protected health information to the minimum necessary to accomplish the intended purpose.
Personal Representatives (45CFR 164.502(g))
Covered entities are required to treat an individual’s personal representative as the individual with respect to uses and disclosures of the individual’s protected health information. The personal representative has the ability to act for the individual, exercise the individual’s rights, and may also authorize disclosures of the individual’s protected health information.
Business Associates (45CFR 164.502(e), 164.504(e), 164.532(d) and (e))
The Privacy Rule allows covered providers to disclose protected health information to these “business associates” if the providers obtain satisfactory assurances that the business associate will use the information only for the purposes for which it was engaged by the covered entity, will safeguard the information from misuse, will help the covered entity comply with some of the covered entity’s duties under the Privacy Rule, and help the covered entity carry out its healthcare functions.