HIPAA Compliance Solutions

 

Health Insurance Portability and Accountability Act (HIPAA) regulates a wide range of policies regarding healthcare services. One of its primary functions is to prevent fraud and abuse of the healthcare system. Strict HIPAA security compliance regulations are specifically designed to protect personal healthcare data from unauthorized access.  Meeting HIPAA requirements can be quite a challenge and generally requires the use of dedicated software to monitor and control user access to sensitive data.

 

Ekran System is an efficient and cost-effective solution for meeting HIPAA IT compliance rules. Ekran System conducts monitoring and audit of user activity regardless of the level of privileges providing you internal visibility accross Windows, Linux / Unix, and virtual enpoints including Citrix servers. It records everything a user sees on their screen as it happens in an easy-to-analyze and search indexed video format that you can use to see exactly who and when accesses sensitive data and what changes are being made. Ekran System is an effective HIPAA compliance software that will help you to fully preserve the integrity of personal health data with minimal investment.

 

Requirement 160.308 – Compliance Reviews

(a) The Secretary will conduct a compliance review to determine whether a covered entity or business associate is complying with the applicable administrative simplification provisions when a preliminary review of the facts indicates a possible violation due to willful neglect.

 

(b) The Secretary may conduct a compliance review to determine whether a covered entity or business associate is complying with the applicable administrative simplification provisions in any other circumstance.

 

Besides the complete logs of each user session, Ekran System can generate a number of customizable reports that can be easily accessed by compliance auditors. The reports can be sent via email, generated by a set schedule or ad hoc, in a format suitable for reading and analysis. Ekran System records all data and provides notifications and reports regardless of the type of program used.

Requirement 164.306 – Security Standards

(a) General requirements. Covered entities and business associates must do the following:

 

(1) Ensure the confidentiality, integrity, and availability of all electronic protected health information the covered entity or business associate creates, receives, maintains, or transmits.

 

(2) Protect against any reasonably anticipated threats or hazards to the security or integrity of such information.

 

(3) Protect against any reasonably anticipated uses or disclosures of such information that are not permitted or required under subpart E of this part.

 

(4) Ensure compliance with this subpart by its workforce.

 

(b) Flexibility of approach.

 

(1) Covered entities and business associates may use any security that allow the covered entity or business associate to reasonably and appropriately implement the standards and implementation specifications as specified in this subpart.

 

(2) In deciding which security to use, a covered entity or business associate must take into account the following factors:

 

(i) The size, complexity, and capabilities of the covered entity or business associate.

(ii) The covered entity's or the business associate's technical infrastructure, hardware, and software security capabilities.

(iii) The costs of security measures.

(iv) The probability and criticality of potential risks to electronic protected health information.

 

(c) Standards. A covered entity or business associate must comply with the applicable standards as provided in this section and in §164.308, §164.310, §164.312, §164.314, and §164.316 with respect to all electronic protected health information.

 

(d) Implementation specifications. In this subpart:

 

(1) Implementation specifications are required or addressable. If an implementation specification is required, the word "Required" appears in parentheses after the title of the implementation specification. If an implementation specification is addressable, the word "Addressable" appears in parentheses after the title of the implementation specification.

 

(2) When a standard adopted in §164.308, §164.310, §164.312, §164.314, and §164.316 includes required implementation specifications, a covered entity or business associate must implement the implementation specifications.

 

(3) When a standard adopted in §164.308, §164.310, §164.312, §164.314, and §164.316 includes addressable implementation specifications, a covered entity or business associate must--

 

(i) Assess whether each implementation specification is a reasonable and appropriate safeguard in its environment, when analyzed with reference to the likely contribution to protecting electronic protected health information; and

(ii) As applicable to the covered entity or business associate--

 

(A) Implement the implementation specification if reasonable and appropriate; or

(B) If implementing the implementation specification is not reasonable and appropriate—

 

(1) Document why it would not be reasonable and appropriate to implement the implementation specification; and,

(2) Implement an equivalent alternative measure if reasonable and appropriate.

 

(e) Maintenance. A covered entity or business associate must review and modify the security implemented under this subpart as needed to continue provision of reasonable and appropriate protection of electronic protected health information, and update documentation of such security in accordance with §164.316(b)(2)(iii).

 

Ekran System can help you ensure the integrity of protected data by using the monitoring tool to control all access to the data and changes made. Real-time notifications and alerts will allow you to detect incidents in a timely manner and respond if data is somehow compromised, including blocking the corresponding user. The automatic USB blocking tool can help you prevent security breaches, and to comply with confidentiality requirements you can use the second layer of authentication provided by Ekran Systems thus ensuring that only authorized users have access to certain sensitive data.

 

Requirement 164.308 – Administrative Safeguards

(a) A covered entity or business associate must, in accordance with §164.306:

 

(1) (i) Standard: Security management process. Implement policies and procedures to prevent, detect, contain, and correct security violations.

 

(ii) Implementation specifications:

 

(A) Risk analysis (Required). Conduct an accurate and thorough assessment of the potential risks and vulnerabilities to the confidentiality, integrity, and availability of electronic protected health information held by the covered entity or business associate.

(B) Risk management (Required). Implement security measures sufficient to reduce risks and vulnerabilities to a reasonable and appropriate level to comply with §164.306(a).

(C) Sanction policy (Required). Apply appropriate sanctions against workforce members who fail to comply with the security policies and procedures of the covered entity or business associate.

(D) Information system activity review (Required). Implement procedures to regularly review records of information system activity, such as audit logs, access reports, and security incident tracking reports.

 

(2) Standard: Assigned security responsibility. Identify the security official who is responsible for the development and implementation of the policies and procedures required by this subpart for the covered entity or business associate.

 

(3) (i) Standard: Workforce security. Implement policies and procedures to ensure that all members of its workforce have appropriate access to electronic protected health information, as provided under paragraph (a)(4) of this section, and to prevent those workforce members who do not have access under paragraph (a)(4) of this section from obtaining access to electronic protected health information.

(ii) Implementation specifications:

 

(A) Authorization and/or supervision (Addressable). Implement procedures for the authorization and/or supervision of workforce members who work with electronic protected health information or in locations where it might be accessed.

(B) Workforce clearance procedure (Addressable). Implement procedures to determine that the access of a workforce member to electronic protected health information is appropriate.

(C) Termination procedures (Addressable). Implement procedures for terminating access to electronic protected health information when the employment of, or other arrangement with, a workforce member ends or as required by determinations made as specified in paragraph (a)(3)(ii)(B) of this section.

 

(4) (i) Standard: Information access management. Implement policies and procedures for authorizing access to electronic protected health information that are consistent with the applicable requirements of subpart E of this part.

(ii) Implementation specifications:

 

(A) Isolating health care clearinghouse functions (Required). If a health care clearinghouse is part of a larger organization, the clearinghouse must implement policies and procedures that protect the electronic protected health information of the clearinghouse from unauthorized access by the larger organization.

(B) Access authorization (Addressable). Implement policies and procedures for granting access to electronic protected health information, for example, through access to a workstation, transaction, program, process, or other mechanism.

(C) Access establishment and modification (Addressable). Implement policies and procedures that, based upon the covered entity's or the business associate's access authorization policies, establish, document, review, and modify a user's right of access to a workstation, transaction, program, or process.

 

(5) (i) Standard: Security awareness and training. Implement a security awareness and training program for all members of its workforce (including management).

(ii) Implementation specifications. Implement:

 

(A) Security reminders (Addressable). Periodic security updates.

(B) Protection from malicious software (Addressable). Procedures for guarding against, detecting, and reporting malicious software.

(C) Log-in monitoring (Addressable). Procedures for monitoring log-in attempts and reporting discrepancies.

(D) Password management (Addressable). Procedures for creating, changing, and safeguarding passwords.

 

(6) (i) Standard: Security incident procedures. Implement policies and procedures to address security incidents.

(ii) Implementation specification: Response and reporting (Required). Identify and respond to suspected or known security incidents; mitigate, to the extent practicable, harmful effects of security incidents that are known to the covered entity or business associate; and document security incidents and their outcomes.

(7) (i) Standard: Contingency plan. Establish (and implement as needed) policies and procedures for responding to an emergency or other occurrence (for example, fire, vandalism, system failure, and natural disaster) that damages systems that contain electronic protected health information.

(ii) Implementation specifications:

 

(A) Data backup plan (Required). Establish and implement procedures to create and maintain retrievable exact copies of electronic protected health information.

(B) Disaster recovery plan (Required). Establish (and implement as needed) procedures to restore any loss of data.

(C) Emergency mode operation plan (Required). Establish (and implement as needed) procedures to enable continuation of critical business processes for protection of the security of electronic protected health information while operating in emergency mode.

(D) Testing and revision procedures (Addressable). Implement procedures for periodic testing and revision of contingency plans.

(E) Applications and data criticality analysis (Addressable). Assess the relative criticality of specific applications and data in support of other contingency plan components.

 

(8) Standard: Evaluation. Perform a periodic technical and nontechnical evaluation, based initially upon the standards implemented under this rule and, subsequently, in response to environmental or operational changes affecting the security of electronic protected health information, that establishes the extent to which a covered entity's or business associate's security policies and procedures meet the requirements of this subpart.

 

(b)(1) Business associate contracts and other arrangements. A covered entity may permit a business associate to create, receive, maintain, or transmit electronic protected health information on the covered entity's behalf only if the covered entity obtains satisfactory assurances, in accordance with §164.314(a), that the business associate will appropriately safeguard the information. A covered entity is not required to obtain such satisfactory assurances from a business associate that is a subcontractor.

 

(2) A business associate may permit a business associate that is a subcontractor to create, receive, maintain, or transmit electronic protected health information on its behalf only if the business associate obtains satisfactory assurances, in accordance with §164.314(a), that the subcontractor will appropriately safeguard the information.

 

(3) Implementation specifications: Written contract or other arrangement (Required). Document the satisfactory assurances required by paragraph (b)(1) or (b)(2) of this section through a written contract or other arrangement with the business associate that meets the applicable requirements of §164.314(a).

 

Ekran System provides an additional authentication feature that allows you to identify users logging in to shared accounts such as “administrator” accounts. Ekran System displays the secondary authentication window whenever a shared account is used to log in to a server machine. To proceed, a user has to enter additional credentials which allows you to precisely identify the person using a shared account. The video recorded from the session and all logs are then associated with that user and can be easily investigated.

 

Requirement 164.312 – Technical Safeguards

A covered entity or business associate must, in accordance with §164.306:

 

(a) (1) Standard: Access control. Implement technical policies and procedures for electronic information systems that maintain electronic protected health information to allow access only to those persons or software programs that have been granted access rights as specified in §164.308(a)(4).

 

(2) Implementation specifications:

 

(i) Unique user identification (Required). Assign a unique name and/or number for identifying and tracking user identity.

(ii) Emergency access procedure (Required). Establish (and implement as needed) procedures for obtaining necessary electronic protected health information during an emergency.

(iii) Automatic logoff (Addressable). Implement electronic procedures that terminate an electronic session after a predetermined time of inactivity.

(iv) Encryption and decryption (Addressable). Implement a mechanism to encrypt and decrypt electronic protected health information.

 

(b) Standard: Audit controls. Implement hardware, software, and/or procedural mechanisms that record and examine activity in information systems that contain or use electronic protected health information.

 

(c) (1) Standard: Integrity. Implement policies and procedures to protect electronic protected health information from improper alteration or destruction.

 

(2) Implementation specification: Mechanism to authenticate electronic protected health information (Addressable). Implement electronic mechanisms to corroborate that electronic protected health information has not been altered or destroyed in an unauthorized manner.

 

(d) Standard: Person or entity authentication. Implement procedures to verify that a person or entity seeking access to electronic protected health information is the one claimed.

 

(e) (1) Standard: Transmission security. Implement technical security measures to guard against unauthorized access to electronic protected health information that is being transmitted over an electronic communications network.

 

(2) Implementation specifications:

 

(i) Integrity controls (Addressable). Implement security measures to ensure that electronically transmitted electronic protected health information is not improperly modified without detection until disposed of.

(ii) Encryption (Addressable). Implement a mechanism to encrypt electronic protected health information whenever deemed appropriate.

 

Ekran System records all visual information from user’s screen and captures all textual information (such as application name, visited URL, entered commands, etc.) including text entered from a user’s keyboard. Log data is generated for applications of any type, even if there is no internal logging of their own. This allows IT auditors to view exact user activity, such as opened windows, accessed folders, executed files and commands, etc.

 

Ekran System uses aper-Client licensing scheme and allows the optional use of a free embedded database providing for a cost-effective solution for healthcare institutions.