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1. From your computer workstation, createa new text document called HIPAA Lab #3.


2. Reviewthe following scenario:




Your manager has asked you to identify information and resources in the health care industry that


address what laws, rules, and guidelines your health care organization needs to follow. Your health


care organization is to have an audit so you need to gather information for the upcoming audit,


which will be more stringent than any that have been done before. The health care organization


that employs you believes it is necessary to conduct a review of its HIPAA compliance (or lack of


compliance) and put the gathered information into a report to show all the requirements the organization


faces. Your manager has asked you to perform this function knowing that your work has been


above reproach. He expects a summary of the HIPAA requirements the organization needs to comply


with and any financial regulatory acts for which it might also be held liable. With your previous


experience researching the financial sector and Sarbanes-Oxley, you will need to dig deeper into the


Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Rule and Security Rule.


You can use resources from HHS.gov, the U.S. Department of Health and Human Services’ website, to


evaluate the HIPAA Privacy and Security rules.



3. Launchyour Web browser. Typethe Web address http://www.himss.org/ASP/index.asp. This is the


Healthcare Information and Management Systems Society (HIMSS) website. Reviewthe website.


4. On the left side of the HIMSS website, click the Healthcare Reformlink. Reviewsome of the documents.


Then, in the upper right corner, typethe words Health Information Technologyin the Search box.


Reviewthe information you find. In your text document, notewhat you learn about the HIMSS




website and how it helps companies and organizations address health care issues.



5. In your browser address bar, typethe following Web address: http://csrc.nist.gov/




Reviewthe following sections:




a. Logging & Audit Requirements


b. Privacy vs. Security


c. Challenges & Barriers



In your text document, notethe information you can gather from these sections of the document.


6. In your Web browser, typethe following Web address: http://healthit.hhs.gov/portal/server.pt?open=51




Browsethe Privacy and Security sectionof The Office of the National Coordinator for Health


Information Technology and reviewthe available information and resources provided. In your text


document, notethe types of information you can gather from The Office of the National Coordinator




for Health Information Technology.



7. In your Web browser, typethe Web address www.HHS.gov. Review HIPAA’s main points and requirements.


In your text document, discussthese requirements.


8. Reviewthe HHS.govwebsite’s information on the HIPAA Security Rule and Privacy Rule. First, review


the HIPAA Security Rule at the following address: http://www.hhs.gov/ocr/privacy


/hipaa/understanding/srsummary.html. In your text document, discussthese topics:




a. Who is covered by the Security Rule?


i. Health plans


ii. Health care clearinghouses


iii. Any health care provider who transmits health information in electronic form in connection


with a transaction for which the secretary of HHS has adopted standards under HIPAA


b. What information is protected?


i. Protected health information (PHI)


ii. De-identified health information

c. General rules


d. Risk analysis and management


e. Administrative, physical, and technical safeguards


i. Security management process


ii. Facility access and control


iii. Access, audit, and integrity controls


iv. Transmission security


f. Policies, documentation, and penalty enforcements



9. Reviewthe HIPAA Privacy Rule at the following address: http://www.hhs.gov/ocr/privacy/hipaa/understanding/


summary/index.html. In your text document, discussthese topics:




a. General principle for uses and disclosures


b. Permitted vs. authorized uses and disclosures to the individual


i. Treatment, payment, health care operations


ii. Opportunity to agree or object


iii. Incidental use and disclosure


iv. Public interest


c. Limiting disclosure and notifications


d. Policies, documentation, and penalty enforcements


i. For violations occurring prior to 2/18/2009


ii. Penalty amount: Up to $100 per violation


iii. For violations occurring on or after 2/18/2009


iv. Calendar year cap respectively: $25,000 and $1,500,000



10. In your text document, writean executive summarythat defines a process for obtaining and




documenting information needed to perform a HIPAA compliancy audit.



11. Submitthe text documentto your instructor as a deliverable for this lab.


20 Lab #3 |Define a Process for Gathering Information Pertaining to a HIPAA Compliance Audit















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