ÿþ<html xmlns:v="urn:schemas-microsoft-com:vml" xmlns:o="urn:schemas-microsoft-com:office:office" xmlns:w="urn:schemas-microsoft-com:office:word" xmlns:m="http://schemas.microsoft.com/office/2004/12/omml" xmlns="http://www.w3.org/TR/REC-html40"> <P><center><table width="600" cellpadding="0" cellspacing="0" border="0"> <tr> <td width="100%" align="center"> <font face="verdana" size="1" color="#444444"> To view this email as a web page, go <a href="%%view_email_url%%" alias="View as a Web Page"> here.</a><br> </font> </td> </tr> </table> </center></P> <head> <meta http-equiv=Content-Type content="text/html; charset=unicode"> <meta name=ProgId content=Word.Document> <meta name=Generator content="Microsoft Word 12"> <meta name=Originator content="Microsoft Word 12"> <link rel=File-List href="HIPAA_06_04_10_files/filelist.xml"> <link rel=Edit-Time-Data href="HIPAA_06_04_10_files/editdata.mso"> <!--[if !mso]> <style> v\:* {behavior:url(#default#VML);} o\:* {behavior:url(#default#VML);} w\:* 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{margin-bottom:0in;} --> </style> <!--[if gte mso 10]> <style> /* Style Definitions */ table.MsoNormalTable {mso-style-name:"Table Normal"; mso-tstyle-rowband-size:0; mso-tstyle-colband-size:0; mso-style-noshow:yes; mso-style-priority:99; mso-style-qformat:yes; mso-style-parent:""; mso-padding-alt:0in 5.4pt 0in 5.4pt; mso-para-margin:0in; mso-para-margin-bottom:.0001pt; mso-pagination:widow-orphan; font-size:10.0pt; font-family:"Times New Roman","serif";} </style> <![endif]--><!--[if gte mso 9]><xml> <o:shapedefaults v:ext="edit" spidmax="4098"/> </xml><![endif]--><!--[if gte mso 9]><xml> <o:shapelayout v:ext="edit"> <o:idmap v:ext="edit" data="1"/> </o:shapelayout></xml><![endif]--> </head> <body lang=EN-US link=blue vlink=purple style='tab-interval:.5in'> <div class=Section1> <div align=center> <table class=MsoNormalTable border=1 cellspacing=0 cellpadding=0 width=500 style='width:375.0pt;mso-cellspacing:0in;border:outset #616559 6.0pt; mso-yfti-tbllook:1184;mso-padding-alt:0in 0in 0in 0in'> <tr style='mso-yfti-irow:0;mso-yfti-firstrow:yes;mso-yfti-lastrow:yes'> <td valign=top style='border:inset #616559 1.0pt;mso-border-alt:inset #616559 .75pt; padding:0in 0in 0in 0in'> <div align=center> <table class=MsoNormalTable border=0 cellspacing=0 cellpadding=0 width=500 style='width:375.0pt;mso-cellspacing:0in;mso-yfti-tbllook:1184;mso-padding-alt: 0in 0in 0in 0in'> <tr style='mso-yfti-irow:0;mso-yfti-firstrow:yes'> <td style='padding:0in 0in 0in 0in'> <p class=MsoNormal align=center style='text-align:center'><a href="http://www.hallrender.com/" title="&quot;Impact Series&quot; t "><span style='mso-fareast-font-family:"Times New Roman";mso-no-proof:yes; text-decoration:none;text-underline:none'><img border=0 width=600 height=100 id="_x0000_i1026" src="http://www.hallrender.com/email/img/hipaa-hdr.jpg" alt="Impact Series"></span></a><span style='mso-fareast-font-family:"Times New Roman"'><o:p></o:p></span></p> </td> </tr> <tr style='mso-yfti-irow:1'> <td style='background:#B5B5A1;padding:2.35pt 2.35pt 2.35pt 2.35pt'> <p class=MsoNormal><span style='mso-fareast-font-family:"Times New Roman"'>&nbsp; &nbsp; &nbsp; <a href="http://www.hallrender.com/?&amp;section=library" title="Hall Render Knowledge Center"><b><span style='font-size:7.0pt; font-family:"Arial","sans-serif";color:white;text-transform:uppercase; text-decoration:none;text-underline:none'>KNOWLEDGE CENTER</span></b></a> &nbsp; <strong><span style='color:#B6121B'>||</span></strong> &nbsp; <a href="mailto:hallrender@hallrender.com" title="Contact Hall Render"><b><span style='font-size:7.0pt;font-family:"Arial","sans-serif";color:white; text-transform:uppercase;text-decoration:none;text-underline:none'>CONTACT</span></b></a> <o:p></o:p></span></p> </td> </tr> <tr style='mso-yfti-irow:2'> <td valign=top style='background:white;padding:0in 0in 0in 0in'> <p class=MsoNormal><span style='mso-fareast-font-family:"Times New Roman"'>&nbsp;<o:p></o:p></span></p> </td> </tr> <tr style='mso-yfti-irow:3'> <td valign=top style='background:white;padding:0in 0in 0in 0in'> <div align=center> <table class=MsoNormalTable border=0 cellpadding=0 width="90%" style='width:90.0%;mso-cellspacing:1.5pt;mso-yfti-tbllook:1184;mso-padding-alt: 0in 5.4pt 0in 5.4pt'> <tr style='mso-yfti-irow:0;mso-yfti-firstrow:yes;mso-yfti-lastrow:yes'> <td valign=top style='padding:.75pt .75pt .75pt .75pt'> <div id="previewcell:cell1"> <table class=MsoNormalTable border=0 cellspacing=0 cellpadding=0 width="100%" style='width:100.0%;mso-cellspacing:0in;background:white; mso-yfti-tbllook:1184;mso-padding-alt:3.75pt 3.75pt 3.75pt 3.75pt'> <tr style='mso-yfti-irow:0;mso-yfti-firstrow:yes;mso-yfti-lastrow:yes'> <td style='padding:3.75pt 3.75pt 3.75pt 3.75pt'> <p align=right style='margin:0in;margin-bottom:.0001pt;text-align:right'><strong><span style='font-size:10.5pt;font-family:"Arial","sans-serif";color:#616459'>June 4, 2010</span></strong><span style='font-size:10.0pt;font-family:"Arial","sans-serif"; color:#616459'><o:p></o:p></span></p> <p><span style='font-size:13.5pt;color:#B5121B'>OCR Guidance on Conducting a HIPAA Security Risk Analysis</span><span style='font-size: 10.0pt;font-family:"Arial","sans-serif";color:#616459'><o:p></o:p></span></p> <p style='text-align:justify'><span style='font-size:10.0pt;font-family: "Arial","sans-serif";color:#616459'>Recently, the Office for Civil Rights (&quot;OCR&quot;) issued the first in a series of guidances on the provisions in the HIPAA Security Rule, as required by the Health Information Technology for Economic and Clinical Health Act (&quot;HITECH&quot;).&nbsp; The purpose of the guidances is to assist organizations, both covered entities and business associates, in identifying and implementing the most effective safeguards to secure electronic protected health information (&quot;ePHI&quot;) and comply with HIPAA's Security Rule.&nbsp; <b><u>The first guidance in the series addressed the risk analysis requirement</u></b> as set forth in 45 C.F.R. §164.308(a)(1)(ii)(A).<o:p></o:p></span></p> <p style='text-align:justify'><span style='font-size:10.0pt;font-family: "Arial","sans-serif";color:#616459'>In its guidance, the OCR emphasized that the first step in complying with the Security Rule is to perform a risk analysis by evaluating the threats and vulnerabilities to the organization's ePHI.&nbsp; This is done by examining the confidentiality, integrity, and availability of all ePHI, and then identifying and implementing the most effective administrative, physical, and technical safeguards to secure it.&nbsp; Risk analysis is an ongoing process; the frequency of review is not specified by the Security Rule, and will vary among organizations based on need.&nbsp; There is not a one-size-fits-all protocol on assessing the risks to an organization.&nbsp; It is up to each entity to find the most appropriate and effective way to achieve compliance, based on the size, complexity, and capabilities of the organization.&nbsp; The Security Rule does, however, contain objectives that each organization must achieve when conducting a risk analysis.&nbsp; <o:p></o:p></span></p> <p style='text-align:justify'><span style='font-size:10.0pt;font-family: "Arial","sans-serif";color:#616459'>Per the OCR, risks can best be identified by assessing 1) the likelihood of a given threat accidentally triggering or intentionally exploiting a particular vulnerability in the organization's security procedures, and 2) the resulting impact on the organization.&nbsp; To guarantee compliance with the Security Rule, the following elements must be incorporated into a risk analysis.&nbsp; <o:p></o:p></span></p> <p style='text-align:justify'><span style='font-size:10.0pt;font-family: "Arial","sans-serif";color:#616459'>The OCR states that an organization must:<o:p></o:p></span></p> <div> <ul type=disc> <li class=MsoNormal style='color:#616459;mso-margin-top-alt:auto; mso-margin-bottom-alt:auto;text-align:justify;mso-list:l0 level1 lfo1; tab-stops:list .5in'><span style='font-size:10.0pt;font-family: "Arial","sans-serif";mso-fareast-font-family:"Times New Roman"'>Include in their analysis all of the ePHI that it creates, receives, maintains, or transmits, regardless of its source or location.<o:p></o:p></span></li> </ul> </div> <div> <ul type=disc> <li class=MsoNormal style='color:#616459;mso-margin-top-alt:auto; mso-margin-bottom-alt:auto;text-align:justify;mso-list:l0 level1 lfo1; tab-stops:list .5in'><span style='font-size:10.0pt;font-family: "Arial","sans-serif";mso-fareast-font-family:"Times New Roman"'>Identify and document data in all locations where ePHI is stored, received, maintained, or transmitted.<o:p></o:p></span></li> </ul> </div> <div> <ul type=disc> <li class=MsoNormal style='color:#616459;mso-margin-top-alt:auto; mso-margin-bottom-alt:auto;text-align:justify;mso-list:l0 level1 lfo1; tab-stops:list .5in'><span style='font-size:10.0pt;font-family: "Arial","sans-serif";mso-fareast-font-family:"Times New Roman"'>Identify and document any and all threats to the confidentiality, integrity, and availability of the ePHI, as well as vulnerabilities that could be triggered or exploited by a threat, which would create a risk of inappropriate access to or disclosure of ePHI.&nbsp; Each of these threat and vulnerability combinations represents a potential risk and will be used extensively throughout the risk analysis.<o:p></o:p></span></li> </ul> </div> <div> <ul type=disc> <li class=MsoNormal style='color:#616459;mso-margin-top-alt:auto; mso-margin-bottom-alt:auto;text-align:justify;mso-list:l0 level1 lfo1; tab-stops:list .5in'><span style='font-size:10.0pt;font-family: "Arial","sans-serif";mso-fareast-font-family:"Times New Roman"'>Assess and document the security measures currently used to safeguard ePHI, whether security measures required by the Security Rule are already employed, and if they are used properly.<o:p></o:p></span></li> </ul> </div> <div> <ul type=disc> <li class=MsoNormal style='color:#616459;mso-margin-top-alt:auto; mso-margin-bottom-alt:auto;text-align:justify;mso-list:l0 level1 lfo1; tab-stops:list .5in'><span style='font-size:10.0pt;font-family: "Arial","sans-serif";mso-fareast-font-family:"Times New Roman"'>Assess the probability of each potential risk to ePHI to determine which threats are &quot;reasonably anticipated&quot; and thus require protection.&nbsp; This should be determined by documenting all the threat and vulnerability combinations along with their associated likelihood estimates.<o:p></o:p></span></li> </ul> </div> <div> <ul type=disc> <li class=MsoNormal style='color:#616459;mso-margin-top-alt:auto; mso-margin-bottom-alt:auto;text-align:justify;mso-list:l0 level1 lfo1; tab-stops:list .5in'><span style='font-size:10.0pt;font-family: "Arial","sans-serif";mso-fareast-font-family:"Times New Roman"'>Consider the impact of each potential risk to the confidentiality, integrity, and availability of the ePHI.&nbsp; The criticality of potential risks should be measured using either a qualitative or quantitative method, or a combination of the two.<o:p></o:p></span></li> </ul> </div> <div> <ul type=disc> <li class=MsoNormal style='color:#616459;mso-margin-top-alt:auto; mso-margin-bottom-alt:auto;text-align:justify;mso-list:l0 level1 lfo1; tab-stops:list .5in'><span style='font-size:10.0pt;font-family: "Arial","sans-serif";mso-fareast-font-family:"Times New Roman"'>Assign risk levels to all of the threat and vulnerability combinations identified.&nbsp; The level may be determined by analyzing the likelihood of threat occurrence and the resulting impact.&nbsp; Organizations should also prepare a list of corrective actions to be performed to mitigate each risk level.<o:p></o:p></span></li> </ul> </div> <div> <ul type=disc> <li class=MsoNormal style='color:#616459;mso-margin-top-alt:auto; mso-margin-bottom-alt:auto;text-align:justify;mso-list:l0 level1 lfo1; tab-stops:list .5in'><span style='font-size:10.0pt;font-family: "Arial","sans-serif";mso-fareast-font-family:"Times New Roman"'>Document the risk analysis.&nbsp; A specific format is not required.<o:p></o:p></span></li> </ul> </div> <div> <ul type=disc> <li class=MsoNormal style='color:#616459;mso-margin-top-alt:auto; mso-margin-bottom-alt:auto;text-align:justify;mso-list:l0 level1 lfo1; tab-stops:list .5in'><span style='font-size:10.0pt;font-family: "Arial","sans-serif";mso-fareast-font-family:"Times New Roman"'>Do a periodic review of risk analysis and update the assessments accordingly.&nbsp; Since there is no set requirement as to the frequency required, organizations should do so &quot;as needed.&quot;<o:p></o:p></span></li> </ul> </div> <p style='text-align:justify'><span style='font-size:10.0pt;font-family: "Arial","sans-serif";color:#616459'>The OCR expects that information gleaned from the risk analysis will be used by the organization to assess whether each addressable implementation specification outlined in the Security Rule is reasonable or appropriate, or whether an equivalent measure is better suited.<o:p></o:p></span></p> <p style='text-align:justify'><span style='font-size:10.0pt;font-family: "Arial","sans-serif";color:#616459'>The OCR is requesting feedback from the public regarding its guidance. Comments may be submitted to <a href="mailto:OCRPrivacy@hhs.gov">OCRPrivacy@hhs.gov</a> and will be accepted through <b><u>June 18, 2010</u></b>.<o:p></o:p></span></p> <p><span style='font-size:10.0pt;font-family:"Arial","sans-serif"; color:#616459'>The OCR guidance can be accessed at: <a href="http://www.hhs.gov/ocr/privacy/hipaa/administrative/securityrule/radraftguidance.pdf">http://www.hhs.gov/ocr/privacy/hipaa/administrative/securityrule/radraftguidance.pdf</a><o:p></o:p></span></p> <p><span style='font-size:10.0pt;font-family:"Arial","sans-serif"; color:#616459'>As you review this information, please contact Elizabeth Callahan-Morris (<a href="mailto:ecallahan@hallrender.com">ecallahan@hallrender.com</a> or 248.457.7854), Mark J. Swearingen (<a href="mailto:mswearingen@hallrender.com">mswearingen@hallrender.com</a> or 317.977.1458) or your regular Hall Render attorney with any questions you may have.&nbsp; We will issue additional articles as the OCR issues more guidance in this series.<o:p></o:p></span></p> <p><span style='font-size:10.0pt;font-family:"Arial","sans-serif"; color:#616459'>For additional articles on this topic and other HIPAA topics, please see our &quot;Impact Series&quot; at </span><span style='font-size:10.0pt;font-family:"Arial","sans-serif"'><a href="http://www.hallrender.com/impact" title="www.hallrender.com/impact" conversion=false alias="www.hallrender.com/impact">www.hallrender.com/impact</a>.</span><span style='font-size:10.5pt;font-family:"Arial","sans-serif"'><o:p></o:p></span></p> </td> </tr> </table> </div> </td> </tr> </table> </div> </td> </tr> <tr style='mso-yfti-irow:4'> <td valign=top style='background:white;padding:0in 0in 0in 0in'> <p class=MsoNormal><span style='mso-fareast-font-family:"Times New Roman"'>&nbsp;<o:p></o:p></span></p> </td> </tr> <tr style='mso-yfti-irow:5'> <td valign=top style='padding:0in 0in 0in 0in'> <p class=MsoNormal align=center style='text-align:center'><span style='mso-fareast-font-family:"Times New Roman";mso-no-proof:yes'><img border=0 width=554 height=70 id="_x0000_i1025" src="http://www.hallrender.com/email/img/health-law-separator.jpg" alt="http://www.hallrender.com/email/img/health-law-separator.jpg"></span><span style='mso-fareast-font-family:"Times New Roman"'><o:p></o:p></span></p> </td> </tr> <tr style='mso-yfti-irow:6'> <td valign=top style='background:white;padding:0in 0in 0in 0in'> <p class=MsoNormal><span style='mso-fareast-font-family:"Times New Roman"'>&nbsp;<o:p></o:p></span></p> </td> </tr> <tr style='mso-yfti-irow:7'> <td valign=top style='background:white;padding:0in 0in 0in 0in'> <div align=center> <table class=MsoNormalTable border=0 cellspacing=0 cellpadding=0 width="80%" style='width:80.0%;mso-cellspacing:0in;mso-yfti-tbllook:1184;mso-padding-alt: 0in 0in 0in 0in'> <tr style='mso-yfti-irow:0;mso-yfti-firstrow:yes'> <td width="35%" valign=top style='width:35.0%;padding:0in 0in 0in 3.95pt'> <p class=MsoNormal><strong><span style='font-size:8.0pt;mso-fareast-font-family: "Times New Roman";color:#616459'>Indiana Offices</span></strong><span style='font-size:8.0pt;mso-fareast-font-family:"Times New Roman"; color:#616459'><br> Suite 2000, Box 82064<br> One American Square<br> Indianapolis, IN 46282 <br> (317) 633-4884<o:p></o:p></span></p> </td> <td width="33%" valign=top style='width:33.0%;padding:0in 0in 0in 0in'> <p class=MsoNormal><strong><span style='font-size:8.0pt;mso-fareast-font-family: "Times New Roman";color:#616459'>Michigan Offices</span></strong><span style='font-size:8.0pt;mso-fareast-font-family:"Times New Roman"; color:#616459'><br> Columbia Center, Suite 1200<br> 201 West Big Beaver Road<br> Troy, MI 48084<br> (248) 740-7505<o:p></o:p></span></p> </td> <td width="32%" valign=top style='width:32.0%;padding:0in 0in 0in 0in'> <p class=MsoNormal><strong><span style='font-size:8.0pt;mso-fareast-font-family: "Times New Roman";color:#616459'>Kentucky</span></strong><span style='font-size:8.0pt;mso-fareast-font-family:"Times New Roman"; color:#616459'><br> 614 West Main Street<br> Suite 4000<br> Louisville, KY 40202<br> (502) 568-1890<o:p></o:p></span></p> </td> </tr> <tr style='mso-yfti-irow:1'> <td colspan=3 style='padding:0in 0in 0in 0in'> <p class=MsoNormal><span style='mso-fareast-font-family:"Times New Roman"'>&nbsp;<o:p></o:p></span></p> </td> </tr> <tr style='mso-yfti-irow:2;mso-yfti-lastrow:yes'> <td width="35%" valign=top style='width:35.0%;padding:0in 0in 0in 3.95pt'> <p class=MsoNormal><span style='font-size:8.0pt;mso-fareast-font-family: "Times New Roman";color:#616459'><br> 8402 Harcourt Road<br> Suite 820<br> Indianapolis, IN 46260<br> (317) 871-6222<o:p></o:p></span></p> </td> <td valign=top style='padding:0in 0in 0in 0in'> <p class=MsoNormal><span style='font-size:8.0pt;mso-fareast-font-family: "Times New Roman";color:#616459'><br> 2390 Woodlake Drive <br> Suite 380 <br> Okemos, MI 48864<br> (517) 706-0920<o:p></o:p></span></p> </td> <td valign=top style='padding:0in 0in 0in 0in'> <p class=MsoNormal><strong><span style='font-size:8.0pt;mso-fareast-font-family: "Times New Roman";color:#616459'>Wisconsin</span></strong><span style='font-size:8.0pt;mso-fareast-font-family:"Times New Roman"; color:#616459'><br> 111 East Kilbourn Avenue<br> Suite 1300 <br> Milwaukee, WI 53202<br> (414) 721-0442<o:p></o:p></span></p> </td> </tr> </table> </div> </td> </tr> <tr style='mso-yfti-irow:8'> <td valign=top style='background:white;padding:0in 0in 0in 0in'> <p class=MsoNormal><span style='mso-fareast-font-family:"Times New Roman"'>&nbsp;<o:p></o:p></span></p> </td> </tr> <tr style='mso-yfti-irow:9'> <td valign=top style='background:white;padding:0in 7.9pt 0in 0in'> <p class=MsoNormal align=right style='text-align:right'><span style='mso-fareast-font-family:"Times New Roman"'><a href="http://www.hallrender.com/" target="_blank"><b><span style='color:#B6121B;text-decoration:none;text-underline:none'>hallrender.com</span></b></a>&nbsp;<o:p></o:p></span></p> </td> </tr> <tr style='mso-yfti-irow:10'> <td valign=top style='background:white;padding:0in 0in 0in 0in'> <p class=MsoNormal><span style='mso-fareast-font-family:"Times New Roman"'>&nbsp;<o:p></o:p></span></p> </td> </tr> <tr style='mso-yfti-irow:11'> <td valign=top style='padding:0in 3.95pt 0in 15.8pt'> <p class=MsoNormal><span style='font-size:8.0pt;mso-fareast-font-family: "Times New Roman";color:#616459'>This publication is intended for general information purposes only and does not and is not intended to constitute legal advice. The reader must consult with legal counsel to determine how laws or decisions discussed herein apply to the reader's specific circumstances. &nbsp;<o:p></o:p></span></p> </td> </tr> <tr style='mso-yfti-irow:12;mso-yfti-lastrow:yes'> <td valign=top style='background:white;padding:0in 0in 0in 0in'> <p class=MsoNormal><span style='mso-fareast-font-family:"Times New Roman"'>&nbsp;<o:p></o:p></span></p> </td> </tr> </table> </div> </td> </tr> </table> </div> <p class=MsoNormal><span style='mso-fareast-font-family:"Times New Roman"'><o:p>&nbsp;</o:p></span></p> <custom name="opencounter" type="tracking"></div> </body> <table cellpadding="2" cellspacing="0" width="600" align="center"> <tr> <td> <font face="verdana" size="1" color="#777777"> This email was sent to: <b>%%emailaddr%%</b><br><br> <table cellpadding="2" cellspacing="0" width="450" ID="Table1" Border=0> <tr> <td> <font face="verdana" size="1" color="#777777"> This email was sent by: %%Member_Busname%%<br> %%Member_Addr%% %%Member_City%%, %%Member_State%% %%Member_PostalCode%% %%Member_Country%% </font> </td> </tr> </table><br><br> We respect your right to privacy - <a href="http://email.exacttarget.com/Company/Policies/PrivacyPolicy.html?linkid=View+Privacy+Policy" alias="View Privacy Policy" style="color: #0000ff">view our policy</a> </font> </td> </tr> <tr> <td colspan="2" align="center"> <font face="verdana" size="1" color="#777777"> <br> <a href="%%subscription_center_url%%" alias="Manage Subscriptions">Manage Subscriptions</a> | <a href="%%profile_center_url%%" alias="Update Profile">Update Profile</a> | <a href="%%unsub_center_url%%" alias="Unsubscribe">One-Click Unsubscribe</a> </font> </td> </tr> </table> </html>