How to Perform a Large Scale HIPAA Security Gap Analysis as a Means of Performance Improvement Roy G. Clay III, BSCS, CDP HIPAA Security Project Coordinator.

How to Perform a Large Scale HIPAA Security Gap

Analysis as a Means of Performance Improvement

Roy G. Clay III, BSCS, CDPHIPAA Security Project Coordinator

Louisiana State University Health Sciences CenterNew Orleans, LA

rclay1@lsuhsc.edu

Louisiana State University

A Hybrid Entity

Louisiana State University

A Hybrid EntityCovered Component

Health Sciences CenterPennington Biomedical

Research CenterDefinity Health Plan

Non-Covered ComponentAgricultural & Mechanical

CollegeLaw SchoolAgricultural CenterLSU at EuniceLSU at AlexandriaLSU at ShreveportUniversity of New Orleans

LSU Health Sciences Center

LSU Health Sciences Center

S h re v ep or t C a m p usU n iv e rs i ty Ho sp ita l

S cho o ls o f M e d ic ine , G M EG rad ua te S tu d ie s , A llie d H ea lth

H e a lth C are S e rv ices D iv is ion(H C S D )

9 Ho sp ita ls

N e w O r lea n s C a m p usM ed icin e , D en tis try

N u rs ing , G rad u ate S tud iesA llie d He a lth

V ice P res ide n to f He a lth A ffa irs

Health Care Services Division

(Large Scale)

Health Care Services Division

(Large Scale)5000+ Inpatient

Admissions/mo.30000+ Outpatient

visits/mo.600+ Deliveries/mo.1,000,000 Lab tests/mo.14,000 Prescriptions

filled/mo.

3000+ Surgical Procedures/mo.

28000 ED visits/mo.32,000+ Diagnostic

Radiology procedures/mo.2000+ Medical Staff

members10000+ Employees

ChallengesChallenges

Large multi-entity organization.Distributed authority.Heterogeneous infrastructure.Budget. (What budget?)Poor organizational communication.Lack of computer literacy.Good practices in some areas but other areas

overlooked.Little (if any) documentation.

Gap Analysis ProcessGap Analysis Process

Appoint Security Officer and Give Him the Authority to Perform the Gap Analysis.

Iterative Discovery Process.Compile Results and Make Recommendations.

Educate Your New Security Officer

Educate Your New Security Officer

Security NPRM - http://aspe.hhs.gov/admnsimp/bannerps.htm#security

AAMC Guidelines - http://www.aamc.org/members/gir/gasp/hipaaresources.htm

WEDI SNIP Whitepapers - http://snip.wedi.org/public/articles/index.cfm?Cat=17

Iterative Discovery Process

Iterative Discovery Process

Where is the data?Surveys.Interviews.

Where is the Data?Where is the Data?

LSUHSCTulane

C entrally Adm inis teredSystem s

PatientM anagem ent LIS

A u g u s t 8 , 2 0 0 1

LSUHSC HCSD HIPAA Gap Analysis ProjectApplication Adm inistration

H ospitalAdm inisteredSystem s

N ovell N etw ork

Vendor Adm inisteredSystem s

M edical T ranscription

N ew Pharm acy System

H L7 Interface

Vendor Adm inisteredSystem s

C learinghouseVendor Blue C ross

W indow s N T N etw ork

LH NLSU H SC C linics

D epartm entAdm inistered System s

PAC S/R M S Biom edM edical R ecordsStorage

Academ ic System s

C oding

Top Down SurveysTop Down Surveys

A pp lica tionL ev e l

S ite /C a m p usL ev e l

E n te rp riseL ev e l

InterviewsInterviews

Five Targeted GroupsExecutive Staff (Including Medical)Human ResourcesTrainingInformation TechnologySystem Users

Use responses from surveys to guide your interviews.

Results and Recommendations

Results and Recommendations

Don’t wait to complete your surveys and interviews to begin compiling recommendations.

Provide management with alternatives wherever possible.

Make sure your recommendations are supported by your results.

RememberRemember

Be prepared to go over things again and again. Plan for items to be late.Know how to escalate. Make every step educate as well as collect

information.

Caveat Emptor!Caveat Emptor!

“20% of HIPAA attorneys are passing incorrect information to their clients.” – Alan Mertz, Executive Vice-President, Healthcare Leadership Council

HIPAA is new. Most of the consultants got to be experts on HIPAA by reading about it.

Vendors probably know less about HIPAA Security than you do.

Performance ImprovementPerformance Improvement

Security Management ProcessPolicies, Standards, and Procedures (PSP Not

P&P)Change ManagementMeasurements

Security Management Process

Security Management Process

Include other areas essential to the security process. (Facilities, Hospital Police, etc.)

This group is the primary security policy making body.

Recommends security projects to be included in overall project list.

Policies, Standards, and Procedures

Policies, Standards, and Procedures

P roced ures

S tan d ards

P o licies

Policies, Standards, and Procedures

Policies, Standards, and Procedures

Policies are developed from the security management process.

Policies should be simple and concise. Standards are set and revised by the appropriate group

(usually IT) as specified in the policy. Procedures are developed to meet the requirements of

policies and standards as needed. http://www.iso-17799.com/iso.htm

StandardsStandards

As few as possible but sufficient to cover all situations.

Must be written.All projects, grants, construction, etc. must be

checked for adherence to standards.

Change ManagementChange Management

Communications Tool.Automate workstation patches.Keep logbooks on servers. Use request form to initiate and track changes.

MeasurementsMeasurements

Identify and track critical statistics. Make sure your measurements make sense from

the users’ perspective. Scan your network.

FinallyFinally

Gap analysis provides a database than can be mined for performance improvement.