‘Tis the season for Meaningful Use, the time of year when eligible professionals (EPs) and eligible hospitals (EHs) compile their data from the meaningful use measures and prepare for attestation. It is also the season of meaningful use audits. A lesson learned from recent audits: CMS means what it says – EPs and EHs must conduct a security risk analysis. This measure is not one to be taken lightly – it’s a HIPAA requirement, and CMS auditors are on the lookout for documentation (remember, all documentation must be retained for 6 years).
Regardless of whether EPs or EHs are attesting to Stage 1 or Stage 2, or the fact that they performed a security risk analysis last year, this objective and measure must be fulfilled each year:
|Objective. Protect electronic health information created or maintained by the certified EHR technology through the implementation of appropriate technical capabilities.Measure. Conduct or review a security risk analysis in accordance with the requirements under 45 CFR 164.308(a)(1) and implement security updates as necessary and correct identified security deficiencies as part of its risk management process.||Objective. Protect electronic health information created or maintained by the Certified EHR Technology through the implementation of appropriate technical capabilities.Measure. Conduct or review a security risk analysis in accordance with the requirements under 45 CFR 164.308(a)(1), including addressing the encryption/security of data stored in Certified EHR Technology in accordance with requirements under 45 CFR 164.312(a)(2)(iv) and 45 CFR 164.306(d)(3), and implement security updates as necessary and correct identified security deficiencies as part of the EP’s risk management process.|
The HIPAA requirement for a Security Risk Analysis pursuant to 45 CFR 164.308(a)(1) is as follows:
“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.”
CMS Meaningful Use audits have specifically called out this objective and measure and are requiring participants to prove that a Security Risk Analysis has actually occurred. Though the HIPAA Security Officer should have conducted a security risk analysis for the entire practice/hospital, EPs and EHs should maintain a copy of this assessment with their meaningful use documentation and should review the assessment to make sure that the risk analysis complies with the meaningful use requirements (note: the Stage 2 requirements are significantly broader).
Below is the audit question that was sent to some Stage 1 EPs:
“Provide proof that a security risk analysis of Certified EHR Technology was performed prior to the end of the reporting period (i.e. report which documents the procedures performed during the analysis and the results of the analysis). If deficiencies are identified in this analysis, please supply the implementation plan; this plan should include the completion dates.”
Note that the audit request indicates that further documentation is needed to satisfy the auditors. EPs must show the implementation plan and the completion dates. As per the measure itself, the requirement is not merely to conduct a security risk analysis, but the EPs and EHs must implement security updates and correct security deficiencies. EPs and EHs should document these steps as well in order to appropriately respond to an audit request.
CMS has recently issued a new tip sheet to assist EPs and EHs in fulfilling the security risk analysis requirement. In addition ONC has published guidance on HIPAA Security Risk Analysis requirements. The CMS tip sheet includes some common myths surrounding risk analysis such as:
- “I only need to do a risk analysis once.”
False. To comply with HIPAA, you must continue to review, correct or modify, and update security protections.
- “My EHR vendor took care of everything I need to do about privacy and security.”
False. Your EHR vendor may be able to provide information, assistance, and training on the privacy and security aspects of the EHR product. However, EHR vendors are not responsible for making their products compliant with HIPAA Privacy and Security Rules. It is solely your responsibility to have a complete risk analysis conducted.
- “The security risk analysis is optional for small providers.”
False. All providers who are “covered entities” under HIPAA are required to perform a risk analysis. In addition, all providers who want to receive EHR incentive payments must conduct a risk analysis.
- “Simply installing a certified EHR fulfills the security risk analysis MU requirement.”
False. Even with a certified EHR, you must perform a full security risk analysis. Security requirements address all electronic protected health information you maintain, not just what is in your EHR.
Responding to a Meaningful Use audit can be time consuming and very detailed oriented — thus, maintaining the appropriate documentation is essential. For assistance with Meaningful Use or HIPAA security risk assessments, please contact Elana Zana.