1. CAMP Med Building a Health Information Infrastructure to Support HIPAA Rick Konopacki, MSBME HIPAA Security Coordinator University of Wisconsin-Madison Madison, Wisconsin

2. CAMP Med 2 Organizational Structure University of Wisconsin - Madison 41,500 students 2,060 Faculty 15,000 Employees Ranks second among public universities, third among all universities for research expenditures

3. CAMP Med 3 Organizational Structure UW Medical School 15 Clinical, 11 Basic Science Departments 1,150 Faculty 550 MD, 427 PhD students 29th for NIH funding in 2003 (~ $142,000,000)

4. CAMP Med 4 UW-Madison Organizational Structure UW Hospital And Clinics UW Medical Foundation UW-Health

5. CAMP Med 5 Organizational Structure UW – Hybrid Covered Entity Non-HCC Health Care Component School of Nursing School of Pharmacy Student Health Hygiene Lab Clinical Departments of the Medical School

6. CAMP Med 6 Organizational Structure UW – Hybrid Covered Entity Affiliated Covered Entity UW Hospital And Clinics UW Medical Foundation USE

7. CAMP Med 7 Administrative Structure Campus (CE): –Security Officer –HIPAA Task Force –Security Committee HCC units: –Security Coordinators

8. CAMP Med 8 CE Requirements under Security Rule Ensure CIA of electronic PHI Protect against any reasonably anticipated threats or hazards to security or integrity of ePHI Protect against any reasonably anticipated uses or disclosures of such information not permitted under the Privacy Rule Ensure compliance by workforce

9. CAMP Med 9 HIPAA Security Rule Essentially requires the implementation of safeguards to protect the CIA of data (ePHI): Confidentiality Integrity Availability Requires reasonable and appropriate measures, not NSA-proof. Same measures that “best practices” suggests should be used with all electronic data

10. CAMP Med 10 Challenges to Compliance Academic, traditionally open environment Research mission encourages collaboration Decentralized organization Multiple research databases Non-uniform IT resources –Each department has separate IT group & budget –Wide range of OS’s, servers, support

11. CAMP Med 11 Approach to Compliance Electronic data, purely IT Solution, right? Improved security awareness Additional technology, e.g., firewall User behavior: –Training –Policies

12. CAMP Med 12 Campus Level Initiatives Campus HIPAA security committee created representing all units in the HCC Series of best practices guidelines developed to ensure security of all data including ePHI All units meeting the best practice guidelines in compliance with security rule Not all of guidelines addressed with pure IT solutions

13. CAMP Med 13 Best Practices Guidelines Encryption Account Creation and Access Control Audit Controls User Authentication Network Device Security Password Management Single Device Remote Access

14. CAMP Med 14 Best Practices Guidelines (cont) Server Security Wireless Communication Information Sensitivity DMZ Network Workstation Use and Workstation Security Portable Devices Disaster Recovery

15. CAMP Med 15 First Step of the 1000 Mile (Li) Trip Sec. 164.308(a) (1)(i) Standard: Security management process. Implement policies and procedures to prevent, detect, contain, and correct security violations. –Risk analysis –Risk management –Sanction policy –Information system activity review

16. CAMP Med 16 Risk Analysis: Risk Assessment Inventory Based on the Security Standard Matrix, the central IT group on campus developed a spreadsheet against which each unit in the HCC can appraise their current condition in terms of risk.

17. CAMP Med 17 Risk Assessment Inventory Spreadsheet configured as separate matrices for: –Technical Assets –Physical Sites –Administrative Units Individual cells given a A – F grade with color coding for easy browsing Each clinical department in the Medical School submits their own RAI

18. CAMP Med 18 Risk Assessment Inventory (Administrative)

19. CAMP Med 19 Risk Assessment Inventory (Physical)

20. CAMP Med 20 Risk Assessment Inventory (Technical)

21. CAMP Med 21 Risk Management Medical School Migration Plan Based on the results of the RAIs from each of the departments, the migration plan is intended to spell out an organized, systematic approach designed to ensure timely Medical School compliance with the Security Rule based on analysis of the current state of data security.

22. CAMP Med 22 1.Develop strategy on steps to take –Using technology to improve CIA of ePHI –Provide training –Develop policies to modify user behavior 2.Evaluate the level at which the implementation most efficiently occurs Migration Plan

23. CAMP Med 23 Campus Level Elements Assign security officer Develop training Develop best practices guidelines for HCC

24. CAMP Med 24 Departmental Elements Risk Assessment Workforce Security Physical Controls Backup Media Controls Authentication

25. CAMP Med 25 Unit (MS) Level Elements Designate HIPAA Security Coordinator Develop security architecture that includes firewall, vulnerability scanning and incident response. Assign a full time position. Contingency planning Security committee represented by all departments Policy

26. CAMP Med 26 Clinical departments, with trusted access to UW Hospital and Clinics (EMR) Medical School Firewall Campus/ Internet Basic science departments, restricted access to PHI HCC UWHC

27. CAMP Med 27 Clinical departments, with trusted access to UW Hospital and Clinics (EMR) Campus/ Internet Campus/ Internet Medicine Biostatistics & Medical Informatics ACE Surgery Medical School Firewall -Clinical

28. CAMP Med 28 Medical School Firewall Allowing limited access from outside to inside A firewall “hole” may be requested to allow limited access to hosts on the inside of the firewall Campus/Internet All open TCP ports periodically scanned

29. CAMP Med 29 Medical School Wireless Network Open wireless useful in MS library, etc No authentication Outside MS firewall Requires remote access client to access networks containing PHI –Citrix –VPN Ensures authentication, end-to-end encryption when accessing PHI

30. CAMP Med 30 Elements to be Addressed by ACE Incident response team Secure E-mail solutions TLS UWMS UWMF UWHC

31. CAMP Med 31 Keys Ongoing process, much different than Y2K problem Security Rule not just IT issue HIPAA Security Rule should be approached as safeguards to all data especially ePHI Reasonable and appropriate

32. CAMP Med 32 Enterprise (CE) Level Authentication Workforce security Enforce “minimal use” part of Privacy Rule Enable audit controls First step in multi-factor authentication