Identity Theft Prevention and Risk Management
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Questions and Answers

What is a recommended action for consumers to prevent identity theft?

  • Ignore unexpected charges on credit reports
  • Share personal information freely with unknown sources
  • Monitor EOBs received from insurance companies (correct)
  • Avoid keeping copies of healthcare records

Which of the following policies should be established for patients affected by identity theft?

  • Policies should restrict access to patients' records
  • Policies should eliminate the need to correct inaccurate information
  • Policies should allow victims access to their patient records (correct)
  • Policies should prioritize security over consumer access

What should organizations do regarding employees related to identity theft prevention?

  • Limit communication about identity theft prevention measures
  • Train employees on identity theft prevention programs (correct)
  • Prevent any training on identity theft issues
  • Encourage employees to ignore service provider arrangements

Which of the following is NOT a recommended operational recommendation for identity theft prevention?

<p>Promote the sharing of sensitive health and financial information (C)</p> Signup and view all the answers

What is a vital step organizations should take in relation to consumer health information?

<p>Establish mechanisms for correcting inaccurate information (A)</p> Signup and view all the answers

What is the primary focus of risk analysis methods in an entity?

<p>To evaluate specific circumstances of the entity (D)</p> Signup and view all the answers

Which of the following elements is part of the risk management process?

<p>Establishing communication protocols (C)</p> Signup and view all the answers

What is a significant aspect of the sanctions policy under the administrative safeguards?

<p>It addresses consequences for noncompliance (A)</p> Signup and view all the answers

What is an important component of workforce security standards?

<p>Instituting termination procedures for access privileges (D)</p> Signup and view all the answers

How is the significance of noncompliance typically communicated in administrative safeguards?

<p>In the sanctions policy documentation (D)</p> Signup and view all the answers

Which of the following is NOT considered a method of risk analysis?

<p>Subjective evaluation of workforce performance (C)</p> Signup and view all the answers

What role does leadership play in risk management processes?

<p>They need to be involved in managing identified risks (A)</p> Signup and view all the answers

What type of issue is considered intentional under human threats?

<p>Deliberate hacking into secure information systems (C)</p> Signup and view all the answers

What does ePHI stand for?

<p>Electronic Protected Health Information (B)</p> Signup and view all the answers

Which of the following best describes a vulnerability in the context of health information security?

<p>An inherent weakness that can be exploited (A)</p> Signup and view all the answers

What is a critical aspect of the Security Risk Analysis?

<p>It involves assessing methods, operational practices, and policies (B)</p> Signup and view all the answers

What type of threats are categorized as natural in health information security?

<p>Incidents caused by storms (C)</p> Signup and view all the answers

Which of the following is NOT a required specification in the Security Rule?

<p>Optional technical safeguards (A)</p> Signup and view all the answers

Which category includes the weaknesses in policies and procedures?

<p>Nontechnical vulnerabilities (C)</p> Signup and view all the answers

Which option best represents a security incident?

<p>An exposure of ePHI through unauthorized access (C)</p> Signup and view all the answers

What are addressable implementation specifications?

<p>Guidelines that can be tailored based on circumstances (D)</p> Signup and view all the answers

What is a requirement for physical safeguards at all workstations that access electronic protected health information (ePHI)?

<p>Access restricted to authorized users (B)</p> Signup and view all the answers

Which technical safeguard standard requires unique user identification?

<p>Access Control (B)</p> Signup and view all the answers

What must be implemented to protect ePHI from improper alteration or destruction?

<p>Integrity policies and procedures (B)</p> Signup and view all the answers

Which of the following is not a required action under the Technical Safeguard Standards?

<p>Implementing automatic logoff (A)</p> Signup and view all the answers

What is the key focus of the technical safeguards provided in the standards?

<p>Protection of electronic protected health information (ePHI) (C)</p> Signup and view all the answers

Which of the following is an addressable standard under Person or Entity Authentication?

<p>Method for emergency access (C)</p> Signup and view all the answers

Which standard involves implementing mechanisms to audit activities in systems that handle ePHI?

<p>Audit Control (A)</p> Signup and view all the answers

What is a required component of device and media controls?

<p>Media reuse procedures (B)</p> Signup and view all the answers

Which of the following is a required standard under Administrative Safeguard related to security incident procedures?

<p>Identify and respond to suspected security incidents (D)</p> Signup and view all the answers

What is included in the contingency plan required under Administrative Safeguard?

<p>Disaster recovery plan (B)</p> Signup and view all the answers

Which of the following is an addressable standard regarding access authorization?

<p>Access establishment and modification (B)</p> Signup and view all the answers

What is the primary focus of the physical safeguard standard regarding facility access control?

<p>Limit access to systems and facilities (C)</p> Signup and view all the answers

Which of the following is NOT a component of the required security awareness and training program?

<p>Data encryption methods (A)</p> Signup and view all the answers

Which of the following procedures is NOT part of a required security incident procedure?

<p>User password updates (D)</p> Signup and view all the answers

Which safeguards are addressable for facility access control?

<p>Access control and validation procedures (B)</p> Signup and view all the answers

What is the primary requirement for existing workforce training related to security?

<p>Training on malicious software protection (A)</p> Signup and view all the answers

What is required for ensuring transmission security of ePHI?

<p>Measures to guard against unauthorized access (A)</p> Signup and view all the answers

Which of the following best describes the concept of integrity in relation to ePHI?

<p>ePHI not being altered or destroyed in an unauthorized manner (D)</p> Signup and view all the answers

What is a significant impact of medical identity theft on victims?

<p>Disruption of the patient’s life (A)</p> Signup and view all the answers

Which of the following is NOT part of an Identity Theft Prevention Program?

<p>Conducting regular staff training (C)</p> Signup and view all the answers

What aspect of ePHI does confidentiality specifically address?

<p>ePHI is accessible only by authorized individuals (B)</p> Signup and view all the answers

During a risk assessment, what is primarily evaluated?

<p>Potential risks and areas of vulnerability related to ePHI security (A)</p> Signup and view all the answers

What consequence can arise from incorrect information in a patient’s health record due to identity theft?

<p>Life-threatening medical situations (C)</p> Signup and view all the answers

What is an addressable measure for securing ePHI in transmission?

<p>Implementation of encryption (D)</p> Signup and view all the answers

Flashcards

ePHI

Information protected by HIPAA rules because it relates to a person's health status.

Security Rule

The set of security standards implemented by covered entities (such as healthcare organizations) to protect ePHI.

Security Risk Analysis

A complete analysis of how an organization safeguards ePHI, including policies, procedures, and technical controls.

Security Incident

A security incident is any event involving ePHI that could compromise its confidentiality, integrity, or availability.

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Vulnerability

Weaknesses in an organization's security that could be exploited by threats. Examples include technical vulnerabilities in software or non-technical vulnerabilities in policies and procedures.

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Threat

A potential danger to a computer, network, or data. Threats can be natural (e.g., storms) or man-made (e.g., malware).

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Availability

The ability to access and use ePHI for authorized purposes.

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Integrity

Ensuring that ePHI is accurate and complete, and that unauthorized modifications are prevented.

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Isolating healthcare clearinghouse functions

This administrative safeguard requires healthcare clearinghouses to isolate their functions from other parts of a healthcare organization's IT system.

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Access Authorization

This addressable safeguard allows covered entities to control who can access protected health information (PHI) and what they can do with it.

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Security Awareness Training

This administrative safeguard requires covered entities to train employees on how to protect PHI.

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Security Incident Procedures

This standard requires covered entities to have a plan for responding to security incidents and mitigating harmful effects.

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Contingency Plan

This required safeguard includes a comprehensive plan for backing up data, restoring data after a disaster, and specifying how the organization will operate in an emergency.

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Facility Access Control

This administrative safeguard requires organizations to limit who can physically access their systems and facilities.

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Workstation Use

This addressable safeguard ensures that only authorized individuals can use workstations to access PHI.

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Contingency Operations

This physical safeguard requires organizations to have a plan to ensure the ongoing operation of their systems after a disaster.

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Risk

The possibility of experiencing harm or loss as a result of threats or vulnerabilities.

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Risk Analysis

A structured process to understand, assess, and manage the risks associated with ePHI.

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Risk Management

Actions taken to minimize or avoid risks, such as implementing policies, procedures, and technical safeguards.

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Administrative Safeguards

A set of security standards outlined in the HIPAA Security Rule to ensure adequate protection of ePHI.

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Security Management

A key administrative safeguard that involves identifying, assessing, and managing the risks associated with ePHI.

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Sanctions Policy

A policy outlining consequences for violating security rules and procedures.

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Information Systems Activity Review

Regularly reviewing and analyzing system activities, including access logs, reports, and incident tracking data.

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Workforce Security

Administrative safeguards that focus on securing the workforce, including authorizing access, conducting background checks, and managing termination procedures.

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Identity Theft Prevention

Ensuring that individuals and organizations practice caution when handling personal information, such as healthcare records and financial details, to prevent identity theft.

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Identity Theft Operational Recommendations

A set of guidelines and best practices designed to safeguard personal information, especially in healthcare, from unauthorized access or misuse.

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Data in the patient record

Maintaining records of data access and changes, allowing for tracking and detection of potential security breaches.

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Provide Victims with Resources and Tools

The process of enabling individuals affected by medical identity theft to correct inaccurate information in their health records and recover from potential harm.

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Urge and Educate Consumers

Emphasizing the importance of security awareness and educating consumers about how to protect their personal information from theft.

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Physical Safeguards

Policies and procedures, workstation environment, and safeguards for both onsite and offsite access to protect ePHI.

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Device and Media Controls (Physical Safeguard)

Control of devices and media used to access and store ePHI.

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Technical Safeguards

Technology and procedures for protecting and controlling access to ePHI.

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Access Control (Technical Safeguard)

Ensuring only authorized individuals can access ePHI by using unique identifiers and emergency access procedures.

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Audit Control (Technical Safeguard)

Recording and examining activity within systems that contain or use ePHI to monitor for unauthorized access.

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Integrity (Technical Safeguard)

Protecting ePHI from unauthorized alteration or destruction.

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Person or Entity Authentication (Technical Safeguard)

Verifying the identity of individuals trying to access ePHI.

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Integrity (Technical Safeguard)

Policies and procedures to safeguard ePHI from accidental or malicious data loss or modification.

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Transmission Security

A security standard that aims to protect electronic protected health information (ePHI) while it's being sent over networks. It includes measures like encryption and integrity controls.

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Integrity Controls

They ensure that ePHI isn't accidentally or maliciously altered or destroyed.

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Encryption

A process of turning ePHI into a coded form that only authorized parties can understand. Helps protect ePHI during transmission.

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Confidentiality

The principle of keeping ePHI private and accessible only to authorized individuals and processes.

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Risk Assessment

A thorough assessment of potential threats and vulnerabilities related to ePHI security.

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Medical Identity Theft

A situation where someone uses another individual's personal information without their consent, often to obtain medical care or submit false billing.

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Study Notes

Introduction to Healthcare Informatics, Third Edition - Chapter 11: Security for Health Information

  • Chapter 11 focuses on security for health information.

  • Types of breaches under investigation include hacking/IT incidents, unauthorized access/disclosure, loss, theft, and improper disposal. A chart shows relative frequencies.

  • ePHI (electronic protected health information) security is a concern throughout its lifecycle (creation, receipt, maintenance, transmission).

  • Security rules include required implementation specifications, addressable implementation specifications, and security incidents.

  • Security risk analysis involves evaluating methods, operational practices, and policies to secure ePHI.

  • Vulnerabilities:

    • Technical weaknesses—inadequate information systems, assault, harm, unauthorized corruption—are found in the National Vulnerability Database.
    • Nontechnical weaknesses—problems with policies and procedures.

  • Threats:

    • Natural (storms, earthquakes).
    • Human (intentional hacking, unintentional—forgetting to log off).
    • Environmental (power failure, environmental agents).

  • Risks involve the likelihood of injury or loss, compared to potential impact. Entities can customize risk analysis methods based on their situations.

  • Administrative safeguards:

    • Security measures to protect ePHI, administrative actions, related policies, and procedures.
    • Security management processes (risk analysis, risk management elements, communication, leadership involvement), sanctions policy for noncompliance (examples, sliding scale of discipline).
    • Information systems activity review through audit logs, access reports, incident tracking reports.
    • Workforce security (authorization and supervision, workforce clearance procedures, termination procedures).
    • Information access management and related functions (isolating healthcare clearinghouse functions, access authorization, access establishment, and modifications).
    • Security awareness and training (existing workforce training on updates, security reminders, protection from malicious software, log-in monitoring, password protection).
    • Security incident procedures (response and reporting, identifying and responding to suspected or known security incidents, mitigating harmful effects, documenting incidents and outcomes).
    • Contingency planning (data backup, disaster recovery, emergency mode plans, testing, revision, application and data criticality analysis).

  • Physical safeguards: Facility access control (limiting physical access to systems and facilities, ensuring authorized access), workstation use (policies and procedures for proper function and manner, physical attributes of workstations both onsite and off-site, physical safeguards restricting access to authorized users), device and media controls (proper disposal, media reuse, accountability, data backup, and storage).

  • Technical safeguards standards cover technology, policies, and procedures to protect ePHI and access control (unique user identification, emergency access procedures, automatic logoff, encryption and decryption).

  • Technical safeguards also include audit controls (implementing hardware, software, and/or procedural mechanisms to record and examine activity in electronic protected health information systems) and integrity (implementing policies and procedures to protect ePHI against alteration or destruction).

  • Technical safeguards also include authentication (verifying the person or entity seeking access to ePHI), and transmission security (measures to prevent unauthorized access to ePHI during transmission over communication networks, including integrity controls and encryption).

  • Confidentiality, integrity, and availability are essential. Confidentiality protects ePHI access to only authorized people and processes; integrity prevents unauthorized alteration or destruction; availability enables authorized users to access ePHI as needed.

  • Risk assessment: Identifying potential risks and vulnerabilities related to ePHI security to aid in audits and complaint investigations

  • Medical identity theft involves unauthorized use of personal information for medical purposes. This can cause disruptions to victims’ lives and damage credit ratings. Additional significant risks involve financial considerations for patients, providers, and third-party payers. The incorrect information can also lead to medical treatment issues, including life-threatening problems.

  • Identity theft prevention programs include identifying covered accounts and discovering relevant red flags; detecting and responding to red flags; overseeing the program; training employees. The program also involves overseeing service provider arrangements, approving the identity theft prevention program, and providing periodic updates.

  • Identity theft recommendations include urging and educating consumers on preventive measures; monitoring EOBs, copies of records, and credit reports, and protecting all health insurance and financial information. It is important to have policies and procedures in place to help victims access patient records, and tools for easier recovery.

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Introduction to Healthcare Informatics, Third Edition - Chapter 11: Security for Health Information PDF

Description

Test your understanding of identity theft prevention strategies and the associated risk management processes. This quiz covers organizational policies, consumer health information security, and compliance issues surrounding identity theft. Ensure you are well-versed in the critical actions for individuals and organizations alike.

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