There is a very good article over at HealthData Management called Want to Impress OCR During a HIPAA Audit? Write a Book
The author discusses the benefits of creating a “Book of Evidence” that your organization is in HIPAA compliance if you were to get audited by the HHS Office of Civil Rights (OCR).
Creating a Book of Evidence on an organization’s compliance with HIPAA privacy, security and breach rules is not difficult, only takes a couple of weeks, and helps an organization not be overwhelmed if it’s selected by the HHS Office for Civil Rights for a random HIPAA audit, says Mark Dill, director of information security at Cleveland Clinic.
Mark Dill goes on to make a very good point:
“If you look disorganized, HHS will think you are.” An organization may be able to avoid an on-site visit just by the quality of data it sends to OCR, or at least can minimize the time spent on site, which avoids auditors finding more issues.
Dill gives some good example of what should be in a Book of Evidence (BOE):
A BOE will show proof of updating the risk analysis with introduction of business changes or new information systems; an incident response system that is quick, effective and a repeatable process; that all employees have received timely HIPAA training with their scores available; that appropriate authentication controls are in place; and can even show the receipts for security technology buys such as encrypted hard drives, Dill says.
At HIPAA Secure Now! we have been thinking about a Book of Evidence for years. Our HIPAA Compliance Portal can be your Book of Evidence. If you were to get audited by OCR, you can give them a userid to access your HIPAA Compliance Portal. All of your “evidence” of HIPAA compliance is in one place. Let’s take a look.
HIPAA Compliance Portal
HIPAA Security Policies and Procedures
All your HIPAA privacy and security policies are stored in our Compliance Portal. All employees have access to the Compliance Portal and access to your policies and procedures. You can even upload OHSA policies, your employee handbook and HR policies and procedures that employees can access online.
HIPAA Risk Assessment, Business Associate Agreements, Disaster Recovery Procedures
The Compliance Portal contains your Risk Assessment reports, tracks Business Associates and allows you to upload Business Associate Agreements, Disaster Recovery Plans and also allows you to upload other contracts or documents. Only administrators have access to this section. Employees do not have access to this sensitive information.
HIPAA Security Training
All training is done online via our Compliance Portal. The administrator training report is accessible only to the administrator(s). The reports shows each of your employees, when they took the HIPAA security training and what grade they received on their HIPAA compliance quiz. There is no better way to prove you have provided HIPAA security training to your employees! Employees also have access to our HIPAA Security Tips and Reminders which helps show that you are in compliance with the requirement to provide periodic security reminders to employees.
HIPAA Security Incidents, Server Room Access, Track ePHI Removed and Received
The Compliance Portal allows you to track HIPAA security incidents and what your response was to each of those incidents. You can also track who has accessed the server room, and ePHI that has left your organization (i.e. USB drives) and any ePHI that has been received by your organization (i.e. DVD drives with x-rays or ultrasound images given to you by patients).
As you can see, the HIPAA Secure Now! Compliance Portal can be your “Book of Evidence” in the event OCR audits your organization. If you would like a live demo of our HIPAA Secure Now! Compliance Portal, fill out the form below and we will be happy to schedule a demo with you.