By Jaikumar Vijayan
June 19, 2007
In March, Atlanta's Piedmont Hospital became the first institution in
the country to be audited for compliance  with the security rules of
the Health Insurance Portability and Accountability Act (HIPAA).
The audit was conducted by the office of the inspector general at the
U.S. Department of Health and Human Service (HHS) and is being seen by
some in the health care industry as a precursor of similar audits to
come at other institutions.
Neither Piedmont nor HHS officials have publicly confirmed the audit or
spoken about it. That silence has sparked considerable curiosity about
why Piedmont was targeted as well as the scope of the audit and the kind
of information HHS was seeking.
A document obtained by Computerworld from a reliable source indicates
that Piedmont was presented with a list of 42 items that HHS officials
wanted information on within 10 days. Specificially, Piedmont was asked
to provide policies and procedures for:
1. Establishing and terminating users' access to systems housing
electronic patient health information (ePHI).
2. Emergency access to electronic information systems.
3. Inactive computer sessions (periods of inactivity).
4. Recording and examining activity in information systems that contain
or use ePHI.
5. Risk assessments and analyses of relevant information systems that
house or process ePHI data.
6. Employee violations (sanctions).
7. Electronically transmitting ePHI.
8. Preventing, detecting, containing and correcting security violations
9. Regularly reviewing records of information system activity, such as
audit logs, access reports and security incident tracking reports.
10. Creating, documenting and reviewing exception reports or logs.
Please provide a list of examples of security violation logging and
11. Monitoring systems and the network, including a listing of all
network perimeter devices, i.e. firewalls and routers.
12. Physical access to electronic information systems and the facility
in which they are housed.
13. Establishing security access controls; (what types of security
access controls are currently implemented or installed in hospitals'
databases that house ePHI data?).
14. Remote access activity i.e. network infrastructure, platform, access
servers, authentication, and encryption software.
15. Internet usage.
16. Wireless security (transmission and usage).
17. Firewalls, routers and switches.
18. Maintenance and repairs of hardware, walls, doors, and locks in
19. Terminating an electronic session and encrypting and decrypting
20. Transmitting ePHI.
21. Password and server configurations.
22. Anti-virus software.
23. Network remote access.
24. Computer patch management.
HHS also had a slew of other requests:
1. Please provide a list of all information systems that house ePHI
data, as well as network diagrams, including all hardware and
software that are used to collect, store, process or transmit ePHI.
2. Please provide a list of terminated employees.
3. Please provide a list of all new hires.
4. Please provide a list of encryption mechanisms use for ePHI.
5. Please provide a list of authentication methods used to identify
users authorized to access ePHI.
6. Please provide a list of outsourced individuals and contractors with
access to ePHI data, if applicable. Please include a copy of the
contract for these individuals.
7. Please provide a list of transmission methods used to transmit ePHI
over an electronic communications network.
8. Please provide organizational charts that include names and titles
for the management information system and information system security
9. Please provide entity wide security program plans (e.g System
10. Please provide a list of all users with access to ePHI data. Please
identify each user's access rights and privileges.
11. Please provide a list of systems administrators, backup operators
12. Please include a list of antivirus servers, installed, including
13. Please provide a list of software used to manage and control access
to the Internet.
14. Please provide the antivirus software used for desktop and other
devices, including their versions.
15. Please provide a list of users with remote access capabilities.
16. Please provide a list of database security requirements and
17. Please provide a list of all Primary Domain Controllers (PDC) and
servers (including Unix, Apple, Linux and Windows). Please identify
whether these servers are used for processing, maintaining,
updating, and sorting ePHI.
18. Please provide a list of authentication approaches used to verify a
person has been authorized for specific access privileges to
information and information systems.
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