HIPAA audit: The 42 questions HHS might ask

HIPAA audit: The 42 questions HHS might ask
HIPAA audit: The 42 questions HHS might ask 

By Jaikumar Vijayan
June 19, 2007

In March, Atlanta's Piedmont Hospital became the first institution in 
the country to be audited for compliance [1] 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 
   (incident reports).
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 
    sensitive areas.
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 
   Security Plan).
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 
    and users.
12. Please include a list of antivirus servers, installed, including 
    their versions.
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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