Course Objectives for Assignment:
- Assess the potential of Information Technology in process and performance improvement.
- Examine Information Technology Implementation by analyzing a case on using integrated systems that collect, track, and share information across local- and wide-area network tools to clinical and administrative audiences.
Assignment Scenario: Continuing to apply your role as a summer intern for the not-for-profit organization, you internship mentor has shared that they are very happy with your input. However, additional research needs to be conducted. Create a report that includes the following items:
1. Review the IoM’s 1999 and 2001 reports under Module 7 Resources.
- Compare and contrast the recommendations in these reports.
- Evaluate the outcomes of their implementation and assess their impact on healthcare quality improvement (familiarize yourself with Quality Improvement points).
- Ascertain the consequences of not using HIT and frame your recommendations for improvement of healthcare quality using HIT?
2. HIPAA (1996) and HITECH (2009) Acts contain provisions for the protection of health information both by Covered Entities (CEs) and Business Associates (BAs).
- Compare Security Rule provisions for CEs and BAs in both Acts?
- Identify the organization responsible for monitoring its compliance by providers and explain its mode of operation. Ascertain the value of the Security Rule provisions for electronic health records.
- Finally, assess implications for noncompliance of the Security Rule provisions by healthcare organizations?
3. Develop an example case that can be used in the presentations where a Chief Information Security Officer (CISO) at a local healthcare facility has not adopted any Password use policy yet.
- Delineate the role of CISO in the implementation of the password use policy.
- Offer approaches to developing a Password use policy for this organization.
Expert Solution Preview
Introduction: In this assignment, we will be addressing three different topics related to healthcare and information technology. The first topic involves reviewing the Institute of Medicine’s (IoM) 1999 and 2001 reports and evaluating the recommendations made in these reports. The second topic focuses on comparing the Security Rule provisions for Covered Entities (CEs) and Business Associates (BAs) in the HIPAA (1996) and HITECH (2009) Acts. Lastly, we will develop an example case that explores the role of a Chief Information Security Officer (CISO) in implementing a password use policy for a healthcare facility.
1. Review the IoM’s 1999 and 2001 reports and compare/contrast their recommendations. Evaluate the outcomes of their implementation and assess their impact on healthcare quality improvement.
The IoM’s 1999 report, titled “To Err is Human: Building a Safer Health System,” focused on the issue of medical errors and patient safety. It highlighted the need for systems improvement and recommended various strategies such as implementing health information technology (HIT), enhancing reporting mechanisms, and fostering a culture of safety. The report emphasized the potential of HIT to reduce errors and improve overall healthcare quality.
In contrast, the IoM’s 2001 report, “Crossing the Quality Chasm: A New Health System for the 21st Century,” expanded the focus beyond patient safety to overall healthcare quality improvement. It identified six aims for healthcare improvement, including safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity. The report emphasized the importance of integrating HIT into healthcare systems to support these aims.
The outcomes of implementing the IoM recommendations have shown both successes and challenges. The adoption of HIT has increased over the years, with electronic health records (EHRs) becoming more prevalent. This has led to improved access to patient information, increased communication among healthcare providers, and enhanced coordination of care. However, challenges such as interoperability issues, implementation costs, and resistance to change have also been observed.
The impact of HIT on healthcare quality improvement has been substantial. It has contributed to reduced medication errors, improved patient outcomes, increased patient engagement, and enhanced population health management. Integration of clinical decision support systems and electronic prescribing has also improved disease management and treatment outcomes. However, additional research is still needed to fully leverage the potential of HIT in achieving optimal healthcare quality.
2. Compare the Security Rule provisions for CEs and BAs in the HIPAA (1996) and HITECH (2009) Acts. Identify the organization responsible for monitoring compliance by providers and explain its mode of operation. Assess the value of the Security Rule provisions for electronic health records.
Both HIPAA and HITECH Acts contain provisions for the protection of health information, specifically in the Security Rule. The Security Rule provisions apply to both Covered Entities (CEs), such as healthcare providers, and Business Associates (BAs), who handle health information on behalf of the CEs.
Some key provisions in both Acts include:
– Implementing administrative, physical, and technical safeguards to protect health information.
– Conducting regular risk assessments and developing risk management plans.
– Implementing policies and procedures to address security incidents and breaches.
– Providing workforce training on security awareness.
The organization responsible for monitoring compliance by providers is the Office for Civil Rights (OCR), which operates under the Department of Health and Human Services (HHS). The OCR oversees compliance with the Security Rule and investigates complaints or breaches reported by individuals. It conducts audits and provides guidance to ensure healthcare organizations implement appropriate security measures.
The value of the Security Rule provisions for electronic health records (EHRs) is significant. These provisions ensure the confidentiality, integrity, and availability of electronic health information, reducing the risk of unauthorized access, breaches, and potential harm to patients. By implementing security measures, healthcare organizations can maintain trust, protect patient privacy, and enhance the overall security posture when dealing with sensitive health information.
3. Develop an example case where a Chief Information Security Officer (CISO) at a local healthcare facility has not adopted any Password use policy yet. Delineate the role of CISO in the implementation of the password use policy and offer approaches to developing a Password use policy for this organization.
In this example case, the Chief Information Security Officer (CISO) at a local healthcare facility has failed to adopt any password use policy. This situation raises concerns about the security of sensitive patient information and potential vulnerability to unauthorized access.
The role of the CISO in implementing a password use policy is crucial. The CISO is responsible for developing and enforcing security policies, including password use policies. They must ensure that the organization’s information systems, networks, and data remain secure from internal and external threats. Specifically, regarding password use, the CISO should:
1. Assess risks: Conduct a thorough risk assessment to identify potential vulnerabilities and the impact of weak password practices. This assessment will help determine the necessary measures to strengthen password security.
2. Develop a comprehensive password use policy: Create a policy that addresses password complexity, length, expiration, and usage guidelines. The policy should also include measures like multi-factor authentication and password encryption.
3. Implement education and training: Provide education and training programs to employees, emphasizing the importance of strong passwords, password management best practices, and the consequences of non-compliance.
4. Enforce policy compliance: Regularly assess and monitor compliance with the password use policy. Implement technical controls, such as password expiration and account lockouts, to enforce compliance actively.
5. Continuous improvement: Regularly review and update the password use policy to align with emerging threats, technology advancements, and industry best practices.
By following these approaches, the CISO can develop a robust password use policy that ensures the security and integrity of the healthcare facility’s sensitive information. This policy will help mitigate the risk of unauthorized access, data breaches, and potential harm to patients due to compromised passwords.