Health Information Management

HIPAA Q&A: You’ve got questions. We’ve got answers!

HIM-HIPAA Insider, August 25, 2014

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Submit your HIPAA questions to Editor Jaclyn Fitzgerald at and we will work with our experts to provide you with the information you need.

Q: My employer is trying to monitor its systems more closely. Which systems in particular are the most important with respect to monitoring? Which activities should the organization monitor?
A: Before setting up a monitoring program, it's a good idea to conduct a risk analysis to determine where PHI is stored. This will help determine which applications should be monitored. It's a good idea to monitor applications such as EHRs, claims adjudication systems, practice management systems, and any other application that is used to access or store PHI.
You should monitor when users log into systems such as your network and applications used to store PHI. In addition, it's sound practice to monitor activity on your network and devices that protect your network, such as firewalls, to ensure no one is hacking into your network.
If you've turned audit logs on in your applications, you do need to look at them. If you don't, that could be considered willful neglect by OCR. You don't need to look at all of the logs—you can set up a monitoring program that reviews a random sample of your logs. Also, it's a good idea to look for clues that your security policies are being violated. For example, if an employee is looking at a patient or health plan member's record with the same last name as the employee, that's a red flag. It doesn't mean access is unauthorized, but it does mean that you should investigate why the employee was looking at information about someone who may be a family member.
Editor’s note: Chris Apgar, CISSP, president of Apgar & Associates, LLC, in Portland, Oregon, answered this question for HCPro’s Briefings on HIPAA newsletter.

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