Health Information Management

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

HIM-HIPAA Insider, October 27, 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: I realize that the HIPAA Security Rule requires information system review audits. Does the HIPAA Privacy Rule require similar reviews aside from performing regular audits to rule out inappropriate access? Currently, the security team at the organization where I work performs monthly information system review audits and issues quarterly reports to leadership. Is this sufficient, or should the privacy team conduct a similar audit?
A: The HIPAA Privacy Rule is pretty general when it comes to security requirements for PHI. You need to implement security measures to protect all PHI no matter the form, though. As part of the HIPAA ­Privacy Rule's required administrative safeguards, you should review access to non-electronic PHI where it's feasible. So in cases where it's feasible, the privacy team should conduct that audit.
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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