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tableofcontents.htm   start.htm   securitysectiontwo.htm   securitysectionthree.htm   securitysectionone.htm   securitycategories.htm   references.htm   privacysectiontwo.htm   privacysectionthree.htm   privacysectionone.htm   privacysectionfour.htm   privacysectionfive.htm   privacycategories.htm   jobdescriptions.htm   introduction.htm   index.htm   hipaatrifold.htm   hipaasuppliment.htm   hipaaresources.htm   hipaaexecsummary.htm   guidelinesorganization.htm   generalpolicyguidelines.htm   generalcategories.htm   definitions.htm   contractsandpolicies.htm   contact.htm   amchipaasecurityandprivacyguidelines.htm   acronyms.htm   acknowledgements.htm  
Page 1
AMC/HIPAA Workgroup
7
AMC Guidelines
This document provides a summary of the requirements of the HIPAA security and privacy
regulations, with advice to the reader on how to address those requirements. The document's
structure has been designed to make it easy to relate the material in this document to the text of
the HIPAA security and privacy regulations.
Organization of the Guidelines
The document starts with specific information about addressing the detailed requirements of the
HIPAA security and privacy regulations where those regulations are clear and specific. It then
moves on to cover areas in which some interpretation of the regulations' requirements is
necessary. It concludes with a treatment of broader organizational implications of HIPAA
security and privacy compliance; this portion of the document covers issues that the regulations
raise but for which they provide neither specific requirements nor clear guidance.
The Security sections discuss provisions of the HIPAA Security Regulations:
Security Section One discusses what a covered entity needs to do to address the security
administration requirements.
Security Section Two discusses what a covered entity needs to do to address the technical
security services and mechanisms requirements.
The Privacy sections discuss provisions of the HIPAA Privacy Regulations:
Privacy Section One discusses the definition of a covered entity and the application of the
regulations to different types of covered entities.
Privacy Section Two discusses consent and authorization requirements.
Privacy Section Three discusses use and disclosure requirements.
Privacy Section Four discusses consumer control requirements.
Privacy Section Five discusses administrative requirements.
The General Section covers areas of the HIPAA regulation that require a covered entity to make
judgments about how the regulations' requirements apply to the organization (for example,
"minimum necessary disclosure," "scalability," and "reasonableness"). This Section also covers
broader organizational implications of compliance with the regulations (for example, how
HIPAA compliance might influence the structure of the organization, how HIPAA compliance
activities might relate to other similar activities, and what time and resources might be required
to achieve and maintain HIPAA compliance).
Page 2
AMC/HIPAA Workgroup
8
The Guideline points themselves are organized as follows:
Point Number, Point Name and Citation
X.## Name
§Citation
HIPAA Requirement
The full text of the HIPAA requirement, taken directly from the regulation. This may include
material from multiple portions of the regulations.
AMC Explanation of HIPAA Requirement
This narrative paragraph summarizes the top features of the requirement as seen from the
vantage point of an AMC, concentrating on the significance of the requirements in the AMC
environment.
Key Issues
Issues to consider before taking any proposed action.
Category I Guideline­Action must be taken to address these
Actions that are
mandatory
in order to address the HIPAA Security and Privacy regulations. The
list includes only those actions that, if not addressed, would place a covered entity in substantial
non-compliance with the requirement. Actions included in this item were included only with the
unanimous consent of all members of the AMC Security and Privacy Workgroup.
Category II Guideline­Action should be considered to address these
Actions that workgroup participants considered
helpful
in order to address the HIPAA Security
and Privacy regulations. Actions in this group are recommended by the AMC Security and
Privacy Workgroup but are not direct requirements of HIPAA.
Roadblocks
Any roadblocks to what must or should be done in order to implement the guidelines. The AMC
Security and Privacy Workgroup defines roadblocks as difficulties in implementing these
guidelines that come after the policy is put in place, e.g. AMC culture, program dollars, people,
etc. This definition distinguishes roadblocks from
issues,
which are concerns associated with
framing an AMC policy through the application of the guideline (and therefore come before the
policy). Funding issues and the problems associated with decentralization in AMCs are
universal roadblocks, so they have not been listed for individual guideline points unless there is a
specific point to be made.
Comments
Any comments to clarify or explain this point above or relate it to another.