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administrative_security [2016/02/29 11:39] jillian_nadette_de_leon |
administrative_security [2016/07/07 20:13] (current) jillian_nadette_de_leon |
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| - | ##ADMINISTRATIVE SECURITY | + | ##ORGANIZATIONAL SECURITY MEASURES |
| - | **POLICIES AND ACTIVITIES**\\ | + | **1. Policies and Procedures.** The Health Facility shall be required to create its own privacy protocol. Privacy and security policies must be documented, maintained and updated as appropriate.\\ |
| - | * Hospitals and health facilities shall formulate their health information security policy that is written down in paper and ensure that the following areas are covered:\\ | + | |
| - | 1. Information on how data transfer will occur.\\ | + | |
| - | 2. Process on how the release of information shall be done.\\ | + | |
| - | 3. Sanctions for information security violation.\\ | + | |
| - | 4. All employment contracts shall contain provisions regarding privacy and security.\\ | + | |
| - | * Information security manuals and training-related guidelines for capacity building shall be made by health facilities. They shall also provide a quality management system to put in place all processes, workflows among others in relation to the implementation of PHIE.\\ | + | |
| - | * Privacy related clause, information security clause and emphasis on the ownership of data shall be embedded in contracts of third party providers and job order personnel.\\ | + | |
| - | * A character/personality check shall be done prior to the hiring and/or the assignment of an employee who shall have direct access to health information. Upon assignment, the said employee shall sign a non-disclosure agreement. Non-allied health staff shall also sign a non-disclosure agreement upon employment. \\ | + | |
| - | * An orientation regarding privacy and security policies shall be done for all employees in the health facility with great emphasis to the information security personnel.\\ | + | |
| - | * For identification and authorization purposes, the authorizing entity shall provide any of the following for identification: \\ | + | |
| - | a. Biometrics\\ | + | |
| - | b. Specimen signature\\ | + | |
| - | c. E-signature\\ | + | |
| - | * The document retention policy issued by the National Archives of the Philippines shall be followed. For archiving purposes, the health facility can either have an internal archiving system or outsource an archiving specialist.\\ | + | |
| - | * Regular privacy and security audit shall be done.\\ | + | |
| - | * Allocation of budget for data security shall be included for government hospitals and LGUs.\\ | + | |
| - | **MANAGEMENT AND ROLES**\\ | + | 1.1. The PHCP shall create policies and procedures to specify the groups and positions that need to access health information to perform their job responsibilities, as well as the type of health information to which they need access.\\ |
| - | * A health information security committee shall be organized rather than a single security officer. The team shall include the medical records officer, medical director, nurse, division heads of front liners, finance officer and legal officer. Their main role is to ensure that health information are made secure. Membership and role of the committee shall vary for other health facilities. Hospitals, LGUs, MHCO/MCO shall create their health information security committee. \\ | + | |
| - | * Roles and responsibilities of health information security committee shall include:\\ | + | |
| - | a. Policy making on health information security.\\ | + | |
| - | b. Procedures on disclosure of health information.\\ | + | |
| - | c. Management of incident reports including attempts on the disclosure of health information.\\ | + | |
| - | d. Validation of security officer rules.\\ | + | |
| - | e. Enforcement of sanctions on violations.\\ | + | |
| - | * The health facility shall have its own security department which would cover the management of security guards. The head of the security department shall be part of the quality committee and will have access to records for tracing purposes. \\ | + | |
| - | * Roles of the IT personnel: \\ | + | 1.2. Participating Health Care Providers shall provide an orientation regarding privacy and security policies for all employees in the health facility with great emphasis to the information security personnel.\\ |
| - | a. The IT shall be the custodian of security videos and they must adhere to the policy on confidentiality of medical records.\\ | + | |
| - | b. They shall be the one to perform system related functions (ex. troubleshooting). \\ | + | |
| - | * Roles of the Medical Records Officer:\\ | + | |
| - | a. The MRO shall be the one to have access to patient's data. He/she has the authority to audit the patient record from time to time in order to determine the integrity of the patient record. \\ | + | |
| - | | + | |
| - | * The Chief Privacy Officer shall be the head of the facility or as may be assigned by the head.\\ | + | 1.3. Participating Health Care Providers shall clearly define access rights and user roles of staff to ensure that only appropriate people have access to the minimum necessary health information.\\ |
| - | * The health facility shall provide 2 system administrators who will serve as system and data auditory. They shall come up with a work flow on the process of accessing health information for standard implementation.\ \ | + | |
| - | * A Privacy Officer, PHIE Compliance Officer and Management Information Systems Officer shall be assigned. The duties and responsibilities of the said officers shall include the following: \\ | + | |
| - | a. Formulate a work flow on the process of accessing health information for standard implementation.\\ | + | |
| - | b. Monitor, account and register devices used in the facility.\\ | + | |
| - | c. Perform system or quality data check, compliance on the reporting form and safekeeping of back-up data.\\ | + | |
| - | d. Delegate data collection to staff but should ensure that data collected are correct. The sole responsibility of encoding is on the appointed individual/unit.\\ | + | |
| - | e. The privacy officer shall regularly audit the quality and integrity of patient records.\\ | + | |
| - | * The following qualifications need to be met in order to become a Privacy Officer, PHIE Compliance Officer, and Management Information Systems Officer: \\ | + | |
| - | a. A graduate of Master's of Science in Health Informatics.\\ | + | |
| - | b. With IT, medical or clinical background.\\ | + | |
| - | c. With training certifications on the security aspect of PHIE. Note however that DOH and PhilHealth shall set the minimum standards based on the body of knowledge for data security, which shall be the basis for hiring a Privacy Officer, PHIE Compliance Officer, and Management Information Systems Officer.\\ | + | |
| - | --- | + | |
| + | 1.4. The Chief of Health Facility shall issue a memorandum containing the list of names and information stated in the preceding statement and a copy shall be furnished to the DOH central office.\\ | ||
| + | |||
| + | 1.5. A regular privacy and security audit shall be done by participating health care providers.\\ | ||
| + | |||
| + | **2. Contract with Third Party.**Contract or agreements between health care providers and a third party shall include:\\ | ||
| + | a.) Policies for document storage and disposal;\\ | ||
| + | b.) Data management process including methods for tracking and controlling records- such as dates and time stamps- as well as the type of data sent and received, and the individuals who have access to records;\\ | ||
| + | c.) Description of the privacy and security programs of the third party;\\ | ||
| + | d.) Description of output reporting-either electronically or in hard copy- so data can be viewed, monitored and reconciled;\\ | ||
| + | e.) Periodic staff training in secure records handling and providing, and appropriate document management tools;\\ | ||
| + | f.) Staff responsibilities for ensuring compliance and allocation of sufficient job time to the task; and\\ | ||
| + | g.) Communication requirements regarding control deficiencies identified through internal or external sources.\\ | ||
| + | |||
| + | **3. Authorization and Document Retention.** For identification and authorization purposes, the authorizing entity shall provide any of the following for identification:\\ | ||
| + | a.) Biometrics\\ | ||
| + | b.) Specimen signature\\ | ||
| + | c.) E-signature\\ | ||
| + | |||
| + | The document retention policy issued by the National Archives of the Philippines shall be followed. For archiving purposes, the PHCP can either have an internal archiving system or outsource an archiving specialist.\\ | ||
| + | |||
| + | **4. The Information Technology Personnel.** Authorized personnel responsible for supporting the implementation of security guidelines must adhere to the policy on confidentiality of medical records. They shall be the one to perform system related functions such as, but not limited to, troubleshooting.\\ | ||
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| + | **5. The Medical Records Officer.** The Medical Records Officer with the Privacy Officer has the authority to audit the patient's shared health record.\\ | ||
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| + | References: \\ | ||
| + | * Grant Thornton (2013). //Third Party Relationships and Your Confidential Data. Assessing Risk and Management Oversight Processes.// Retrieved from https://www.grantthornton.com/~/media/content-page-files/health-care/pdfs/2013/HC-2013-AIHA-wp-HIPAA-rule-data-control-concerns.ashx | ||
| ##See Also | ##See Also | ||
| + | * [[Human Resources]] | ||
| * [[consolidated_workshop_outputs|Consolidated Workshop Outputs]] | * [[consolidated_workshop_outputs|Consolidated Workshop Outputs]] | ||
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