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administrative_security [2016/07/07 20:13] (current) jillian_nadette_de_leon |
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| - | ##ADMINISTRATIVE SECURITY | + | ##ORGANIZATIONAL SECURITY MEASURES |
| - | **POLICIES AND PROCEDURES**\\ | + | **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.\\ |
| - | * Privacy and security policies must be documented, maintained and updated as appropriate, and retained for at least 6 years. | + | |
| - | + | ||
| - | //Manuals and guidelines//\\ | + | |
| - | * 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.\\ | + | |
| - | //Employment and Contracts//\\ | + | 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.\\ |
| - | * 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 formal process for ending a person's employment or a user's access shall be formulated so that inappropriate access to health information does not occur.\\ | + | |
| - | * 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.\\ | + | |
| - | //Authorization and Document Retention//\\ | + | 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.\\ |
| - | * 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.\\ | + | |
| - | **ACCOUNTABILITY/ Health Information Security Committee**\\ | + | 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.\\ |
| - | * 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.\\ | + | |
| - | //Security Department//\\ | + | 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.\\ |
| - | * 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. \\ | + | |
| - | //The IT personnel// \\ | + | 1.5. A regular privacy and security audit shall be done by participating health care providers.\\ |
| - | 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 such as but not limited to troubleshooting.\\ | + | |
| - | //The Medical Records Officer//\\ | + | **2. Contract with Third Party.**Contract or agreements between health care providers and a third party shall include:\\ |
| - | 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. \\ | + | 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;\\ | |
| - | //Chief Privacy Officer, PHIE Compliance Officer, Management Information Systems Officer// | + | 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.\\ | ||
| - | * The Chief Privacy Officer shall be the head of the facility or as may be assigned by the head.\\ | + | **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\\ | ||
| - | * 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: \\ | + | 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.\\ |
| - | 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.\\ | + | |
| - | --- | + | |
| + | **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.\\ | ||
| + | |||
| + | **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]] | ||