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administrative_security [2016/04/19 10:28] 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 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.\\ | + | |
| - | * An assessment of the applicant's personal information shall be done to determine if the person has the capacity to perform the functions of the position being applied for. Once determined that the applicant is highly emotionally unstable, he/she shall not be put in a position requiring a great deal of reliability and consistency.\\ | + | |
| - | * Upon assignment, the said employee shall sign a non-disclosure agreement. Non-allied health staff shall also sign a non-disclosure agreement upon employment. \\ | + | |
| - | * Other than personality assessment, other possible conditions for hiring employees may include background information, past criminal record, if any, past administrative record, if any, background checks on prior employers, review of prior incidents, especially those which may involve issues on honesty and moral turpitude. This is also in line with ISO 27002 (17799), Sec. 8.1.2.\\ | + | |
| - | * 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.\\ | + | |
| - | //Contract between third party relationships// | + | 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.\\ |
| - | * Contracts/agreements between the health care provider and the third party shall include:\\ | + | |
| - | (a) Policies for document storage and disposal; \\ | + | |
| - | (b) Data management processes, 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 vendor's privacy and security programs; \\ | + | |
| - | (d) Description of output reporting- either electronically or in hard copy- so data can be reviewed, 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; \\ | + | |
| - | (g) Right to audit clauses; and \\ | + | |
| - | (h) Communication requirements regarding control deficiencies identified through internal or external sources.\\ | + | |
| - | //Authorization and Document Retention//\\ | + | 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.\\ |
| - | * 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**\\ | + | 1.4. 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.\\ |
| - | * 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//\\ | + | 1.5. A regular privacy and security audit shall be done by participating health care providers.\\ |
| - | * 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// \\ | + | **2. Contract with Third Party.**Contract or agreements between health care providers and a third party shall include:\\ |
| - | a. The IT shall be the custodian of security videos and they must adhere to the policy on confidentiality of medical records.\\ | + | a.) Policies for document storage and disposal;\\ |
| - | b. They shall be the one to perform system related functions such as but not limited to troubleshooting.\\ | + | 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.\\ | ||
| - | //The Medical Records Officer//\\ | + | **3. Authorization and Document Retention.** For identification and authorization purposes, the authorizing entity shall provide any of the following for identification:\\ |
| - | 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.) Biometrics\\ |
| - | + | b.) Specimen signature\\ | |
| - | //Chief Privacy Officer, PHIE Compliance Officer, Management Information Systems Officer//\\ | + | c.) E-signature\\ |
| - | * The Chief Privacy Officer shall be the head of the facility or as may be assigned by the head.\\ | + | 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.\\ | ||
| + | |||
| + | **5. The Medical Records Officer.** The Medical Records Officer with the Privacy Officer has the authority to audit the patient's shared health record.\\ | ||
| - | * 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.\\ | ||
| - | --- | ||
| References: \\ | References: \\ | ||
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| ##See Also | ##See Also | ||
| + | * [[Human Resources]] | ||
| * [[consolidated_workshop_outputs|Consolidated Workshop Outputs]] | * [[consolidated_workshop_outputs|Consolidated Workshop Outputs]] | ||