Medium High Related Information: Things to Consider to Help Answer the Question: Consider whether your practice understands that training is an ongoing, evolving process that responds to environmental and operational changes affecting the security of ePHI. Possible Threats and Vulnerabilities: Your practice may not be able to safeguard its ePHI if it does not periodically review and update its security awareness and training program in response to changes in organization, facilities or environment. Some potential impacts include: Unauthorized or inappropriate access to ePHI can compromise the confidentiality, integrity, and availability of your practice’s ePHI. Unauthorized disclosure, loss, or theft of ePHI can lead to medical identity theft. Accurate ePHI may not be available when needed, which can adversely impact your healthcare professionals’ ability to diagnose and treat their patients. Examples of Safeguards: Some potential safeguards to use against possible threats/vulnerabilities. NOTE: The safeguards you may choose will depend on the degree of risk (likelihood) and the potential harm that the threat/vulnerability poses to you and the individuals who are the subjects of the ePHI. Implement a security awareness and training program for all members of its workforce (including management). [45 CFR §164.308(a)(5)(i)] Review and update the current security awareness and training policy and procedures based on environmental and operational changes affecting the security of ePHI. [NIST SP 800-53 AT-1] Does your practice provide ongoing basic security awareness A36 - §164.308(a)(5)(i) Standard to all workforce members, including physicians? Yes
Medium High Related Information: Things to Consider to Help Answer the Question: Consider whether your practice understands that training is an ongoing, evolving process that responds to environmental and operational changes affecting the security of ePHI. Possible Threats and Vulnerabilities: Your practice may not be able to safeguard its ePHI if it does not periodically review and update its security awareness and training program in response to changes in organization, facilities or environment. Some potential impacts include: Unauthorized or inappropriate access to ePHI can compromise the confidentiality, integrity, and availability of your practice’s ePHI. Unauthorized disclosure, loss, or theft of ePHI can lead to medical identity theft. Accurate ePHI may not be available when needed, which can adversely impact your healthcare professionals’ ability to diagnose and treat their patients. Examples of Safeguards: Some potential safeguards to use against possible threats/vulnerabilities. NOTE: The safeguards you may choose will depend on the degree of risk (likelihood) and the potential harm that the threat/vulnerability poses to you and the individuals who are the subjects of the ePHI. Implement a security awareness and training program for all members of its workforce (including management). [45 CFR §164.308(a)(5)(i)] Review and update the current security awareness and training policy and procedures based on environmental and operational changes affecting the security of ePHI. [NIST SP 800-53 AT-1] A36 - §164.308(a)(5)(i) Standard Does your practice provide ongoing basic security awareness to all workforce members, including physicians? Yes
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