Stage 1 Meaningful Use Audits and Security Risk Analysis

There is an awful lot of news lately about Stage 1 Meaningful Use audits and the number one reason so far for failing an audit has been Core Set Objective number 15.

Protect Electronic Health Information

Objective Protect electronic health information created or maintained by the certified EHR technology through the implementation of appropriate technical capabilities.
Measure Conduct or review a security risk analysis in accordance with the requirements under 45 CFR 164.308(a)(1) and implement security updates as necessary and correct identified security deficiencies as part of its risk management process.
Exclusion  No exclusion.


In order to help clarify this ruling, we have included a chart of Common Myths vs. Facts.

Security Risk Analysis Myths and Facts



The security risk analysis is optional for small providers. False. All providers who are “covered entities” under HIPAA are required to perform a risk analysis. In addition, all providers ho want to receive EHR incentive payments must conduct a risk analysis.
Simply installing a certified EHR fulfills the security risk analysis MU requirement. False. Even with a certified EHR, you must perform a full security risk analysis. Security requirements address all electronic protected health information you maintain, not just what is in your EHR.
My EHR vendor took care of everything I need to do about privacy and security. False. Your EHR vendor may be able to provide information, assistance, and training on the privacy and security aspects of the EHR product. However, EHR vendors are not responsible for making their products compliant with HIPAA Privacy and Security Rules. It is solely your responsibility to have a complete risk analysis conducted.
I have to outsource the security risk analysis. False. It is possible for small practices to do risk analysis themselves using self-help tools. However, doing a thorough and professional risk analysis that will stand up to a compliance review will require expert knowledge that could be obtained through services of an experienced outside professional.
A checklist will suffice for the risk analysis requirement. False. Checklists can be useful tools, especially when starting a risk analysis, but they fall short of performing a systematic security risk analysis or documenting that one has been performed.
There is a specific risk analysis method that I must follow. False. A risk analysis can be performed in countless ways.  OCR has issued Guidance on Risk Analysis Requirements of the Security Rule. This guidance assists organizations in identifying and implementing the most effective and appropriate safeguards to secure e-PHI.
My security risk analysis only needs to look at my EHR. False. Review all electronic devices that store, capture, or modify electronic protected health information. Include your EHR hardware and software and devices that can access your EHR data (e.g., your tablet computer, your practice manager’s mobile phone). Remember that copiers also store data. Please see U.S. Department of Health and Human Services (HHS) guidance on remote use.
I only need to do a risk analysis once. False. To comply with HIPAA, you must continue to review, correct or modify, and update security protections. For more on reassessing your security practices, please see the Reassessing Your Security Practice in a Health IT Environment.
Before I attest for an EHR incentive program, I must fully mitigate all risks. False. The EHR incentive program requires correcting any deficiencies (identified during the risk analysis) during the reporting period, as part of its risk management process.
Each year, I’ll have to completely redo my security risk analysis. Perform the full security risk analysis as you adopt an EHR.  Each year or when changes to your practice or electronic systems occur, review and update the prior analysis for changes in risks. Under the Meaningful Use Programs, reviews are required for each EHR reporting period.  For EPs, the EHR reporting period will be 90 days or a full calendar year, depending on the EP’s year of participation in the program.

To learn more, visit the Privacy and Security Resources page for more information.

This chart is also available as a pdf here.

We have come across a handy guide that we are happy to make available to you, it is the Health Information Technology (HIT) Security Risk Assessment Questionnaire. You are welcome to use this questionnaire to assist you with conducting your own Security Risk Assessment.


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