Week 3 Research – Use of Audit trails in monitoring compliance To protect the privacy and security of patient information, healthcare organizations must address the circumstances that threaten the information and implement ways to secure the information from wrongful access.  The HIPAA Security Rule requires safeguards be implemented to protect electronic protected health information.

QUESTION

Week 3 Research – Use of Audit trails in monitoring compliance

To protect the privacy and security of patient information, healthcare organizations must address the circumstances that threaten the information and implement ways to secure the information from wrongful access.  The HIPAA Security Rule requires safeguards be implemented to protect electronic protected health information.

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Week 3 Research – Use of Audit trails in monitoring compliance To protect the privacy and security of patient information, healthcare organizations must address the circumstances that threaten the information and implement ways to secure the information from wrongful access.  The HIPAA Security Rule requires safeguards be implemented to protect electronic protected health information.
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Requirements:

Research articles on audit trails and designing audit trails.  After your research is completed, determine an audit process for one of these events:

  • VIP patient records
  • Records of those involved in high-profile events in the community
  • Records with sensitive health information such as those involving psychiatric disorders, drug and alcohol records and HIV/AIDS
  • Records of patients with the same last name or address as an employee

You should include information about what an audit trail is, why it is necessary to perform these audits, what steps would be performed to complete the audit, the frequency of the audit, how the results will be reported and how long the audit results should be retained.

Submit your response in a Word document .  The length of the paper should be a minimum of 3 pages and a maximum of 4 pages and must include a title page and reference page.

Purpose:

  1. To demonstrate your knowledge of the HIPAA Security Rule.
  2. To demonstrate your research abilities to find information and formalize a solution.
  3. To express you

CLOs covered:

  • #1 Analyze legal concepts and principles to the practice of HIM
  • #2 Recommend elements included in the design of audit trails and data quality monitoring programs.

Evaluation Criteria:

  1. Did you research articles about audit trails and design?
  2. Did you design an audit process for one of the events listed in the assignment?
  3. Did you use correct grammar and spelling and meet the submission requirements?
  4. Did your document flow coherently?
  5. Do not copy and paste from your research, write this paper in your own words.

ANSWER

The Use of Audit Trails in Monitoring Compliance: Safeguarding Patient Information

Introduction

In the healthcare industry, protecting the privacy and security of patient information is of utmost importance. To ensure compliance with regulations such as the Health Insurance Portability and Accountability Act (HIPAA) Security Rule, healthcare organizations must implement safeguards to protect electronic protected health information (ePHI). One effective measure for monitoring compliance and detecting unauthorized access is the use of audit trails. This research paper aims to explore the concept of audit trails, their significance in healthcare organizations, and propose an audit process for specific events requiring heightened security measures.

Understanding Audit Trails

An audit trail is a chronological record that captures and logs activities and events related to a system or application. In the context of healthcare, audit trails are used to monitor access to patient records, track changes made to sensitive information, and identify any unauthorized or suspicious activities (Hayes, 2022). Audit trails provide a comprehensive and reliable trail of information, enabling healthcare organizations to detect security breaches, conduct investigations, and ensure compliance with regulatory requirements.

Necessity of Performing Audits

Performing audits using audit trails is essential for several reasons. Firstly, audits help healthcare organizations identify and mitigate risks related to unauthorized access, data breaches, and privacy violations. By regularly reviewing audit trails, organizations can identify any unusual or suspicious activities and take appropriate action promptly. Secondly, audits demonstrate compliance with regulatory requirements, such as the HIPAA Security Rule, which mandates the implementation of safeguards to protect ePHI. Audits serve as evidence of an organization’s commitment to ensuring the privacy and security of patient information.

Audit Process for Different Events

VIP Patient Records

Audit trails for VIP patient records should include a robust set of monitoring and control measures. The audit process may involve the following steps:

Enable comprehensive logging of access to VIP records, including user identification, date, time, and actions performed.

Regularly review audit logs to identify unauthorized access attempts, unusual patterns, or inappropriate access.

Conduct periodic user access reviews to ensure that only authorized personnel have access to VIP records.

Document and report any suspicious activities or breaches to the appropriate authorities promptly.

Records of Those Involved in High-Profile Community Events

To safeguard the records of individuals involved in high-profile community events, the following audit process can be implemented:

Implement stricter access controls for these records, limiting access only to authorized personnel.

Maintain a separate audit trail specifically for these records, capturing all access and modifications.

Perform regular audits to ensure compliance with access policies and detect any unauthorized or suspicious activities.

Review audit logs to identify any breaches or inappropriate access, reporting findings to management for further action.

Records with Sensitive Health Information

For records involving sensitive health information, such as psychiatric disorders, drug and alcohol records, and HIV/AIDS, the audit process should include the following steps:

Implement role-based access controls, limiting access to only authorized individuals with a need-to-know.

Enable detailed audit logging to capture access, modifications, and data exports related to sensitive records.

Regularly review audit logs to identify any unauthorized access attempts or suspicious activities.

Conduct periodic user access reviews to assign and maintain appropriate access rights.

Records of Patients with the Same Last Name or Address as an Employee

To address potential conflicts of interest and prevent unauthorized access, the following audit process can be applied:

Establish controls to prevent employees from accessing records of patients sharing the same last name or address.

Maintain separate audit logs for these specific records, capturing all access attempts and modifications.

Conduct regular audits to ensure compliance with access restrictions and identify any unauthorized access.

Document and report any instances of inappropriate access or breaches to management and the organization’s privacy and security officers.

Frequency of Audits, Reporting, and Retention

The frequency of audits may vary depending on the organization’s size, resources, and risk assessment. However, it is recommended to conduct audits regularly, such as monthly or quarterly, to ensure timely detection of any unauthorized activities (Marker, n.d.). Audit results should be documented and reported to appropriate personnel, including management, privacy officers, and IT security teams (What Is an Audit? – Types of Audits & Auditing Certification | ASQ, n.d.-b). To comply with regulatory requirements and potential legal obligations, audit results should be retained for a defined period, typically between six to ten years.

Conclusion

Audit trails play a crucial role in monitoring compliance, ensuring the privacy and security of patient information within healthcare organizations. By implementing effective audit processes for specific events, such as VIP patient records, records of high-profile community events, records with sensitive health information, and records related to employees’ family members, organizations can enhance their ability to detect unauthorized access, mitigate risks, and demonstrate compliance with regulatory requirements. Regular auditing, reporting, and retention of audit results are vital for maintaining a robust security posture and protecting patient privacy in the ever-evolving healthcare landscape.

References

Hayes, A. (2022). What is an audit trail, how does it work, types, and example. Investopedia. https://www.investopedia.com/terms/a/audittrail.asp 

Marker, A. (n.d.). Audit trails: Managing the who, what, and when of business transactions. Smartsheet. https://www.smartsheet.com/audit-trails-and-logs 

What is an Audit? – Types of Audits & Auditing Certification | ASQ. (n.d.-b). https://asq.org/quality-resources/auditing 

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