The HIPAA regulations with its commentary, together with the Privacy Act and the Administrative Simplification Act run a staggering 1500 pages. That's a lot of legalese!
For clarity and ease of understanding we have listed just the definitions for the HIPAA standards for Privacy and Security in this glossary.
For additional clarity, a number of terms listed below may be restated in a slightly different context within our requlations and procedural matrixes throughout our web site.
Ability to add attributes: One possible capability of a digital signature technology. For example, the ability to add a time stamp as part of a digital signature.
Access: The ability or the means necessary to read, write, modify, or communicate data/information or otherwise make use of any system resource.
Access authorization: Information-use policies/procedures that establish the rules for granting and/or restricting access to a user, terminal, transaction, program, or process.
Access control: A method of restricting access to resources, allowing only privileged entities access. Types of access control include, among others, mandatory access control, discretionary access control, time-of-day, classification, and subject-object separation.
Access controls: The protection of sensitive communications transmissions over open or private networks so that it cannot be easily intercepted and interpreted by parties other than the intended recipient.
Access establishment: The security policies, and the rules established therein, that determine an entity’s initial right of access to a terminal, transaction, program, or process.
Access level: A level associated with an individual who may be accessing information (for example, a clearance level) or with the information which may be accessed (for example, a classification level).
Access modification: The security policies, and the rules established therein, that determine types of, and reasons for, modification to an entity’s established right of access to a terminal, transaction, program, or process.
Accountability: The property that ensures that the actions of an entity can be traced uniquely to that entity.
Administrative procedures to guard data integrity, confidentiality and availability: Documented, formal practices to manage (1) the selection and execution of security measures to protect data, and (2) the conduct of personnel in relation to the protection of data.
Alarm, event reporting, and audit trail: (1) alarm: In communication systems, any device that can sense an abnormal condition within the system and provide, either locally or remotely, a signal indicating the presence of the abnormality. The signal may be in any desired form ranging from a simple contact closure (or opening) to a time-phased automatic shutdown and restart cycle. (2) event reporting: Network message indicating operational irregularities in physical elements of a network or a response to the occurrence of a significant task, typically the completion of a request for information. (3) audit trail: Data collected and potentially used to facilitate a security audit.
Applications and data criticality analysis: An entity’s formal assessment of the sensitivity, vulnerabilities, and security of its programs and information it receives, manipulates, stores, and/or transmits.
Assigned security responsibility: Practices put in place by management to manage and supervise (1) the execution and use of security measures to protect data, and (2) the conduct of personnel in relation to the protection of data.
Assure supervision of maintenance personnel by authorized, knowledgeable person: Documented formal procedures/instruction for the oversight of maintenance personnel when such personnel are in the vicinity of health information pertaining to an individual.
Asymmetric encryption: Encryption and decryption performed using two different keys, one of which is referred to as the public key and one of which is referred to as the private key. Also known as public-key encryption.
Asymmetric key: One half of a key pair used in an asymmetric (“public-key”) encryption system. Asymmetric encryption systems have two important properties: (1) the key used for encryption is different from the one used for decryption (2) neither key can feasibly be derived from the other.
Audit controls: The mechanisms employed to record and examine system activity.
Authorization control: The mechanism for obtaining consent for the use and disclosure of health information.
Automatic logoff: After a pre-determined time of inactivity (for example, 15 minutes), an electronic session is terminated.
Availability: The property of being accessible and useable upon demand by an authorized entity.
Awareness training for all personnel (including management): All personnel in an organization should undergo security awareness training, including, but not limited to, password maintenance, incident reporting, and an education concerning viruses and other forms of malicious software.
Biometric: A biometric identification system identifies a human from a measurement of a physical feature or repeatable action of the individual (for example, hand geometry, retinal scan, iris scan, fingerprint patterns, facial characteristics, DNA sequence characteristics, voice prints, and hand written signature).
Certification: The technical evaluation performed as part of, and in support of, the accreditation process that establishes the extent to which a particular computer system or network design and implementation meet a pre-specified set of security requirements. This evaluation may be performed internally or by an external accrediting agency.
Chain of Trust Partner Agreement: Contract entered into by two business partners in which it is agreed to exchange data and that the first party will transmit information to the second party, where the data transmitted is agreed to be protected between the partners. The sender and receiver depend upon each other to maintain the integrity and confidentiality of the transmitted information. Multiple such two-party contracts may be involved in moving information from the originator to the ultimate recipient, for example, a provider may contract with a clearing house to transmit claims to the clearing house; the clearing house, in turn, may contract with another clearing house or with a payer for the further transmittal of those same claims.
Classification: Protection of data from unauthorized access by the designation of multiple levels of access authorization clearances to be required for access, dependent upon the sensitivity of the information.
Clearing House: A public or private entity that processes or facilitates the processing of nonstandard data elements of health information into standard data elements.
Combination locks changed: Documented procedure for changing combinations of locking mechanisms, both on a recurring basis and when personnel knowledgeable of combinations no longer have a need to know or a requirement for access to the protected facility/system.
Confidentiality: The property that information is not made available or disclosed to unauthorized individuals, entities or processes.
Context-based access: An access control based on the context of a transaction (as opposed to being based on attributes of the initiator or target). The “external” factors might include time of day, location of the user, strength of user authentication, etc.
Contingency Plan: A plan for responding to a system emergency. The plan includes performing backups, preparing critical facilities that can be used to facilitate continuity of operations in the event of an emergency, and recovering from a disaster. Contingency plans should be updated routinely.
Continuity of signature capability: The public verification of a signature shall not compromise the ability of the signer to apply additional secure signatures at a later date.
Counter signatures: It shall be possible to prove the order of application of signatures. This is analogous to the normal business practice of countersignatures, where some party signs a document which has already been signed by another party.
Data: A sequence of symbols to which meaning may be assigned.
Data authentication: The corroboration that data has not been altered or destroyed in an unauthorized manner. Examples of how data corroboration may be assured include the use of a check sum, double keying, a message authentication code, or digital signature.
Data backup: A retrievable, exact copy of information.
Data backup plan: A documented and routinely updated plan to create and maintain, for a specific period of time, retrievable exact copies of information.
Data Integrity: The property that dat has [sic] not been altered or destroyed in an unauthorized manner.
Data storage: The retention of health care information pertaining to an individual in an electronic format.
Digital signature: An electronic signature based upon cryptographic methods of originator authentication, computed by using a set of rules and a set of parameters such that the identity of the signer and the integrity of the data can be verified.
Disaster recovery: The process whereby an enterprise would restore any loss of data in the event of fire, vandalism, natural disaster, or system failure, human error, or any other reason.
Disaster recovery plan: Part of an overall contingency plan. The plan for a process whereby an enterprise would restore any loss of data in the event of fire, vandalism, natural disaster, or system failure.
Discretionary access control: Discretionary Access Control (DAC) is used to control access by restricting a subject’s access to an object. It is generally used to limit a user’s access to a file. In this type of access control it is the owner of the file who controls other users’ accesses to the file.
Disposal: The final disposition of electronic data, and/or the hardware on which electronic data is stored.
Documentation: Written security plans, rules, procedures, and instructions concerning all components of an entity’s security.
Electronic data interchange (EDI): Intercompany, computer-to-computer transmission of business information in a standard format. For EDI purists, “computer-to-computer” means direct transmission from the originating application program to the receiving, or processing, application program, and an EDI transmission consists only of business data, not any accompanying verbiage or free-form messages. Purists might also contend that a standard format is one that is approved by a national or international standards organization, as opposed to formats developed by industry groups or companies.
Electronic signature: The attribute that is affixed to an electronic document to bind it to a particular entity. An electronic signature process secures the user authentication (proof of claimed identity, such as by biometrics (fingerprints, retinal scans, hand written signature verification, etc.), tokens or passwords) at the time the signature is generated; creates the logical manifestation of signature (including the possibility for multiple parties to sign a document and have the order of application recognized and proven) and supplies additional information such as time stamp and signature purpose specific to that user; and ensures the integrity of the signed document to enable transportability, interoperability, independent verifiability, and continuity of signature capability. Verifying a signature on a document verifies the integrity of the document and associated attributes and verifies the identity of the signer. There are several technologies available for user authentication, including passwords, cryptography, and biometrics.
Emergency mode operation: Access controls in place that enable an enterprise to continue to operate in the event of fire, vandalism, natural disaster, or system failure.
Emergency mode operation plan: Part of an overall contingency plan. The plan for a process whereby an enterprise would be able to continue to operate in the event of fire, vandalism, natural disaster, or system failure.
Encryption: Transforming confidential plaintext into ciphertext to protect it. Also called encipherment. An encryption algorithm combines plaintext with other values called keys, or ciphers, so the data becomes unintelligible. Once encrypted, data can be stored or transmitted over unsecured lines.
Entity authentication: 1. The corroboration that an entity is the one claimed. 2. A communications/network mechanism to irrefutably identify authorized users, programs, and processes, and to deny access to unauthorized users, programs and processes.
Equipment control (into and out of site): Documented security procedures for bringing hardware and software into and out of a facility and for maintaining a record of that equipment. This includes, but is not limited to, the marking, handling, and disposal of hardware and storage media.
Facility security plan:A plan to safeguard the premises and building(s) (exterior and interior) from unauthorized physical access, and to safeguard the equipment therein from unauthorized physical access, tampering, and theft.
Formal mechanism for processing records: Documented policies and procedures for the routine, and non-routine, receipt, manipulation, storage, dissemination, transmission, and/or disposal of health information.
Hardware/software installation & maintenance review and testing for security features: Formal, documented procedures for (1) connecting and loading new equipment and programs, (2) periodic review of the maintenance occurring on that equipment and programs, and (3) periodic security testing of the security attributes of that hardware/software.
Independent verifiability: The capability to verify the signature without the cooperation of the signer. Technically, it is accomplished using the public key of the signatory, and it is a property of all digital signatures performed with asymmetric key encryption
Information: Data to which meaning is assigned, according to context and assumed conventions.
Information access control: Formal, documented policies and procedures for granting different levels of access to health care information.
Integrity controls: Security mechanism employed to ensure the validity of the information being electronically transmitted or stored.
Internal audit: The in-house review of the records of system activity (for example, logins, file accesses, security incidents) maintained by an organization.
Interoperability: The applications used on either side of a communication, between trading partners and/or between internal components of an entity, being able to read and correctly interpret the information communicated from one to the other.
Inventory: Formal, documented identification of hardware and software assets.
Key: An input that controls the transformation of data by an encryption algorithm.
Maintenance of record of access authorizations: Ongoing documentation and review of the levels of access granted to a user, program, or procedure accessing health information.
Maintenance records: Documentation of repairs and modifications to the physical components of a facility. For example, hardware, software, walls, doors, locks.
Mandatory Access Control (MAC): A means of restricting access to objects that is based on fixed security attributes assigned to users and to files and other objects. The controls are mandatory in the sense that they cannot be modified by users or their programs.
Media controls: Formal, documented policies and procedures that govern the receipt and removal of hardware/software (for example, diskettes, tapes) into and out of a facility.
Message: A digital representation of information.
Message authentication: Ensuring, typically with a message authentication code, that a message received (usually via a network) matches the message sent.
Message authentication code: Data associated with an authenticated message that allows a receiver to verify the integrity of the message.
Message integrity: The assurance of unaltered transmission and receipt of a message from the sender to the intended recipient.
Multiple signatures: It shall be possible for multiple parties to sign a document. Multiple signatures are conceptually, simply appended to the document.
Need-to-know procedures for personnel access: A security principle stating that a user should have access only to the data he or she needs to perform a particular function.
Nonrepudiation: Strong and substantial evidence of the identity of the signer of a message and of message integrity, sufficient to prevent a party from successfully denying the origin, submission or delivery of the message and the integrity of its contents.
Operating, and in some cases, maintenance personnel have proper access authorizations: Formal, documented policies and procedures to be followed in determining the access level to be granted to individuals working on, or in the vicinity of, health information.
Password: Confidential authentication information composed of a string of characters.
Periodic security reminders: Employees, agents and contractors should be made aware of security concerns on an ongoing basis.
Personnel clearance procedure: Automated information is admissible. The need for and extent of a screening process is normally based on an assessment of risk, cost, benefit, and feasibility as well as other protective measures in place. Effective screening processes are applied in such a way as to allow a range of implementation, from minimal procedures to more stringent procedures commensurate with the sensitivity of the data to be accessed and the magnitude of harm or loss that could be caused by the individual.
Personnel security: The procedures established to ensure that all personnel who have access to sensitive information have the required authority as well as appropriate clearances.
Personnel security policy/procedure: Formal, documentation of policies and procedures established to ensure that all personnel who have access to sensitive information have the required authority as well as appropriate clearances.
PHI: Protected Health Information.
Physical access controls (limited access): Those formal, documented policies and procedures to be followed to limit physical access to an entity while ensuring that properly authorized access is allowed.
Physical safeguards:Protection of physical computer systems and related buildings and equipment from fire and other natural and environmental hazards, as well as from intrusion. Also covers the use of locks, keys, and administrative measures used to control access to computer systems and facilities.
PIN (Personal Identification Number): A number or code assigned to an individual and used to provide verification of identity.
Policy/guideline on work station use: Documented instructions/procedures delineating the proper functions to be performed, the manner in which those functions are to be performed, and the physical attributes of the surroundings, of a specific computer terminal site or type of site, dependant upon the sensitivity of the information accessed from that site.
Procedure for emergency access: Documented instructions for obtaining necessary information during a crisis.
Procedures for verifying access authorizations prior to physical access: Formal, documented policies and instructions for validating the access privileges of an entity prior to granting those privileges.
Provider: A supplier of services as defined in section 1861(u) of the HIPAA.
Public key: One of the two keys used in an asymmetric encryption system. The public key is made public, to be used in conjunction with a corresponding private key.
Removal from access lists: The physical eradication of an entity’s access privileges.
Removal of user account(s): The termination or deletion of an individual’s access privileges to the information, services, and resources for which they currently have clearance, authorization, and need-to-know when such clearance, authorization and need-to-know no longer exists.
Report procedures: The documented formal mechanism employed to document security incidents.
Response procedures: The documented formal rules/instructions for actions to be taken as a result of the receipt of a security incident report.
Risk analysis: Risk analysis, a process whereby cost-effective security/control measures may be selected by balancing the costs of various security/control measures against the losses that would be expected if these measures were not in place.
Risk management: Risk is the possibility of something adverse happening. Risk management is the process of assessing risk, taking steps to reduce risk to an acceptable level and maintaining that level of risk.
Role-based access control: Role-based access control (RBAC) is an alternative to traditional access control models (e.g., discretionary or non-discretionary access control policies) that permits the specification and enforcement of enterprise-specific security policies in a way that maps more naturally to an organization’s structure and business activities. With RBAC, rather than attempting to map an organization’s security policy to a relatively low-level set of technical controls (typically, access control lists), each user is assigned to one or more predefined roles, each of which has been assigned the various privileges needed to perform that role.
Sanction policy:Organizations must have policies and procedures regarding disciplinary actions which are communicated to all employees, agents and contractors, for example, verbal warning, notice of disciplinary action placed in personnel files, removal of system privileges, termination of employment and contract penalties. In addition to enterprise sanctions, employees, agents, and contractors must be advised of civil or criminal penalties for misuse or misappropriation of health information. Employees, agents and contractors, must be made aware that violations may result in notification to law enforcement officials and regulatory, accreditation and licensure organizations.
Secure work station location: Physical safeguards to eliminate or minimize the possibility of unauthorized access to information, for example, locating a terminal used to access sensitive information in a locked room and restricting access to that room to authorized personnel, not placing a terminal used to access patient information in any area of a doctor’s office where the screen contents can be viewed from the reception area.
Security: Security encompasses all of the safeguards in an information system, including hardware, software, personnel policies, information practice policies, disaster preparedness, and the oversight of all these areas. The purpose of security is to protect both the system and the information it contains from unauthorized access from without and from misuse from within. Through various security measures, a health information system can shield confidential information from unauthorized access, disclosure and misuse, thus protecting privacy of the individuals who are the subjects of the stored data.
Security awareness training: All employees, agents, and contractors must participate in information security awareness training programs. Based on job responsibilities, individuals may be required to attend customized education programs that focus on issues regarding use of health information and responsibilities regarding confidentiality and security.
Security configuration management: Measures, practices and procedures for the security of information systems should be coordinated and integrated with each other and other measures, practices and procedures of the organization so as to create a coherent system of security.
Security incident procedures: Formal, documented instructions for reporting security breaches.
Security management process: A security management process encompasses the creation, administration and oversight of policies to ensure the prevention, detection, containment, and correction of security breaches. It involves risk analysis and risk management, including the establishment of accountability, management controls (policies and education), electronic controls, physical security, and penalties for the abuse and misuse of its assets, both physical and electronic.
Security policy: The framework within which an organization establishes needed levels of information security to achieve the desired confidentiality goals. A policy is a statement of information values, protection responsibilities, and organization commitment for a system. (OTA, 1993) The American Health Information Management Association recommends that security policies apply to all employees, medical staff members, volunteers, students, faculty, independent contractors, and agents.
Security testing: A process used to determine that the security features of a system are implemented as designed and that they are adequate for a proposed applications environment. This process includes hands-on functional testing, penetration testing, and verification.
Sign-in for visitors and escort, if appropriate: Formal, documented procedure governing the reception and hosting of visitors.
Subject/object separation: Access to a subject does not guarantee access to the objects associated with that subject. Subject is defined as an active entity, generally in the form of a person, process, or device that causes information to flow among objects or changes the system state. Technically, a process/domain pair. Object is defined as a passive entity that contains or receives information. Access to an object potentially implies access to the information it contains. Examples of objects are: records blocks, pages, segments, files, directories, directory trees, and programs, as well as bits, bytes, words, fields, processors, video displays, keyboards, clocks, printers, network nodes, etc.
System users, including maintenance personnel, trained in security: See Awareness training (including management).
Technical security mechanisms The processes that are put in place to guard against unauthorized access to data that is transmitted over a communications network,
Technical security services: The processes that are put in place (1) to protect information and (2) to control and monitor individual access to information.
Telephone callback: A method of authenticating the identity of the receiver and sender of information through a series of “questions” and “answers” sent back and forth establishing the identity of each. For example, when the communicating systems exchange a series of identification codes as part of the initiation of a session to exchange information, or when a host computer disconnects the initial session before the authentication is complete, and the host calls the user back to establish a session at a predetermined telephone number.
Termination procedures: Formal, documented instructions, which include appropriate security measures, for the ending of an employee’s employment, or an internal/external user’s access.
Testing and revision: (1)Testing and revision of contingency plans refers to the documented process of periodic testing to discover weaknesses in such plans and the subsequent process of revising the documentation if necessary. (2)Testing and revision of programs should be restricted to formally authorized personnel.
Time-of-day: Access to data is restricted to certain time frames, e.,g., Monday through Friday, 8:00 a.m. to 6:00 p.m
Time-stamp: To create a notation that indicates, at least, the correct date and time of an action, and the identity of the person that created the notation
Token: A physical item that’s used to provide identity. Typically an electronic device that can be inserted in a door or a computer system to obtain access.
Training: Education concerning the vulnerabilities of the health information in an entity’s possession and ways to ensure the protection of that information.
Transportability: A signed document can be transported (over an insecure network) to another system, while maintaining the integrity of the document.
Turn in keys, token or cards that allow access: Formal, documented procedure to ensure all physical items that allow a terminated employee to access a property, building, or equipment are retrieved from that employee, preferably prior to termination.
Unique user identification: The combination name/number assigned and maintained in security procedures for identifying and tracking individual user identity.
User authentication: The provision of assurance of the claimed identity of an entity.
User-based access: A security mechanism used to grant users of a system access based upon the identity of the user.
User education in importance of monitoring log in success/failure, and how to report discrepancies: Training in the user’s responsibility to ensure the security of health care information.
User education concerning virus protection: Training relative to user awareness of the potential harm that can be caused by a virus, how to prevent the introduction of a virus to a computer system, and what to do if a virus is detected.
User education in password management: A type of user training in the rules to be followed in creating and changing passwords and the need to keep them confidential.
Virus checking: A computer program that identifies and disables: (1) another “virus” computer program, typically hidden, that attaches itself to other programs and has the ability to replicate. (Unchecked virus programs result in undesired side effects generally unanticipated by the user.) (2) A type of programmed threat. A code fragment (not an independent program) that reproduces by attaching to another program. It may damage data directly, or it may degrade system performance by taking over system resources which are then not available to authorized users. (3) Code embedded within a program that causes a copy of itself to be inserted in one or more other programs. In addition to propagation, the virus usually performs some unwanted function.