HIPAA / HITECH

The goal of the Health Insurance Portability and Accountability Act (HIPAA) is to simplify the administrative processes of the healthcare system and to protect patients’ privacy. Any organization maintaining or transmitting electronic Protected Health Information (ePHI) must comply with HIPAA. This now includes business associates, which are contractors and subcontractors that perform services on behalf of a covered entity.

HIPAA is comprised of three major rules related to data protection: the security rule, the privacy rule and the breach notification rule. Each one is included in the overarching Omnibus Rule, which was mandated by the Health Information Technology for Economic and Clinical Health (HITECH) Act, passed in 2009 as part of the American Recovery and Reinvestment Act (ARRA).

What is ePHI?

ePHI is defined as “identifiable demographic and other information relating to the past, present or future physical or mental health or condition of an individual.”

Core HIPAA / HITECH Rules

This rule dictates the administrative, physical and technical controls necessary to secure ePHI, whether it is created, maintained, stored or in transit. Covered entities and business associates must conduct risk assessments and prevent against unauthorized access.

This rule institutes safeguards for the control of personal health information, no matter its format — oral, written or electronic. It sets limits for the disclosure of patient information without their consent and spells out the rights patients have over their data.

In the event of a data breach involving ePHI, this rule requires HIPAA-covered entities and their business associates to notify affected individuals, the Secretary of the U.S. Department of Health and Human Services (HHS), and in some cases, prominent media outlets — unless they can prove there is a low risk of compromise based on a risk assessment.

Since 2012, the Office of Civil Rights (OCR) has been conducting random audits to ensure covered entities and business associates are in compliance with these rules. Failure to comply can result in steep civil and criminal penalties that are based on the care and diligence your organization takes to protect your customer’s ePHI.

38North’s HIPAA compliance consultants currently support multiple healthcare and research providers, and we have significant experience measuring HIPAA compliance and implementing an arsenal of required safeguards. We take a holistic view of your compliance challenges, integrate them into your existing information security and privacy programs, while remaining sensitive to your budgetary and resourcing constraints.

 

Our HIPAA services include:

HIPAA Gap Analysis:

This is perfect for organizations that are new to HIPAA/HITECH regulations and don’t know how to get started. Our HIPAA gap analysis educates you on the process while taking a look at your information security and privacy programs to see how they fare against the three HIPAA rules. We also advise you on how much it will cost to attain HIPAA/HITECH compliance, identify any risks and/or challenges and focus on the most critical items to get you ready for action.

HIPAA Risk Assessment:

We conduct a detailed HIPAA-focused risk assessment to gain an understanding of your business and existing security and privacy controls to see how they fare against all HIPAA/HITECH requirements. We then present you with a detailed roadmap with prioritized recommendations on remediating weaknesses with existing administrative, physical and technical safeguards.

HIPAA Remediation Support:

Once you’ve obtained an unbiased view of your compliance posture, it’s time to start planning, developing and implementing remedial measures. This may be in the form of new technologies, policies, plans and/or procedures or training and awareness sessions. It also may include tailoring organizational processes to squeeze a little more out of your existing investments.

Jeremiah Thompson

Director of Cloud Security Architecture

Jeremiah Thompson is 38North’s Director of Cloud Security Architecture. He leads 38North’s technical teams as they tackle engineering challenges and design secure, compliant cloud security architectures.

For over 18 years Jeremiah has helped clients in the commercial, defense and federal civilian sectors engineer secure solutions to modern cyber challenges. Prior to 38North, he served as a Director at Coalfire, one of the nation’s preeminent Third-Party Assessment Organizations (3PAOs). At Coalfire he led FedRAMP and DoD FedRAMP+ assessments supporting Fortune 500 organizations. He was also a Lead Information Security Compliance Auditor supporting the National Cancer Institute, and an Information Security Compliance Auditor at IBM.

Jeremiah currently holds CISSP, CISM, CAP, C|EH, Security+, Network+, CCSK and MCP certifications.

Andy Davidson

Senior Director of Cloud Security

Andy Davidson is Senior Director of Cloud Security at 38North. He leads 38North Senior Advisors as they prepare IaaS, PaaS and SaaS providers for the rigors of FedRAMP authorization. One of the nation’s most experienced FedRAMP practitioners, Andy has been supporting FedRAMP assessment and consulting efforts since the initial FedRAMP pilot project. He specializes in helping hyperscale Cloud Service Providers (CSPs) navigate FedRAMP requirements and successfully achieve Provisional Authorities to Operate (P-ATO).

Prior to 38North, Andy was Senior Director of FedRAMP and Assessment Services at Coalfire, one of the leading Third-Party Assessment Organizations (3PAOs). At Coalfire, he was responsible for growing the 3PAO practice and managing assessor teams in the execution of high profile assessments for Fortune 500 CSPs. He also helped start Veris Group’s 3PAO practice. Prior to Veris, Andy was an IT security consultant at Booz Allen Hamilton, supporting security assessments and engineering efforts across the federal government.

Linda Morales

Senior Director of Assessments

Linda Morales is the Senior Director of Assessments at 38North Security. She leads assessments for customers in the healthcare, federal and commercial spaces. She specializes in helping organizations prepare for and complete FISMA, FedRAMP and HIPAA assessments. She is adept at leading teams to deliver efficient, accurate security reviews that withstand scrutiny from federal regulators. Linda is also a recognized expert in Healthcare security, helping Health-IT providers secure and defend Protected Health Information (PHI).

Prior to 38North, Linda served as a Director at Endeavor Systems, where she played a key role growing the federal security services practice. She also served as Security Manager for the Federal Aviation Administration’s (FAA) enterprise-wide assessment program, with responsibility for 150+ systems across FAA.

Linda earned a BS in Computer Science and a Masters in Engineering Management, with a focus in Information Security, both from The George Washington University. She is also a Certified Information Systems Security Professional (CISSP), Project Management Professional (PMP), and a Registered Practitioner with the Cybersecurity Maturity Model Certification Advisory Board (CMMC-AB).

Spence Witten

Senior Advisor and Director of Business Development

Spence Witten is a 38North Senior Advisor and Director of Business Development. He serves as a trusted security advisor to 38North’s clients in the cloud services, healthcare, financial, defense and critical infrastructure communities.

Prior to 38North, Spence was Vice President of Global Sales at Lunarline. Spence led sales and marketing across ten cybersecurity business units, culminating in Lunarline’s acquisition by Motorola Solutions. Prior to becoming VP of Global Sales, Spence ran Lunarline’s US Federal Security Services practice, overseeing Lunarline’s defense, intelligence and federal civilian portfolio. He was also an early employee of Endeavor Systems. He played a key role in Endeavor’s rapid expansion in the federal, civilian, defense, and research and development markets, through to Endeavor’s successful acquisition.

An Adjunct Professor at Cleveland-Marshall College of Law, Spence serves on the Board of Directors for the Center for Cybersecurity and Privacy Protection at Cleveland State University. He is also a member of CyberOhio, the official cybersecurity advisory board for the Governor of Ohio.

Virginia Suazo

Senior Director of Cloud Security Advisory

Virginia Suazo is 38North’s Senior Director of Cloud Security Advisory. She is responsible for leading 38North’s cloud security and compliance efforts, with a speciality in helping global CSPs juggle multiple overlapping regulatory frameworks.

Before joining 38North, Virginia worked at a tech startup supporting the first and only Red Hat OpenStack Platform that is FedRAMP-authorized. She played a vital role in successfully obtaining FedRAMP Moderate and High authorizations for IaaS, PaaS, and SaaS systems, while supporting other certifications including DoD IL4/5, PCI DSS, HIPAA and HITECH. Her 15 years of cybersecurity experience also includes several tours supporting US federal agencies, including State Department, Department of Justice, Health and Human Services, Food and Drug Administration, General Services Administration and Department of Transportation.

Matt Earley

Founder

Matt Earley is 38North’s founder and President. He started 38North – the premier cloud security advisory company, in the US and internationally – to solve complex security challenges while developing trusted relationships with an elite client base.

For over 20 years Matt Earley has designed and implemented security solutions for the US and Australian federal governments, critical infrastructure, utilities, and for global finance and healthcare organizations. He focuses on lean security architecture design and prioritizing security efforts based on the critical needs of his clients.

Prior to founding 38North, Matt was the director of federal services at Endeavor Systems, where he was responsible for Endeavor’s largest business unit, serving the Federal Aviation Administration, Department of Homeland Security and some of the world’s largest security operations centers. He was also a Senior Manager in the Australian Department of Defense, where he represented Australasia on the Common Criteria Management Board.

Matt has a Bachelor of Engineering in computer engineering from the University of Canberra in Australia, and a Master’s in engineering management from George Washington University. He also is a Certified Information Systems Security Professional (CISSP) and Project Management Professional (PMP).