Reflect back to the health information system you proposed in Week 1. Before any health information system can be successfully implemented, there must be a team of experts who understand the vision and mission of both the health care organization and its stakeholders. Strategic health care leaders are positioned to propose system upgrades and/or implementations that can withstand inevitable organizational changes. Health information systems’ leaders understand that data is the overall management of the availability, usability, integrity and security of the data.
Assessing and Achieving Value in Health Care Information Systems
Virtually all the discussion in this book focuses on the knowledge and management processes
necessary to achieve one fundamental objective: organizational investments in IT resulting in a
desired value. That value might be the furtherance of organizational strategies, improvement in
the performance of core processes, or the enhancement of decision making. Achieving value
requires the alignment of IT with overall strategies, thoughtful governance, solid information
system selection and implementation approaches, and effective organizational change.
Failure to achieve desired value can result in significant problems for the organization. Money is
wasted. Execution of strategies is hamstrung. Organizational processes can be damaged.
This chapter carries the IT value discussion further. Specifically, it covers the following topics:
The definition of IT-enabled value
The IT project proposal
Ensuring the delivery of value
Analyses of the IT value challenge
Definition of IT-Enabled Value
We can make several observations about IT-enabled value:
IT value can be tangible and intangible.
IT value can be significant.
IT value can be variable across organizations.
IT value can be diverse across IT proposals.
A single IT investment can have a diverse value proposition.
Different IT investments have different objectives and hence different value propositions and
value assessment techniques.
These observations will be discussed in more detail in the following sections.
Tangible and Intangible
Tangible value can be measured whereas intangible value is very difficult, perhaps practically
impossible, to measure.
Some tangible value can be measured in terms of dollars:
Increases in revenue
Reductions in labor costs: for example, through staff layoffs, overtime reductions, or shifting
work to less expensive staff members
Reductions in supply costs: for example, because of improvements in purchasing
Reductions in maintenance costs for computer systems
Reductions in use of patient care services: for example, fewer lab tests are performed or care is
conducted in less expensive settings
Some tangible value can be measured in terms of process improvements:
Faster turnaround times for test results
Reductions in elapsed time to get an appointment
A quicker admissions process
Improvement in access to data
Improvements in the percentage of care delivery that follows medical evidence
Some tangible value can be measured in terms of strategically important operational and market
Growth in market share
Reduction in turnover
Increase in brand awareness
Increase in patient and provider satisfaction
Improvement in reliability of computer systems
By contrast, intangible value can be very difficult to measure. The organization is trying to
measure such things as
Improved decision making
Becoming more state of the art
Improved organizational competencies: for example, becoming better at managing chronic
Becoming more customer friendly
IT can be leveraged to achieve significant organization value. The following are some example
A study that compared the quality of diabetes care between physician practices that used EHRs
and practices that did not found that the EHR sites had composite standards for diabetes care
that were 35.1 percent higher than paper-based sites and had 15 percent better care outcomes
(Cebul, Love, Jain, & Herbert, 2011).
EMC (a company that makes data storage devices and other information technologies) reported
a reduction of $200 million in health care costs over ten years through the use of data analytics,
lifestyle coaches, and remote patient monitoring to help employees manage health risks and
chronic diseases (Mosquera, 2011).
A cross-sectional study of hospitals in Texas (Amarasingham, Plantinga, Diener-West, Gaskin,
& Powe, 2009) found that higher levels of the automation of notes and patient records were
associated with a 15 percent decrease in the adjusted odds of a fatal hospitalization. Higher
scores in the use of computerized provider order entry (CPOE) were associated with 9 percent
and 55 percent decreases in the adjusted odds of death for myocardial infarction and coronary
artery bypass graft procedures, respectively. For all cases of hospitalization, higher levels of
clinical decision-support use were associated with a 16 percent decrease in the adjusted odds
of complications. And higher levels of CPOE, results reporting, and clinical decision support
were associated with lower costs for all hospital admissions.
A clinical decision support (CDS) module, embedded within an EHR, was used to provide early
detection of situations that could result in venous thromboembolism (VTE). A study of the
impact of the module showed that the VTE rate declined from 0.954 per one thousand patient
days to 0.434 comparing baseline to full VTE CDS. Compared to baseline, patients benefitting
from VTE CDS were 35 percent less likely to have a VTE (Amland et. al., 2015).
Even when they implement the same system, not all organizations experience the same value.
Organizational factors such as change management prowess and governance have a
significant impact on an organization’s ability to be successful in implementing health information
As an example of variability, two children’s hospitals implemented the same EHR (including
CPOE) in their pediatric intensive care units. One hospital experienced a significant increase in
mortality (Han et al., 2005), whereas the other did not (Del Beccaro, Jeffries, Eisenberg, &
Harry, 2006). The hospital that did experience an increase in mortality noted that several
implementation factors contributed to the deterioration in quality; specific order sets for critical
care were not created, changes in workflow were not well executed, and orders for patients
arriving via critical care transportation could not be written before the patient arrived at the
hospital, delaying life-saving treatments.
Even when organizations have comparable implementation skill levels, the value achieved can
vary because different organizations decide to focus on different objectives. For example, some
organizations may decide to improve the quality of diabetes care, and others may emphasize
the reduction in care costs. Hence, if an outcome is of modest interest to an organization and it
devotes few resources to achieving that outcome, it should not be surprised if the outcome does
Diverse across Proposals
Consider three proposals (real ones from a large integrated delivery system) that might be in
front of organizational leadership for review and approval: a disaster notification system, a
document imaging system, and an e-procurement system. Each offers a different type of value
to the organization.
The disaster notification system would enable the organization to page critical personnel, inform
them that a disaster—for example, a train wreck or biotoxin outbreak—had taken place, and tell
them the extent of the disaster and the steps they would need to take to help the organization
respond to the disaster. The system would cost $520,000. The value would be “better
preparedness for a disaster.”
The document imaging system would be used to electronically store and retrieve scanned
images of paper documents, such as payment reconciliations, received from insurance
companies. The system would cost $2.8 million, but would save the organization $1.8 million per
year ($9 million over the life of the system) through reductions in the labor required to look for
paper documents and in the insurance claim write-offs that occur because a document cannot
The e-procurement system would enable users to order supplies, ensure that the ordering
person had the authority to purchase supplies, transmit the order to the supplier, and track the
receipt of the supplies. Data from this system could be used to support the standardization of
supplies, that is, to reduce the number of different supplies used. Such standardization might
save $500,000 to $3 million per year. The actual savings would depend on physician willingness
to standardize. The system would cost $2.5 million.
These proposals reflect a diversity of value, ranging from “better disaster response” to a clear
financial return (document imaging) to a return with such a wide potential range (e-procurement)
that it could be a great investment (if you really could save $3 million a year) or a terrible
investment (if you could save only $500,000 a year).
Diverse in a Single Investment
Picture archiving and communication systems (PACS) are used to store radiology (and other)
images, support interpretation of images, and distribute the information to the physician
providing direct patient care. These systems are an example of the diversity of value that can
result from one IT investment. A PACS can do the following:
Reduce costs for radiology film and the need for film librarians.
Improve service to the physician delivering care, through improved access to images.
Improve productivity for the radiologists and for the physicians delivering care (both groups
reduce the time they spend looking for images).
Generate revenue, if the organization uses the PACS to offer radiology services to physician
groups in the community.
This one investment has a diverse value proposition; it has the potential to deliver cost
reduction, productivity gains, service improvements, and revenue gains.
Different Analyses for Different Objectives
The Committee to Study the Impact of Information Technology on the Performance of Service
Activities (1994), organized by the National ResearchCouncil (NRC), has identified six
categories of IT investments in service industries, reflecting different objectives. The techniques
used to assess IT investment value should vary by the type of objective that the IT investment
intends to support. One technique does not fit all IT investments.
IT investments may be for infrastructure that enables other investments or applications to be
implemented and deliver desired capabilities. Examples of infrastructure are data
communication networks, workstations, and clinical data repositories. A delivery system–wide
network enables a large organization to implement applications to consolidate clinical
laboratories, implement organization-wide collaboration tools, and share patient health data
It is difficult to quantitatively assess the impact or value of infrastructure investments because of
They enable applications. Without those applications, infrastructure has no value. Hence,
infrastructure value is indirect and depends on application value.
The allocation of infrastructure value across applications is complex. When millions of dollars
are invested in a data communication network, it may be difficult or impossible to determine how
much of that investment should be allocated to the ability to create delivery system–wide EHRs.
A good IT infrastructure is often determined by its agility, potency, and ability to facilitate
integration of applications. It is very difficult to assign return on investment (ROI) numbers or
any meaningful numerical value to most of these characteristics. What, for instance, is the value
of being agile enough to speed up the time it takes to develop and enhance applications?
Information system infrastructure is as hard to evaluate as other organizational infrastructure,
such as having talented, educated staff members. As with other infrastructure,
Evaluation is often instinctive and experientially based.
In general, underinvesting can severely limit the organization.
Investment decisions involve choosing between alternatives that are assessed for their ability to
achieve agreed-on goals. For example,if an organization wishes to improve security, it might
ask whether it should invest in network monitoring tools or enhanced virus protection. Which of
these investments would enable it to make the most progress toward its goal?
Four Types of IT Investment
Complementing the NRC study, Jeanne Ross and Cynthia Beath (2002) studied the IT
investment approaches of thirty companies from a wide range of industries. They identified four
classes of investment:
Transformation. These IT investments had an impact that would affect the entire organization or
a large number of business units. The intent of the investment was to effect a significant
improvement in overall performance or change the nature of the organization.
Renewal. Renewal investments were intended to upgrade core IT infrastructure and applications
or reduce the costs or improve the quality of IT services. Examples of these investments
include application replacements, upgrades of the network, or expansion of data storage.
Process improvement. These IT investments sought to improve the operations of a specific
business entity—for example, to reduce costs and improve service.
Experiments. Experiments were designed to evaluate new information technologies and test
new types of applications. Given the results of the experiments, the organization would decide
whether broad adoption was desirable.
Different organizations will allocate their IT budgets differently across these classes. An office
products company had an investment mix of experiments (15 percent), process improvement
(40 percent), renewal (25 percent), and transformation (20 percent). An insurance firm had an
investment mix of experiments (3 percent), process improvement (25 percent), renewal (18
percent), and transformation (53 percent).
The investment allocation is often an after-the-fact consideration—the allocation is not planned, it
just “happens.” However, ideally, the organization decides its desired allocation structure and
does so before the budget discussions. An organization with an ambitious and perhaps radical
strategy may allocate a very large portion of its IT investment to the transformation class,
whereas an organization with a conservative, stay-the-course strategy may have a large
process improvement portion to its IT investments.
Source: Ross and Beath (2002, p. 54).
Information system investment may be necessary because of mandated initiatives. Mandated
initiatives might involve reporting quality data to accrediting organizations, making required
changes in billing formats, or improving disaster notification systems. Assessing these
initiatives is generally approached by identifying the least expensive and the quickest to
implement alternative that will achieve the needed level of compliance.
Information system investments directed to cost reduction are generally highly amenable to ROI
and other quantifiable dollar-impact analyses. The ability to conduct a quantifiable ROI analysis
is rarely the question. The ability of management to effect the predicted cost reduction or cost
avoidance is often a far more germane question.
Specific New Products and Services
IT can be critical to the development of new products and services. At times the information
system delivers the new service, and at other times it is itself the product. Examples of
information system–based new services include bank cash-management programs and
programs that award airline mileage for credit card purchases. A new service offered by some
health care providers is a personal health record that enables a patient to communicate with his
or her physician and to access care guidelines and consumer-oriented medical textbooks.
The value of some of these new products and services can be quantifiably assessed in terms of
a monetary return. These assessments include analyses of potential new revenue, either
directly from the service or from service-induced use of other products and services. An ROI
analysis will need to be supplemented by techniques such as sensitivity analyses of consumer
response. Despite these analyses, the value of this IT investment usually has a speculative
component. This component involves consumer utilization, competitor response, and impact on
Information system investments are often directed to improving the quality of service or medical
care. These investments may be intended to reduce waiting times, improve the ability of
physicians to locate information, improve treatment outcomes, or reduce errors in treatment.
Evaluation of these initiatives, although quantifiable, is generally done in terms of service
parameters that are known or believed to be important determinants of organizational success.
These parameters might be measures of aspects of organizational processes that customers
encounter and then use to judge the organization, for example, waiting times in the physician’s
office. A quantifiable dollar outcome for the service of care quality improvement can be very
difficult to predict. Service quality is often necessary to protect current business, and the effect
of a failure to continuously improve service or medical care can be difficult to project.
Major Strategic Initiative
Strategic initiatives in information technology are intended to significantly change the competitive
position of the organization or redefine the core nature of the enterprise. In health care it is
unusual that information systems are the centerpiece of a redefinition of the organization,
although as we discussed in Chapter Four IT is a critical foundation for provider efforts to
manage population health. However, several other industries have attempted IT-centric
Amazon is an effort to transform retailing. Venmo (which enables micropayments between
individuals) is an effort to disrupt aspects of the branch bank. There can be a ROI core or
component to analyses of such initiatives, because they often involve major reshaping or
reengineering of fundamental organizational processes. However, assessing the ROIs of these
initiatives and their related information systems with a high degree of accuracy can be very
difficult. Several factors contribute to this difficulty:
These major strategic initiatives usually recast the organization’s markets and its roles. The
outcome of the recasting, although visionary, can be difficult to see with clarity and certainty.
The recasting is evolutionary; the organization learns and alters itself as it progresses over what
are often lengthy periods of time. It is difficult to be prescriptive about this evolutionary process.
Most accountable care organizations are confronting this phenomenon.
Market and competitor responses can be difficult to predict.
IT value is diverse and complex. This diversity indicates the power of IT and the diversity of its
use. Nonetheless, the complexity of the value proposition means that it is difficult to make
choices between IT investments and also difficult to assess whether the investment ultimately
chosen delivered the desired value or not.
The IT Project Proposal
The IT project proposal is a cornerstone in examining value. Clearly, ensuring that all proposals
are well crafted does not ensure value. To achieve value, alignment with organizational
strategies must occur, factors for sustained IT excellence must be managed, budget processes
for making choices between investments must exist, and projects must be well managed.
However, the proposal (as will be discussed in Chapter Thirteen) does describe the intended
outcome of the IT investment. The proposal requests money and an organizational commitment
to devote management attention and staff effort to implementing an information system. The
proposal describes why this investment of time, effort, and money is worth it—that is, the
proposal describes the value that will result. In this section we discuss the value portion of the
proposal and some common problems encountered with it.
Sources of Value Information
As project proponents develop their case for an IT investment, they may be unsure of the full
gamut of potential value or of the degree to which a desired value can be truly realized. The
organization may not have had experience with the proposed application and may have
insufficient analyst resources to perform its own assessment. It may not be able to answer such
questions as, What types of gains have organizations seen as a result of implementing a
population health system? To what degree will IT be a major contributor to our efforts to improve
patient access through telehealth?
Information about potential value can be obtained from several sources (discussed in Appendix
A). Conferences often feature presentations that describe the efforts of specific individuals or
organizations in accomplishing initiatives of interest to many others. Industry publications may
offer relevant articles and analyses. Several industry research organizations—for example,
Gartner and the Advisory Board—can offer advice. Consultants can be retained who have
worked with clients who are facing or have addressedsimilar questions. Vendors of applications
can describe the outcomes experienced by their customers. And colleagues can be contacted
to determine the experiences of their organizations.
Garnering an understanding of the results of others is useful but insufficient. It is worth knowing
that Organization Y adopted computerized provider order entry (CPOE) and reduced
unnecessary testing by x percent. However, one must also understand the CPOE features that
were critical in achieving that result and the management steps taken and the process changes
made in concert with the CPOE implementation.
Formal Financial Analysis
Most proposals should be subjected to formal financial analyses regardless of their value
proposition. Several types of financial measures are used by organizations. An organization’s
finance department will work with leadership to determine which measures will be used and how
these measures will be compiled.
Two common financial measures are net present value and internal rate of return:
Net present value is calculated by subtracting the initial investment from the future cash flows
that result from the investment. The cash can be generated by new revenue or cost savings.
The future cash is discounted, or reduced, by a standard rate to reflect the fact that a dollar
earned one or more years from now is worth less than a dollar one has today (the rate depends
on the time period considered). If the cash generated exceeds the initial investment by a certain
amount or percentage, the organization may conclude that the IT investment is a good one.
Internal rate of return is the discount rate at which the present value of an investment’s future
cash flow equals the cost of the investment. Another way to look at this is to ask, Given the
amount of the investment and its promised cash, what rate of return am I getting on my
investment? On the one hand, a return of 1 percent is not a good return (just as one would not
think that a 1 percent return on one’s savings was good). On the other hand, a 30 percent return
is very good.
Table 7.1 shows the typical form of a financial analysis for an IT application.
Table 7.1 Financial analysis of a patient accounting document imaging system
Current Year Year 1 Year 2 Year 3 Year 4 Year 5 Year 6 Year 7
One-time capital expense $1,497,466 $1,302,534
System maintenance — 288,000 $288,000 $288,000 $288,000
$288,000 $288,000 $288,000
System maintenance — 152,256 152,256 152,256 152,256
152,256 152,256 152,256
TOTAL COSTS 1,497,466 1,742,790 440,256 440,256 440,256
440,256 440,256 440,256
Rebilling of small secondary balances — 651,000 868,000 868,000
868,000 868,000 868,000 868,000
Medicaid billing documentation — 225,000 300,000 300,000
300,000 300,000 300,000 300,000
bad debt audit — — — — 100,000 100,000 100,000
Projected staff savings — 36,508 136,040 156,504 169,065
169,065 169,065 171,096
Projected operating savings — 64,382 77,015 218,231 222,550 226,436
TOTAL BENEFITS — 976,891 1,381,055 1,542,735 1,659,615
1,663,502 1,663,608 1,669,031
CASH FLOW (1,497,466) (765,899) 940,799 1,102,479 1,219,359
1,223,246 1,223,352 1,228,775
CUMULATIVE CASH FLOW (1,497,466) (2,263,365) (1,322,566) (220,087)
999,272 2,222,517 3,445,869 4,674,644
NPV (12% discount ) 1,998,068
Comparing Different Types of Value
Given the diversity of value, it is very challenging to compare IT proposals that have different
value propositions. How does one compare a proposal that promises to increase revenue and
improve collaboration to one that offers improved compliance, faster turnaround times, and
reduced supply costs?
At the end of the day, judgment is used to choose one proposal over another. Health care
executives review the various proposals and associated value statements and make choices
based on their sense of organizational priorities, available monies, and the likelihood that the
proposed value will be seen. These judgments can be aided by developing a scoring approach
that enables leaders to apply a common metric across proposals. For example, the organization
might decide to score each proposal according to how much value it promises to deliver in each
of the following areas:
Patient or customer satisfaction
Quality of work life
Quality of care
Potential learning value
In this approach, each of these areas in each proposal is assigned a score, ranging from 5
(significant contribution to the area) to 1 (minimal or no contribution). The scores are then totaled
for each proposal, and, in theory, one picks those proposals with the highest aggregate scores.
In practice, IT investment decisions are rarely that purely algorithmic. However, such scoring
can be very helpful in sorting through complex and diverse value propositions:
Scoring forces the leadership team to discuss why different members of the team assigned
different scores—why, for example, did one person assign a score of 2 for the revenue impact
of a particular proposal and another person assign a 4? These discussions can clarify people’s
understandings of proposal objectives and help the team arrive at a consensus on each project.
Scoring means that the leadership team will have to defend any decision not to fund a project
with a high score or to fund one with a low score. In the latter case, team members will have to
discuss why they are all in favor of a project when it has such a low score.
Prerequisites for Effective IT Project Prioritization
Jeanne Ross and Emmett Johnson (2009) identified four prerequisites to effective IT project
Explicit operating vision of the business. An operating vision is more than the sum of the
operations of individual departments. Rather, it is a solid understanding of how the organization
wants to operate as a whole. For example, how will the organization manage patients with a
chronic disease? What processes must be in place to ensure a superior patient experience?
Operating visions lead to enterprise-wide requirements for integration and standardization. IT
projects should support this vision and conform to these requirements.
Business process owners. Process owners are those senior leaders who are responsible for
the performance of core organization processes, such as patient access. These owners must
sponsor IT initiatives and be held accountable for their successful completion and value delivery.
These owners are in a good position to understand the IT priorities of their processes.
Transparent IT operating costs. Organizational leadership must understand IT costs and the
drivers of those costs. This understanding prepares them to thoughtfully assess the risks and
benefits of proposed new systems and to identify alternative approaches to achieving desired
Rigorous project governance. Excellent IT governance must exist for the overall IT agenda (to
be discussed in Chapter Twelve) and for individual projects (to be discussed in Chapter
Source: Ross and Johnson (2009).
The organization can decide which proposal areas to score and which not to score. Some
organizations give different areas different weights—for example, reducing costs might be
considered twice as important as improving organizational learning. The resulting scores are not
binding, but they canbe helpful in arriving at a decision about which projects will be approved and
what value is being sought.
Tactics for Reducing the Budget
Proposals for IT initiatives may originate from a wide variety of sources in an organization. The
IT group will submit proposals, as will department directors and physicians. Many of these
proposals will not be directly related to an overall strategy but may nevertheless be good ideas
that if implemented would lead to improved organizational performance. So it is common for an
organization to have more proposals than it can fund. For example, during the IT budget
discussion, the leadership team may decide that although it is looking at $2.2 million in requests,
the organization can afford to spend only $1.7 million, so $500,000 worth of requests must be
denied. Table 7.2 presents a sample list of requests.
Table 7.2 Requests for new information system projects
Community General Hospital
Project Name Operating Cost
Clinical portfolio development 38,716
Enterprise monitoring 70,133
HIPAA security initiative 36,950
Accounting of disclosure—HIPAA 35,126
Ambulatory Center patient tracking 62,841
Bar-coding infrastructure 64,670
Capacity management 155,922
Chart tracking 34,876
Clinical data repository 139,902
CRP research facility 7,026
Emergency Department data warehouse 261,584
Emergency Department order entry 182,412
Medication administration system 315,323
Order communications 377,228
Transfusion services replacement system 89,772
Wireless infrastructure 44,886
Next-generation order entry 3,403
Graduate medical education duty hours 163,763
Reducing the budget in situations such as this requires a value discussion. The leadership is
declaring some initiatives to have more value than others. Scoring initiatives according to criteria
is one approach to addressing this challenge.
In addition to such scoring, other assessment tactics can be employed, prior to the scoring, to
assist leaders in making reduction decisions.
Some requests are mandatory. They may be mandatory because of a regulation requirement
(such as a new Medicare rule) or because a current system is so obsolete that it is in danger of
crashing—permanently—and it must be replaced soon. These requests must be funded.
Some projects can be delayed. They are worthwhile, but a decision on them can be put off until
next year. The requester will get by in the meantime.
Key groups within IT, such as the staff members who manage clinical information systems, may
already have so much on their plate that they cannot possibly take on another project. Although
the organization wants to do the project, it would be ill-advised to do so now, and so the project
can be deferred to next year.
The user department proposing the application may not have strong management or may be
experiencing some upheaval; hence, implementing a new system at this time would be risky.
The project could be denied or delayed until the management issues have been resolved.
The value proposition or the resource estimates or both are shaky. The leadership team does
not trust the proposal, so it could be denied or sent back for further analysis. Further analysis
means that the proposal will be examined again next year.
Less expensive ways of addressing the problems cited in the proposal may exist, such as a
less expensive application or a non-IT approach. The proposal could be sent back for further
The proposal is valuable, and the leadership team would like to move it forward. However, the
team may reduce the budget, enabling progress to occur but at a slower pace. This delays
realizing the value but ensures that resources are devoted to making progress.
These tactics are routinely employed during budget discussions aimed at trying to get as much
value as possible given finite resources.
Common Proposal Problems
During the review of IT investment proposals, organizational leadership might encounter several
problems related to the estimates of value and the estimates of the resources needed to obtain
the value. If undetected, these problems might lead to a significant overstatement of potential
return or understatement of costs. An overstatement or understatement, obviously, may result
in significant organizational unhappiness when the value that people thought they would see
never materializes and never could have materialized.
Fractions of Effort
Proposal analyses might indicate that the new IT initiative will save fractions of staff time, for
example, that each nurse will spend fifteen minutes less per shift on clerical tasks. To suggest a
total value, the proposal might multiply as follows (this example is highly simplified): 200 nurses
× 15 minutes saved per 8-hour shift × 250 shifts worked per year = 12,500 hours saved. The
math might be correct, and the conclusion that 12,500 hours will become available for doing
other work such as direct patient care might also be correct. But the analysis will be incorrect if
it then concludes that the organization would thus “save” the salary dollars of six nurses
(assuming 2,000 hours worked per year per nurse).
Saving fractions of staff effort does not always lead to salary savings, even when there are large
numbers of staff members, because there may be no practical way to realize the savings—to,
for example, lay off six nurses. If, for example, there are six nurses working each eight-hour
shift in a particular nursing unit, the fifteen minutes saved per nurse would lead to a total savings
of 1.5 hours per shift. But if one were then to lay off one nurse on a shift, it would reduce the
nursing capacity on that shift by eight hours, damaging the unit’s ability to deliver care. Saving
fractions of staff member effort does not lead to salary savings when staff members are
geographically highly fragmented or when they work in small units or teams. It leads to possible
salary savings only when staff members work in very large groups and some work of the
reduced staff members can be redistributed to others.
Reliance on Complex Behavior
Proposals may project with great certainty that people will use systems in specific ways. For
example, several organizations expect that consumers will use Internet-based quality report
cards to choose their physicians andhospitals. However, few consumers appear to actually rely
on such sites. Organizations may expect that nurses will readily adopt systems that help them
discharge patients faster. However, nurses often delay entering discharge transactions so that
they can grab a moment of peace in an otherwise overwhelmingly busy day.
System use is often not what was anticipated. This is particularly true when the organization has
no experience with the relevant class of users or with the introduction of IT into certain types of
tasks. The original value projection can be thrown off by the complex behaviors of system
users. People do not always behave as we expect or want them to. If user behavior is uncertain,
the organization would be wise to pilot an application and learn from this demonstration.
Project proponents are often guilty of optimism that reflects a departure from reality. Proponents
may be guilty of any of four mistakes:
They assume that nothing will go wrong with the project.
They assume that they are in full control of all variables that might affect the project—even, for
example, quality of vendor products and organizational politics.
They believe that they know exactly what changes in work processes will be needed and what
system features must be present, when what they really have, at best, are close
approximations of what must happen.
They believe that everyone can give full time to the project and forget that people get sick or
have babies and that distracting problems unrelated to the project will occur, such as a sudden
deterioration in the organization’s fiscal performance, and demand attention.
Decisions based on such optimism eventually result in overruns in project budgets and
timetables and compromises in system goals. Overruns and compromises change the value
Projects often achieve gains in the first year of their implementation, and proponents are quick to
project that such gains will continue during the remaining life of the project. For example, an
organization may see 10 percentof its physicians move from using dictation when developing a
progress note to using structured, computer-based templates. The organization may then
erroneously extrapolate that each year will see an additional 10 percent shift. In fact, the first
year might be the only year in which such a gain will occur. The organization has merely
convinced the more computer-facile physicians to change, and the rest of the physicians have
no interest in ever changing.
Underestimating the Effort
Project proposals might count the IT staff member effort in the estimates of project costs but not
count the time that users and managers will have to devote to the project. A patient care system
proposal, for instance, may not include the time that will be spent by dozens of nurses working
on system design, developing workflow changes, and attending training. These efforts are real
costs. They often lead to the need to hire temporary nurses to provide coverage on the inpatient
care units, or they might lead to a reduced patient census because there are fewer nursing
hours available for patient care. Such miscounting of effort understates the cost of the project.
IT project proposals may note that the project can reduce the expenses of a department or
function, including costs for staff members, supplies, and effort devoted to correcting mistakes
that occur with paper-based processes. Department managers will swear in project approval
forums that such savings are real. However, when asked if they will reduce their budgets to
reflect the savings that will occur, these same managers may become significantly less
convinced that the savings will result. They may comment that the freed-up staff member effort
or supplies budgets can be redeployed to other tasks or expenses. The managers may be right
that the expenses should be redeployed, and all managers are nervous when asked to reduce
their budgets and still do the same amount of work. However, the savings expected have now
Failure to Account for Post-Implementation Costs
After a system goes live, the costs of the system do not go away. System maintenance
contracts are necessary. Hardware upgrades will be required. Staff members may be needed to
provide enhancements to the application. These support costs may not be as large as the costs
of implementation, butthey are costs that will be incurred every year, and over the course of
several years they can add up to some big numbers. Proposals often fail to adequately account
for support costs.
Ensuring the Delivery of Value
Achieving value from IT investments requires management effort. There is no computer genie
that descends on the organization once the system is live and waves its wand
and—shazzam!—value has occurred. Achieving value is hard work but doable work.
Management can take several steps to ensure the delivery of value (Dragoon, 2003; Glaser,
2003a, 2003b). These steps are discussed in the sections that follow.
Make Sure the Homework Was Done
IT investment decisions are often based on proposals that are not resting on solid ground. The
proposer has not done the necessary homework, and this elevates the risk of a suboptimal
Clearly, the track record of the investment proposer will have a significant influence on the
investment decision and on leaders’ thinking about whether or not the investment will deliver
value. However, regardless of the proposer’s track record, an IT proposal should enable the
leadership team to respond with a strong yes to each of the following questions:
Is it clear how the plan advances the organization’s strategy?
Is it clear how care will improve, costs will be reduced, or service will be improved? Are the
measures of current performance and expected improvement well researched and realistic?
Have the related changes in operations, workflow, and organizational processes been defined?
Are the senior leaders whose areas are the focus of the IT plan clearly supportive? Could they
give the project proposal presentation?
Are the resource requirements well understood and convincingly presented? Have these
requirements been compared to those experienced by other organizations undertaking similar
Have the investment risks been identified, and is there an approach to addressing these risks?
Do we have the right people assigned to the project, have we freed up their time, and are they
Answering with a no, a maybe, or an equivocal yes to any of these questions should lead one to
believe that the discussion is perhaps focusing on an expense rather than an investment.
Require Formal Project Proposals
It is a fact of organizational life that projects are approved as a result of hallway conversations or
discussions on the golf course. Organizational life is a political life. While recognizing this reality,
the organization should require that every IT project be written up in the format of a proposal and
that each proposal should be reviewed and subjected to scrutiny before the organization will
commit to supporting it. However, an organization may also decide that small projects—for
example, those that involve less than $25,000 in costs and less than 120 person-hours—can be
handled more informally.
Increase Accountability for Investment Results
Few meaningful organizational initiatives are accomplished without establishing appropriate
accountability for results. Accountability for IT investment results can be improved by taking
three major steps.
First, the business owner of the IT investment should defend the investment—for example, the
director of clinical laboratories should defend the request for a new laboratory system and the
director of nursing should defend the need for a new nursing system. The IT staff members will
need to work with the business owner to define IT costs, establish likely implementation time
frames, and sort through application alternatives. But the IT staff members should never defend
an application investment.
Second, as will be discussed in Chapter Thirteen, project sponsors and business owners must
be defined, and they must understand the accountability that they now have for the successful
completion of the project.
Third, the presentation of these projects should occur in a forum that routinely reviews such
requests. Seeing many proposals, and their results, over the course of time will enable the
forum participants to develop a seasoned understanding of good versus not-so-good proposals.
Forum members are also able to compare and contrast proposals as they decide which ones
should be approved. A manager might wonder (and it’s a good question), “If I approve this
proposal, does that mean that we won’t have resources for another project that I might like even
better?” Examining as many proposals together as possible enables the organization to take a
portfolio view of its potential investments.
Figure 7.1 displays an example of a project investment portfolio represented graphically. The
size of each bubble reflects the magnitude of a particular IT investment. The axes are labeled
“reward” (the size of the expected value) and “risk” (the relative risk that the project will not
deliver the value). Other axes may be used. One commonly used set of axes consists of
“support of operations” and “support of strategic initiatives.”
Diagrams such as the one in Figure 7.1 serve several functions:
They summarize IT activity on one piece of paper, enabling leaders to consider a new request in
the context of prior commitments.
They help to ensure a balanced portfolio, promptly revealing imbalances such as a clustering of
projects in the high-risk quadrant.
They help to ensure that the approved projects cover an appropriate spectrum of organizational
needs: for example, that projects are directed to revenue cycle improvement, to operational
improvement, and to patient safety.
Manage the Project Well
One guaranteed way to reduce value is to mangle the management of the implementation
project. Implementation failures or significant budget and timetable overruns or really unhappy
users—any of these can dilute value.
Types of Portfolio Investments
Peter Weill and Sinan Aral (2006) note that organizations should manage their IT investments as
a portfolio. Specifically, they describe four types of IT investments in a portfolio.
Infrastructure. Infrastructure refers to the core information technology that serves as the
foundation for all applications. Examples of infrastructure include networks, servers, operating
systems, and mobile devices.
Transactional. Transactional systems are those applications that support the core operations
processes. Examples of transactional systems include CPOE, scheduling, clinical laboratory
automation, and clinician documentation.
Informational. Informational IT assets are those that support decision making such as clinical
decision support, quality measurement and analyses, market assessment, and budget
Strategic. Strategic investments are IT systems that are critical to the furthering of an
organization’s strategy. These investments could be infrastructure, transactional, and
informational, but they differ in that they are clearly directed to furthering a strategic initiative as
distinct from being helpful to support ongoing operations.
Weill and Aral note that different industries have different allocations of IT investments across
these categories. Financial services emphasize infrastructure in an effort to ensure high
reliability and low costs. However, retail has emphasized informational as they seek to
understand customer buying patterns.
Source: Weill and Aral (2006).
Among the many factors that can lead to mangled project management are the following:
The project’s scope is poorly defined.
The accountability is unclear.
The project participants are marginally skilled.
The magnitude of the task is underestimated.
Users feel like victims rather than participants.
All the world has a vote and can vote at any time.
Many of these factors were discussed in Chapters Five and Six.
Value is not an automatic result of implementing an information system. Value must be
managed into existence. Figure 7.2 depicts a reduction in days in accounts receivable (AR) at a
physician practice. During the interval depicted, a new practice management system was
implemented. The practice did not see a precipitous decline in days in AR (a sign of improved
revenue performance) in the time immediately following the implementation in the second
quarter of 2015. The practice did see a progressive improvement in days in AR because
someone was managing that improvement using the new capabilities that came with the new
Figure 7.2 Days in accounts receivable
If the gain in revenue performance had been an “automatic” result of the information system
implementation, the practice would have seen a quick, sharp drop in days in AR. Instead it saw
a gradual improvement over time. This gradual change reflects the following:
The gain occurred through day-in, day-out changes in operational processes, fine-tuning of
system capabilities, and follow-ups in staff training.
A person had to be in charge of obtaining this improvement. Someone had to identify and make
operational changes, manage changes in system capabilities, and ensure that needed training
Conduct Post-Implementation Audits
Rarely do organizations revisit their IT investments to determine if the promised value was
actually achieved. They tend to believe that once the implementation is over and the change
settles in, value will have been automatically achieved. This is unlikely.
Post-implementation audits can be conducted to identify value achievement progress and the
steps still needed to achieve maximum gain. An organization might decide to audit two to four
systems each year, selecting systems that have been live for at least six months. During the
course of the audit meeting, these five questions can be asked:
What goals were expected at the time the project investment was approved?
How close have we come to achieving those original goals?
What do we need to do to close the goal gap?
How much have we invested in system implementation, and how does that compare to our
If we had to implement this system again, what would we do differently?
Post-implementation audits assist value achievement by the following:
Signaling leadership interest in ensuring the delivery of results
Identifying steps that still need to be taken to ensure value
Supporting organizational learning about IT value realization
Reinforcing accountability for results
Celebrate Value Achievement
Business value should be celebrated. Organizations usually hold parties shortly after
applications go live. These parties are appropriate; a lot of people worked very hard to get the
system up and running and used. However, up and running and used does not mean that value
has been delivered. In addition to go-live parties, organizations should consider business value
parties,celebrations conducted once the value has been achieved—for example, a party that
celebrates the achievement of service improvement goals. Go-live parties alone risk sending
the inappropriate signal that implementation is the end point of the IT initiative. Value delivery is
the end point.
Leverage Organizational Governance
The creation of an IT committee of the board of directors can enhance organizational efforts to
achieve value from IT investments. At times the leadership team of an organization is
uncomfortable with some or all of the IT conversation. Board members may not understand why
infrastructure is so expensive or why large implementations can take so long and cost so much.
They may feel uncomfortable with the complexity of determining the likely value to be obtained
from IT investments. The creation of a subcommittee made up of the board members most
experienced with such discussions can help to ensure that hard questions are being asked and
that the answers are sound.
Shorten the Deliverables Cycle
When possible, projects should have short deliverable cycles. In other words, rather than asking
the organization to wait twelve or eighteen months to see the first fruits of its application
implementation labors, make an effort to deliver a sequence of smaller implementations. For
example, one might conduct pilots of an application in a subset of the organization, followed by a
staged rollout. Or one might plan for serial implementation of the first 25 percent of the
Pilots, staged rollouts, and serial implementations are not always doable. When they are
possible, however, they enable the organization to achieve some value earlier rather than later,
support organizational learning about which system capabilities are really important and which
were only thought to be important, facilitate the development of reengineered operational
processes, and create the appearance (whose importance is not to be underestimated) of more
Organizations should benchmark their performance in achieving value against the performance
of their peers. These benchmarks might focus on process performance—for example, days in
accounts receivable or average time to get an appointment. An important aspect of value
benchmarkingis the identification of the critical IT application capabilities and related operational
changes that enabled the achievement of superior results. This understanding of how other
organizations achieved superior IT-enabled performance can guide an organization’s efforts to
continuously achieve as much value as possible from its IT investments.
Once a year the IT department should develop a communication plan for the twelve months
ahead. This plan should indicate which presentations will be made in which forums and how
often IT-centric columns will appear in organizational newsletters. The plan should list three or
so major themes—for example, specific regional integration strategies or efforts to improve IT
service—that will be the focus of these communications. Communication plans try to remedy
the fact that even when value is being delivered, most people in the organization may not be fully
aware of it.
Analyses of the IT Value Challenge
The IT investment and value challenge plagues all industries. It is not a problem peculiar to
health care. The challenge has been with us for fifty years, ever since organizations began to
spend money on big mainframes. This challenge is complex and persistent, and we should not
believe we can fully solve it. We should believe we can be better at dealing with it. This section
highlights the conclusions of several studies and articles that have examined this challenge.
Factors That Hinder Value Return
The Committee to Study the Impact of Information Technology on the Performance of Service
Activities (1994) found these major contributors to failures to achieve a solid return on IT
The organization’s overall strategy is wrong, or its assessment of its competitive environment is
The strategy is fine, but the necessary IT applications and infrastructure are not defined
appropriately. The information system, if it is solving a problem, is solving the wrong problem.
The organization fails to identify and draw together well all the investments and initiatives
necessary to carry out its plans. The ITinvestment then falters because other changes, such as
reorganization or reengineering, fail to occur.
The organization fails to execute the IT plan well. Poor planning or less than stellar management
can diminish the return from any investment.
Value may also be diluted by factors outside the organization’s control. Weill and Broadbent
(1998) noted that the more strategic the IT investment, the more its value can be diluted. An IT
investment directed to increasing market share may have its value diluted by non-IT decisions
and events—for example, pricing decisions, competitors’ actions, and customers’ reactions. IT
investments that are less strategic but have business value—for example, improving nursing
productivity—may be diluted by outside factors—for example, shortages of nursing staff
members. And the value of an IT investment directed toward improving infrastructure
characteristics may be diluted by outside factors—for example, unanticipated technology
immaturity or business difficulties confronting a vendor.
The Investment-Performance Relationship
A study by Strassmann (1990) examined the relationship between IT expenditures and
organizational effectiveness. Data from an Information Week survey of the top one hundred
users of IT were used to correlate IT expenditures per employee with profits per employee.
Strassmann concluded that there is no overall obvious direct relationship between expenditure
and organizational performance. This finding has been observed in several other studies (for
example, Keen, 1997). It leads to several conclusions:
Spending more on IT is no guarantee that the organization will be better off. There has never
been a direct correlation between spending and outcomes. Paying more for care does not give
one correspondingly better care. Clearly, one can spend so little that nothing effective can be
done. And one can spend so much that waste is guaranteed. But moving IT expenditures from 4
percent of the operating budget to 6 percent of the operating budget does not inherently lead to a
50 percent increase in desirable outcomes.
Factors other than the appropriateness of the tool to the task also influence the relationship
between IT investment and organizational performance. These factors include the nature of the
work (for example, IT is likely to have a greater impact on bank performancethan on consulting
firm performance), the basis of competition in an industry (for example, cost per unit of
manufactured output versus prowess in marketing), and an organization’s relative competitive
position in the market.
The Value of the Overall Investment
Many analyses and academic studies have been directed to answering this broad question:
How can an organization assess the value of its overall investments in IT? Assessing the value
of the aggregate IT investment is different from assessing the value of a single initiative or other
specific investment. And it is also different from assessing the caliber of the IT department.
Developing a definitive, accurate, and well-accepted way to answer this question has so far
eluded all industries and may continue to be elusive. Nonetheless there are some basic
questions that can be asked in pursuit of answering the larger question. Interpreting the answers
to these basic questions is a subjective exercise, making it difficult to derive numerical scores.
Bresnahan (1998) suggests five questions:
How does IT influence the customer experience?
Do patients and physicians, for example, find that organizational processes are more efficient,
less error prone, and more convenient?
Does IT enable or retard growth? Can the IT organization support effectively the demands of a
merger? Can IT support the creation of clinical product lines—for example, cardiology—across
the integrated delivery system?
Does IT favorably affect productivity?
Does IT advance organizational innovation and learning?
Progressive Realization of IT Value
Brown and Hagel (2003) made three observations about IT value.
First, IT value requires innovation in business practices. If an organization merely computerizes
existing processes without rectifying (or at times eliminating) process problems, it may have
merely made process problems occur faster. In addition, those processes are now more
expensive because there is a computer system to support. Providing appointment scheduling
systems may not make waiting times any shorter or enhance patients’ ability to get an
appointment when they need one.
All IT initiatives should be accompanied by efforts to materially improve the processes that the
system is designed to support. IT often enables the organization to think differently about a
process or expand its options for improving a process. If the process thinking is narrow or
unimaginative, the value that could have been achieved will have been lost, with the organization
settling for an expensive way to achieve minimal gain.
For example, if Amazon had thought that the Internet enabled it to simply replace the catalogue
and telephone as a way of ordering something, it would have missed ideas such as presenting
products to the customer based on data about prior orders or enabling customers to leave their
own ratings of books and music.
Second, the economic value of IT comes from incremental innovations rather than “big bang”
initiatives. Organizations will often introduce very large computer systems and process change
all at once. Two examples of such big bangs are the replacement of all systems related to the
revenue cycle and the introduction of a new EHR over the course of a few weeks.
Big bang implementations are very tricky and highly risky. They may be haunted by series of
technical problems. Moreover, these systems introduce an enormous number of process
changes affecting many people. It is exceptionally difficult to understand the ramifications of
such change during the analysis and design stages that precede implementation. A full
understanding is impossible. As a result, the implementing organization risks material damage.
This damage destroys value. It may set the organization back, and even if the organization
grinds its way through the disruption, the resulting trauma may make the organization unwilling
to engage in future ambitious IT initiatives.
By contrast, IT implementations (and related process changes) that are more incremental and
iterative reduce the risk of organizational damage and permit the organization to learn. The
organization has time to understand the value impact of phase n and then can alter its course
before it embarks upon phase n + 1. Moreover, incremental change leads the organization’s
members to understand that change, and realizing value, are never-ending aspects of
organizational life rather than things to be endured every couple of years.
Third, the strategic impact of IT investments comes from the cumulative effect of sustained
initiatives to innovate business practices. If economic value is derived from a series of
thoughtful, incremental steps, then the aggregate effect of those steps should be a competitive
advantage. Most of the time, organizations that wind up dominating an industry do so through
incremental movement over the course of several years (Collins, 2001).
Persistent innovation by a talented team, over the course of years, will result in significant
strategic gains. The organization has learned how toimprove itself, year in and year out.
Strategic value is a marathon. It is a long race that is run and won one mile at a time.
Companies with Digital Maturity
CapGemini (2012) examined digital innovations at four hundred large companies. The study
examined the digital maturity of these companies and compared this maturity with the
performance of the companies. Digital maturity is defined according to two variables:
Digital intensity, or the extent to which the company had invested in technology-enabled
initiatives to change how the company operates. Example investments included advanced
analytics, social media, digital design of products, and real-time monitoring of operations.
Transformation management intensity, or the extent of the leadership capabilities necessary to
drive digital transformation throughout the company. Example capabilities included vision,
governance, and ability to change culture.
The study examined the degree to which digital intensity and transformation-management
intensity separated those that performed well from those that did not. (See Figure 7.3.)
The study found that companies that had low scores on both intensity dimensions fared the
poorest (24 percent less profitable than their competitors), whereas companies that had high
scores on both intensity dimensions performed the best (26 percent more profitable than their
However, the study found that transformation-management intensity was more important than
digital intensity. Companies that had high transformation-management intensity but low digital
intensity performed 9 percent better than their competitors. And companies that had high digital
intensity but low transformation intensity were 11 percent less profitable than competitors.
Transformation ability was more important than investment in IT although IT investments
enabled transformation skills to achieve more value.
IT value is complex, multifaceted, and diverse across and within proposed initiatives. The
techniques used to analyze value must vary with the nature of the value.
Figure 7.3 Digital intensity versus transformation intensity
Source: CapGemini (2012). CapGemini Consulting and the MIT Center for Digital Business,
“The Digital Advantage: How digital leaders outperform their peers in every industry,” Nov. 5,
2012. Used with permission.
The project proposal is the core means for assessing the potential value of an IT initiative. IT
proposals have a commonly accepted structure. And approaches exist for comparing proposals
with different types of value propositions. Project proposals often present problems in the way
they estimate value—for example, they may unrealistically combine fractions of effort saved, fail
to appreciate the complex behavior of system users, or underestimate the full costs of the
Many factors can dilute the value realized from an IT investment. Poor linkage between the IT
agenda and the organizational strategy, the failure to set goals, and the failure to manage the
realization of value all contribute to dilution.
There are steps that can be taken to improve the achievement of IT value. Leadership can
ensure that project proponents have done their homework, that accountability for results has
been established, that formal proposalsare used, and that post-implementation audits are
conducted. Even though there are many approaches and factors that can enhance the
realization of IT-enabled value, the challenges of achieving this value will remain a management
issue for the foreseeable future.
Health care organization leaders often feel ill-equipped to address the IT investment and value
challenge. However, no new management techniques are required to evaluate IT plans,
proposals, and progress. Leadership teams are often asked to make decisions that involve
strategic hunches (such as a belief that developing a continuum of care would be of value) about
areas where they may have limited domain knowledge (new surgical modalities) and where the
value is fuzzy (improved morale). Organizational leaders should treat IT investments just as
they would treat other types of investments; if they don’t understand, believe, or trust the
proposal or its proponent, they should not approve it.
Organizing Information Technology Services
Privacy is an individual’s constitutional right to be left alone, to be free from unwarranted
publicity, and to conduct his or her life without its being made public. In the health care
environment, privacy is an individual’s right to limit access to his or her health care information.
In spite of this constitutional protection and other legislated protections discussed in this chapter,
approximately 112 million Americans (a third of the United States population) were affected by
breaches of protected health information (PHI) in 2015 (Koch, 2016). Three large
insurance-related corporations accounted for nearly one hundred million records being exposed
(Koch, 2016). In one well-publicized security breach at Banner Health, where hackers gained
entrance through food and beverage computers, approximately 3.7 million individuals’
information was accessed, much of it health information (Goedert, 2016).
Health information privacy and security are key topics for health care administrators. In today’s
ever-increasing electronic world, where the Internet of Things is on the horizon and nearly every
health care organization employee and visitor has a smart mobile device that is connected to at
least one network, new and more virulent threats are an everyday concern. In this chapter we
will examine and define the concepts of privacy, confidentiality, and security as they apply to
health information. Major legislative efforts, historic and current, to protect health care
information are outlined, with a focus on the Health Insurance Portability and Accountability Act
(HIPAA) Privacy, Security, and Breach Notification rules. Different types of threats, intentional
and unintentional, to health information will be discussed. Basic requirements for a strong health
care organization security program will be outlined, and the chapter will conclude with the
cybersecurity challenges in today’s environment of mobile and cloud-based devices, wearable
fitness trackers, social media, and remote access to health information.
Privacy, Confidentiality, and Security Defined
As stated, privacy is an individual’s right to be left alone and to limit access to his or her health
care information. Confidentiality is related to privacy but specifically addresses the expectation
that information shared with a health care provider during the course of treatment will be used
only for its intended purpose and not disclosed otherwise. Confidentiality relies on trust. Security
refers to the systems that are in place to protect health information and the systems within
which it resides. Health care organizations must protect their health information and health
information systems from a range of potential threats. Certainly, security systems must protect
against unauthorized access and disclosure of patient information, but they must also be
designed to protect the organization’s IT assets—such as the networks,hardware, software, and
applications that make up the organization’s health care information systems—from harm.
Legal Protection of Health Information
There are many sources for the legal and ethical requirements that health care professionals
maintain the confidentiality of patient information and protect patient privacy. Ethical and
professional standards, such as those published by the American Medical Association and
other organizations, address professional conduct and the need to hold patient information in
confidence. Accrediting bodies, such as the Joint Commission, state facility licensure rules, and
the government through Centers for Medicare and Medicaid, dictate that health care
organizations follow standard practice and state and federal laws to ensure the confidentiality
and security of patient information.
Today, legal protection specially addressing the unauthorized disclosure of an individual’s health
information generally comes from one of three sources (Koch, 2016):
Federal HIPAA Privacy, Security, and Breach Notification rules
State privacy laws. These laws typically apply more stringent protections for information related
to specific health conditions (HIV/AIDS, mental or reproductive health, for example).
Federal Trade Commission (FTC) Act consumer protection, which protects against unfair or
deceptive practices. The FTC issued the Health Breach Notification Rule in 2010 to require
certain businesses not covered by HIPAA, including PHR vendors, PHR-related entities, or
third-party providers for PHR vendors or PHR-related entities to notify individuals of a security
However, there are two other major federal laws governing patient privacy that, although they
have been essentially superseded by HIPAA, remain important, particularly from a historical
The Privacy Act of 1974 (5 U.S.C. §552a; 45 C.F.R. Part 5b; OMB Circular No. A-108 )
Confidentiality of Substance Abuse Patient Records (42 U.S.C. §290dd- 2, 42 C.F.R. Part 2)
The Privacy Act of 1974
In 1966, the Freedom of Information Act (FOIA) was passed. This legislation provides the
American public with the right to obtain informationfrom federal agencies. The act covers all
records created by the federal government, with nine exceptions. The sixth exception is for
personnel and medical information, “the disclosure of which would constitute a clearly
unwarranted invasion of personal privacy.” There was, however, concern that this exception to
the FOIA was not strong enough to protect federally created patient records and other health
information. Consequently, Congress enacted the Privacy Act of 1974. This act was written
specifically to protect patient confidentiality only in federally operated health care facilities, such
as Veterans Administration hospitals, Indian Health Service facilities, and military health care
organizations. Because the protection was limited to those facilities operated by the federal
government, most general hospitals and other nongovernment health care organizations did not
have to comply. Nevertheless, the Privacy Act of 1974 was an important piece of legislation, not
only because it addressed the FOIA exception for patient information but also because it
explicitly stated that patients had a right to access and amend their medical records. It also
required facilities to maintain documentation of all disclosures. Neither of these things was
standard practice at the time.
Confidentiality of Substance Abuse Patient Records
During the 1970s, people became increasingly aware of the extra-sensitive nature of drug and
alcohol treatment records. This led to the regulations currently found in 42 C.F.R. (Code of
Federal Regulations) Part 2, Confidentiality of Substance Abuse Patient Records. These
regulations have been amended twice, with the latest version published in 1999. They offer
specific guidance to federally assisted health care organizations that provide referral, diagnosis,
and treatment services to patients with alcohol or drug problems. Not surprisingly, they set
stringent release of information standards, designed to protect the confidentiality of patients
seeking alcohol or drug treatment.
HIPAA is the first comprehensive federal regulation to offer specific protection to private health
information. Prior to the enactment of HIPAA there was no single federal regulation governing
the privacy and security of patient-specific information, only the limited legislative protections
previously discussed. These laws were not comprehensive and protected only specific groups
The Health Insurance Portability and Accountability Act of 1996 consists of two main parts:
Title I addresses health care access, portability, and renewability, offering protection for
individuals who change jobs or health insurance policies. (Although Title I is an important piece
of legislation, it does not address health care information specifically and will therefore not be
addressed in this chapter.)
Title II includes a section titled, “Administrative Simplification.”
The requirements establishing privacy and security regulations for protecting individually
identifiable health information are found in Title II of HIPAA. The HIPAA Privacy Rule was
required beginning April 2003 and the HIPAA Security Rule beginning April 2005. Both rules
were subsequently amended and the Breach Notification Rule was added as a part of the
HITECH Act in 2009.
The information protected under the HIPAA Privacy Rule is specifically defined as PHI, which is
Relates to a person’s physical or mental health, the provision of health care, or the payment for
Identifies the person who is the subject of the information
Is created or received by a covered entity
Is transmitted or maintained in any form (paper, electronic, or oral)
Unlike the Privacy Rule, the Security Rule addressed only PHI transmitted or maintained in
electronic form. Within the Security Rule this information is identified as ePHI.
The HIPAA rules also define covered entities (CEs), those organizations to which the rules
Health plans, which pay or provide for the cost of medical care
Health care clearinghouses, which process health information (for example, billing services)
Health care providers who conduct certain financial and administrative transactions
electronically (These transactions are defined broadly so that the reality of HIPAA is that it
governs nearly all health care providers who receive any type of third-party reimbursement.)
If any CE shares information with others, it must establish contracts to protect the shared
information. The HITECH Act amended HIPAA and added “Business Associates” as a category
of CE. It further clarified that certain entities, such as health information exchange organizations,
regional health information organizations, e-prescribing gateways, or a vendor that contracts
with a CE to allow the CE to offer a personal health record as a part of its EHR, are business
associates if they require access to PHI on a routine basis (Coppersmith, Gordon, Schermer, &
Brokelman, PLC, 2012).
HIPAA Privacy Rule
Although the HIPAA Privacy Rule is a comprehensive set of federal standards, it permits the
enforcement of existing state laws that are more protective of individual privacy, and states are
also free to pass more stringent laws. Therefore, health care organizations must still be familiar
with their own state laws and regulations related to privacy and confidentiality.
The major components to the HIPAA Privacy Rule in its original form include the following:
Boundaries. PHI may be disclosed for health purposes only, with very limited exceptions.
Security. PHI should not be distributed without patient authorization unless there is a clear basis
for doing so, and the individuals who receive the information must safeguard it.
Consumer control. Individuals are entitled to access and control their health records and are to
be informed of the purposes for which information is being disclosed and used.
Accountability. Entities that improperly handle PHI can be charged under criminal law and
punished and are subject to civil recourse as well.
Public responsibility. Individual interests must not override national priorities in public health,
medical research, preventing health care fraud, and law enforcement in general.
With HITECH, the Privacy Rule was expanded to include creation of new privacy requirements
for HIPAA-covered entities and business associates. In addition, the rights of individuals to
request and obtain their PHI are strengthened, as is the right of the individual to prevent a health
care organization from disclosing PHI to a health plan, if the individual paid in full out of pocket
for the related services. There were also some new provisionsfor accounting of disclosures
made through an EHR for treatment, payment, and operations (Coppersmith et al., 2012).
The HIPAA Privacy Rule attempts to sort out the routine and nonroutine use of health
information by distinguishing between patient consent to use PHI and patient authorization to
release PHI. Health care providers and others must obtain a patient’s written consent prior to
disclosure of health information for routine uses of treatment, payment, and health care
operations. This consent is fairly general in nature and is obtained prior to patient treatment.
There are some exceptions to this in emergency situations, and the patient has a right to
request restrictions on the disclosure. However, health care providers can deny treatment if they
feel that limiting the disclosure would be detrimental. Health care providers and others must
obtain the patient’s specific written authorization for all nonroutine uses or disclosures of PHI,
such as releasing health records to a school or a relative.
Exhibit 9.1 is a sample release of information form used by a hospital, showing the following
elements that should be present on a valid release form:
Patient identification (name and date of birth)
Name of the person or entity to whom the information is being released
Description of the specific health information authorized for disclosure
Statement of the reason for or purpose of the disclosure
Date, event, or condition on which the authorization will expire, unless it is revoked earlier
Statement that the authorization is subject to revocation by the patient or the patient’s legal
Patient’s or legal representative’s signature
Signature date, which must be after the date of the encounter that produced the information to be
Health care organizations need clear policies and procedures for releasing PHI. A central point
of control should exist through which all nonroutine requests for information pass, and all
disclosures should be well documented.
In some instances, PHI can be released without the patient’s authorization. For example, some
state laws require disclosing certain health information. It is always good practice to obtain a
patient authorization prior to releasing information when feasible, but in state-mandated cases it
is not required. Some examples of situations in which information might need to be disclosed to
authorized recipients without the patient’s consent are the presence of a communicable disease,
such as AIDS and sexually transmitted diseases, which must be reported to the state or county
department of health; suspected child abuse or adult abuse that must be reported to designated
authorities; situations in which there is a legal duty to warn another person of a clear and
imminent danger from a patient; bona fide medical emergencies; and the existence of a valid
The HIPAA Security Rule
The HIPAA Security Rule is closely connected to the HIPAA Privacy Rule. The Security Rule
governs only ePHI, which is defined as protected health information maintained or transmitted in
electronic form. It is important to note that the Security Rule does not distinguish between
electronic forms of information or between transmission mechanisms. ePHI may be stored in
any type of electronic media, such as magnetic tapes and disks, optical disks, servers, and
personal computers. Transmission may take place over the Internet or on local area networks
(LANs), for example.
The standards in the final rule are defined in general terms, focusing on what should be done
rather than on how it should be done. According to the Centers for Medicare and Medicaid
Services (CMS, 2004), the final rule specifies “a series of administrative, technical, and physical
security procedures for covered entities to use to assure the confidentiality of electronic
protected health information (ePHI). The standards are delineated into either required or
addressable implementation specifications.” A required specification must be implemented by a
CE for that organization to be in compliance. However, the CE is in compliance with an
addressable specification if it does any one of the following:
Implements the specification as stated
Implements an alternative security measure to accomplish the purposes of the standard or
Chooses not to implement anything, provided it can demonstrate that the standard or
specification is not reasonable and appropriate and that the purpose of the standard can still be
met; because the Security Rule is designed to be technology neutral, this flexibility was granted
for organizations that employ nonstandard technologies or have legitimate reasons not to need
the stated specification (AHIMA, 2003)
The standards contained in the HIPAA Security Rule are divided into sections, or categories, the
specifics of which we outline here. You will notice overlap among the sections. For example,
contingency plans are covered under both administrative and physical safeguards, and access
controls are addressed in several standards and specifications.
The HIPAA Security Rule
The HIPAA Security Administrative Safeguards section of the Final Rule contains nine
1. Security management functions. This standard requires the CE to implement policies and
procedures to prevent, detect, contain, and correct security violations. There are four
implementation specifications for this standard:
Risk analysis (required). The CE must conduct an accurate and thorough assessment of the
potential risks to and vulnerabilities of the confidentiality, integrity, and availability of ePHI.
Risk management (required). The CE must implement security measures that reduce risks and
vulnerabilities to a reasonable and appropriate level.
Sanction policy (required). The CE must apply appropriate sanctions against workforce
members who fail to comply with the CE’s security policies and procedures.
Information system activity review (required). The CE must implement procedures to regularly
review records of information system activity, such as audit logs, access reports, and security
incident tracking reports.
Assigned security responsibility. This standard does not have any implementation
specifications. It requires the CE to identify the individual responsible for overseeing
development of the organization’s security policies and procedures.
Workforce security. This standard requires the CE to implement policies and procedures to
ensure that all members of its workforce have appropriate access to ePHI and to prevent those
workforce members who do not have access from obtaining access. There are three
implementation specifications for this standard:
Authorization and/or supervision (addressable). The CE must have a process for ensuring that
the workforce working with ePHI has adequate authorization and supervision.
Workforce clearance procedure (addressable). There must be a process to determine what
access is appropriate for each workforce member.
Termination procedures (addressable). There must be a process for terminating access to ePHI
when a workforce member is no longer employed or his or her responsibilities change.
Information access management. This standard requires the CE to implement policies and
procedures for authorizing access to ePHI. There are three implementation specifications within
this standard. The first (not shown here) applies to health care clearinghouses, and the other two
apply to health care organizations:
Access authorization (addressable). The CE must have a process for granting access to ePHI
through a workstation, transaction, program, or other process.
Access establishment and modification (addressable). The CE must have a process (based on
the access authorization) to establish, document, review, and modify a user’s right to access a
workstation, transaction, program, or process.
Security awareness and training. This standard requires the CE to implement awareness and
training programs for all members of its workforce. This training should include periodic security
reminders and address protection from malicious software, log-in monitoring, and password
management. (These items to be addressed in training are all listed as addressable
Security incident reporting. This standard requires the CE to implement policies and procedures
to address security incidents.
Contingency plan. This standard has five implementation specifications:
Data backup plan (required)
Disaster recovery plan (required)
Emergency mode operation plan (required)
Testing and revision procedures (addressable); the CE should periodically test and modify all
Applications and data criticality analysis (addressable); the CE should assess the relative
criticality of specific applications and data in support of its contingency plan
Evaluation. This standard requires the CE to periodically perform technical and nontechnical
evaluations in response to changes that may affect the security of ePHI.
Business associate contracts and other arrangements. This standard outlines the conditions
under which a CE must have a formal agreement with business associates in order to
The HIPAA Security Physical Safeguards section contains four standards:
Facility access controls. This standard requires the CE to implement policies and procedures to
limit physical access to its electronic information systems and the facilities in which they are
housed to authorized users. There are four implementation specifications with this standard:
Contingency operations (addressable). The CE should have a process for allowing facility
access to support the restoration of lost data under the disaster recovery plan and emergency
mode operation plan.
Facility security plan (addressable). The CE must have a process to safeguard the facility and
its equipment from unauthorized access, tampering, and theft.
Access control and validation (addressable). The CE should have a process to control and
validate access to facilities based on users’ roles or functions.
Maintenance records (addressable). The CE should have a process to document repairs and
modifications to the physical components of a facility as they relate to security.
2. Workstation use. This standard requires the CE to implement policies and procedures that
specify the proper functions to be performed and the manner in which those functions are to be
performed on a specific workstation or class of workstation that can be used to access ePHI
and that also specify the physical attributes of the surroundings of such workstations.
Workstation security. This standard requires the CE to implement physical safeguards for all
workstations that are used to access ePHI and to restrict access to authorized users.
Device and media controls. This standard requires the CE to implement policies and procedures
for the movement of hardware and electronic media that contain ePHI into and out of a facility
and within a facility. There are four implementation specifications with this standard:
Disposal (required). The CE must have a process for the final disposition of ePHI and of the
hardware and electronic media on which it is stored.
Media reuse (required). The CE must have a process for removal of ePHI from electronic media
before the media can be reused.
Accountability (addressable). The CE must maintain a record of movements of hardware and
electronic media and any person responsible for these items.
Data backup and storage (addressable). The CE must create a retrievable, exact copy of ePHI,
when needed, before movement of equipment.
The HIPAA Security Technical Safeguards section has five standards:
Access control. This standard requires the CE to implement technical policies and procedures
for electronic information systems that maintain ePHI in order to allow access only to those
persons or software programs that have been granted access rights as specified in the
administrative safeguards. There are four implementation specifications within this standard:
Unique user identification (required). The CE must assign a unique name or number for
identifying and tracking each user’s identity.
Emergency access procedure (required). The CE must establish procedures for obtaining
necessary ePHI in an emergency.
Automatic log-off (addressable). The CE must implement electronic processes that terminate an
electronic session after a predetermined time of inactivity.
Encryption and decryption (addressable). The CE should implement a mechanism to encrypt
and decrypt ePHI as needed.
Audit controls. This standard requires the CE to implement hardware, software, and procedures
that record and examine activity in the information systems that contain ePHI.
Integrity. This standard requires the CE to implement policies and procedures to protect ePHI
from improper alteration or destruction.
Person or entity authentication. This standard requires the CE to implement procedures to verify
that a person or entity seeking access to ePHI is in fact the person or entity claimed.
Transmission security. This standard requires the CE to implement technical measures to guard
against unauthorized access to ePHIbeing transmitted across a network. There are two
implementation specifications with this standard:
Integrity controls (addressable). The CE must implement security measures to ensure that
electronically transmitted ePHI is not improperly modified without detection.
Encryption (addressable). The CE should encrypt ePHI whenever it is deemed appropriate.
The Policies, Procedures, and Documentation section has two standards:
Policies and procedures. This standard requires the CE to establish and implement policies and
procedures to comply with the standards, implementation specifications, and other
Documentation. This standard requires the CE to maintain the policies and procedures
implemented to comply with the Security Rule in written form. There are three implementation
Time limit (required). The CE must retain the documentation for six years from the date of its
creation or the date when it was last in effect, whichever is later.
Availability (required). The CE must make the documentation available to those persons
responsible for implementing the policies and procedures.
Updates (required). The CE must review the documentation periodically and update it as
HIPAA Breach Notification Rule
The HIPAA Breach Notification Rule requires CEs and their business associates to provide
notification following a breach of unsecured protected health information. “‘Unsecured’ PHI is
PHI that has not been rendered unusable, unreadable, or indecipherable to unauthorized
persons through the use of a technology or methodology specified by the Secretary in guidance”
(US Department of Health and Human Services, n.d.c). To meet the requirement of “secured”
PHI, it must have been encrypted using a valid encryption process, or the media on which the
PHI is stored have been destroyed. Paper or other hard copy media, such as film, must be
shredded or otherwise destroyed so that it cannot be read or reconstructed. Electronic media
must be “sanitized” according to accepted standards so that PHI cannot be retrieved (US
Department of Health and Human Services, n.d.c).
The notification requirements include, depending on the circumstances, notification to these
The Health and Human Services Secretary (via the Office for Civil Rights [OCR])
Major media outlets
All individuals affected by breaches of unsecured PHI must be notified within a reasonable
length of time—less than sixty days—after the breach is discovered. If the CE does not have
sufficient information to contact ten or more individuals directly, the notification must be made on
the home page of its website for at least ninety days or by a major media outlet. A CE that
experiences a breach involving five hundred or more individuals must, in addition to sending
individual notices, provide notice to a major media outlet serving the area. This notification must
also be made within sixty days. All breaches must also be reported to the secretary of HHS; the
breaches involving more than five hundred individuals must be reported within sixty days; all
others may be reported on an annual basis (US Department of Health and Human Services,
HIPAA Enforcement and Violation Penalties
The Department of Health and Human Services (HHS) Office for Civil Rights (OCR) is
responsible for enforcing HIPAA Privacy and Security rules. In addition, HITECH gave state
attorneys general the authority to bring civil actions on behalf of the residents of their states for
HIPAA violations. From April 2003 until May 2016, OCR has received over 134,000 HIPAA
complaints and has initiated 879 compliance reviews. The resolution of the complaints and
reviews is as follows (US Department of Health and Human Services, 2016):
Settled thirty-five cases resulting in $36,639,200 in penalties
Resolved 24,241 cases by requiring a change in privacy practices and corrective actions by, or
providing technical assistance to, CEs or business associates
Identified 11,018 cases as no violation and 79,865 cases as non-eligible
HIPAA criminal and civil penalties for noncompliance are applied using a tiered schedule that
ranges from $100 for a single violation, when the individual did not know he or she was not in
compliance, to $1,500,000 for multiple violations because of willful neglect. It is important to note
that civil penalties cannot be levied in situations when the violation is corrected within a specified
period of time.
The structure for HIPAA violations reflect four categories of violations and associated penalties.
Table 9.1 outlines the categories and penalties.
Table 9.1 HIPAA violation categories
Source: What are the penalties for HIPAA violations? (2015).
Violation Category Category Fine*
Category 1: A violation that the CE was unaware of, and could not have realistically avoided,
had a reasonable amount of care been taken to abide by HIPAA rules Minimum fine of $100
per violation up to $50,000
Category 2: A violation that the CE should have been aware of but could not have avoided even
with a reasonable amount of care (but falling short of willful neglect of HIPAA rules)
Minimum fine of $1,000 per violation up to $50,000
Category 3: A violation suffered as a direct result of “willful neglect” of HIPAA rules, in cases in
which an attempt has been made to correct the violation Minimum fine of $10,000 per
violation up to $50,000
Category 4: A violation of HIPAA rules constituting willful neglect, and no attempt has been
made to correct the violation Minimum fine of $50,000 per violation
*The fines are issued per violation category, per year that the violation was allowed to persist.
The maximum fine per violation category, per year, is $1,500,000.
In addition to these civil penalties, a HIPAA violation may result in criminal charges. The criminal
penalties are divided into the following three tiers (What are the penalties for HIPAA violations,
Tier 1: Reasonable cause or no knowledge of violation—Up to one year in jail
Tier 2: Obtaining PHI under false pretenses—Up to five years in jail
Tier 3: Obtaining PHI for personal gain or with malicious intent—Up to ten years in jail
As stated, most HIPAA violations are resolved with corrective action. In 2015 six financial
penalties were issued. However, a serious violation can cost a health care organization a
significant about of money. One such case resulting in a substantial financial settlement is
outlined in the Perspective. The top ten largest fines levied for HIPAA violations as of August
2016 are listed in Table 9.2.
Table 9.2 Top ten largest fines levied for HIPAA violations as of August 2016
Source: Bazzoli (2016).
Organization Individuals Affected Fine Awarded ($ million) Data Awarded
Advocate Health Care: Lacked appropriate safeguards, including an unencrypted laptop was left
in a vehicle overnight 4 million 5.55 August 2016
New York Presbyterian Hospital and Columbia University: PHI accessible on Google and other
search engines 6,800 4.8 May 2014
Cignet Health: Did not allow patients access to medical records and refused to cooperate with
OCR 41 4.3 February 2011
Feinstein Institute for Medical Research: Lacked appropriate safeguards leading to theft
Unknown 3.9 March 2016
Triple-S Management Corp (Blue Cross/Blue Shield licensee in Puerto Rico): Did not deactivate
user IDs and passwords, allowing previous employees to access PHI 398,000 3.5
University of Mississippi Medical Center: Did not manage risks appropriately, although aware of
risks and vulnerabilities 10,000 2.75 July 2016
Oregon Health & Science University: Lacked safeguards with regards to stolen laptop and used
cloud storage without a business associate agreement in place 7,000 2.7 July 2016
CVS Pharmacy: Improperly disposed of PHI such as prescription labels Unknown 2.25
New York Presbyterian Hospital: Allowed filming of two patients for a TV series creating the
potential for PHI to be compromise. (Note: Hospital continues to maintain it was not a violation.)
Unknown 2.2 April 2016
Concentra Health Services: Failed to remediate an identified lack of encryption after an
unencrypted laptop was stolen 870 1.73 April 2014
$750,000 HIPAA Settlement Underscores the Need for Organization-Wide Risk Analysis
The University of Washington Medicine (UWM) has agreed to settle charges that it potentially
violated the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Security Rule
by failing to implement policies and procedures to prevent, detect, contain, and correct security
violations. UWM is an affiliated covered entity, which includes designated health care
components and other entities under the control of the University of Washington, including
University of Washington Medical Center, the primary teaching hospital of the University of
Washington School of Medicine. Affiliated covered entities must have in place appropriate
policies and processes to assure HIPAA compliance with respect to each of the entities that are
part of the affiliated group. The settlement includes a monetary payment of $750,000, a
corrective action plan, and annual reports on the organization’s compliance efforts.
The US Department of Health and Human Services Office for Civil Rights (OCR) initiated its
investigation of the UWM following receipt of a breach report on November 27, 2013, which
indicated that the electronic protected health information (e-PHI) of approximately 90,000
individuals was accessed after an employee downloaded an email attachment that contained
malicious malware. The malware compromised the organization’s IT system, affecting the data
of two different groups of patients: (1) approximately 76,000 patients involving a combination of
patient names, medical record numbers, dates of service, and/or charges or bill balances; and
(2) approximately 15,000 patients involving names, medical record numbers, other
demographics such as address and phone number, dates of birth, charges or bill balances,
Social Security numbers, insurance identification or Medicare numbers.
OCR’s investigation indicated UWM’s security policies required its affiliated entities to have
up-to-date, documented system-level risk assessments and to implement safeguards in
compliance with the Security Rule. However, UWM did not ensure that all of its affiliated entities
were properly conducting risk assessments and appropriately responding to the potential risks
and vulnerabilities in their respective environments.
Source: HHS.gov (2015). Used with permission.
Threats to Health Care Information
What are the threats to health care information systems? In general, threats to health care
information systems fall into one of these three categories:
Human tampering threats
Natural and environmental threats, such as floods and fire
Environmental factors and technology malfunctions, such as a drive that fails and has no
backup or a power outage
Threats to health care information systems from human beings can be intentional or
unintentional. They can be internal, caused by employees, or external, caused by individuals
outside the organization.
Intentional threats include knowingly disclosing patient information without authorization, theft,
intentional alteration of data, and intentional destruction of data. The culprit could be a computer
hacker, a disgruntled employee, or a prankster. Cybercrime directed at health information
systems has increased significantly in recent years. In the 2014–2015 two-year period, more
than 90 percent of health care organizations reported a health information security breach, and
of these reports, nearly half were because of criminal activity (Koch, 2016). Intentional
destruction or disruption of health care information is generally caused by some form of
malware, a general term for software that is written to “infect” and subsequently harm a host
computer system. The best-known form of malware is the computer virus, but there are others,
including the particularly virulent ransomware, attacks from which are on the rise in health care.
The following list includes common forms of malware with a brief description of each (Comodo,
Viruses are generally spread when software is shared among computers. It is a “contagious”
piece of software code that infects the host system and spreads itself.
Trojans (or Trojan Horses) are a type of virus specifically designed to look like a safe program.
They can be programmed to steal personal information or to take over the resources of the host
computer making it unavailable for its intended use.
Spyware tracks Internet activities assisting the hacker in gathering information without consent.
Spyware is generally hidden and can be difficult to detect.
Worms are software code that replicates itself and destroys files that are on the host computer,
including the operating system.
Ransomware is an advanced form of malware that hackers use to cripple the organization’s
computer systems through malicious code, generally launched via an e-mail that is opened
unwittingly by an employee, a method known as phishing. The malicious code then encrypts
and locks folders and operating systems. The hacker demands money, generally in the form of
bitcoins, a type of digital currency, to provide the decryption key to unlock the organization’s
systems (Conn, 2016).
Some of the causes of unintentional health information breaches are lack of training in proper
use of the health information system or human error. Users may unintentionally share patient
information without proper authorization. Other examples include users sharing passwords or
downloading information from nonsecure Internet sites, creating the potential for a breach in
security. Some of the more common forms of internal breaches of security across all industries
are the installation or use of unauthorized software, use of the organization’s computing
resources for illegal or illicit communications or activities (porn surfing, e-mail harassment, and
so forth), and the use of the organization’s computing resources for personal profit. Losing or
improperly disposing of electronic devices, including computers and portable electronic devices,
also constitute serious forms of unintentional health information exposure. In 2015, the OCR
portal, which lists breach incidents potentially affecting five hundred or more individuals, reported
more than seventy-five thousand individuals’ data were breached either because of loss or
improper disposal of a device containing PHI (OCR, n.d.).
Threats from natural causes, such as fire or flood, are less common than human threats, but
they must also be addressed in any comprehensive health care information security program.
Loss of information because of environmental factors and technical malfunctions must be
secured against by using appropriate safeguards.
The Health Care Organization’s Security Program
The realization of any of the threats discussed in the previous section can cause significant
damage to the organization. Resorting to manual operations if the computers are down for days,
for example, can lead to organizational chaos. Theft or loss of organizational data can lead to
litigation by the individuals harmed by the disclosure of the data and HIPAA violations. Malware
can corrupt databases, corruption from which there may be no recovery. The function of the
health care organization’s security program is to identify potential threats and implement
processes to remove these threats or mitigate their ability to cause damage. The primary
challenge of developing an effective security program in a health care organization is balancing
the need for security with the cost of security. An organization does not know how to calculate
the likelihood that a hacker will cause serious damage or a backhoe will cut through network
cables under the street. The organization may not fully understand the consequences of being
without its network for four hours or four days. Hence, it may not be sure how much to spend to
remove or reduce the risk.
Another challenge is maintaining a satisfactory balance between health care information system
security and health care data and information availability. As we saw in Chapter Two, the major
purpose of maintaining health information and health records is to facilitate high-quality care for
patients. On the one hand, if an organization’s security measures are so stringent that they
prevent appropriate access to the health information needed to care for patients, this important
purpose is undermined. On the other hand, if the organization allows unrestricted access to all
patient-identifiable information to all its employees, the patients’ rights to privacy and
confidentiality would certainly be violated and the organization’s IT assets would be at
The ONC (2015) publication Guide to Privacy and Security of Electronic Health Information for
health care providers includes a chapter describing a seven-step approach for implementing a
security management process. The guidance is directed at physician practices or other small
health care organizations, and it does not include specific technical solutions. Specific solutions
for security protection will be driven by the organization’s overall plan and will be managed by
the organizations IT team. Larger organizations must also develop comprehensive security
programs and will follow the same basic steps, but it will likely have more internal resources for
security than smaller practices.
Each step in the ONC security management process for health care providers is listed in the
Step 1: Lead Your Culture, Select Your Team, and Learn
This step includes six actions:
Designate a security officer, who will be responsible for developing and implementing the
security practices to meet HIPAA requirements and ensure the security of PHI.
Discuss HIPAA security requirements with your EHR developer to ensure that your system can
be implemented to meet the security requirements of HIPAA and Meaningful Use.
Consider using a qualified professional to assist with your security risk analysis. The security
risk analysis is the opportunity to discover as much as possible about risks and vulnerabilities to
health information within the organization.
Use tools to preview your security risk analysis. Examples of available tools are listed within
Refresh your knowledge base of the HIPAA rules.
Promote a culture of protecting patient privacy and securing patient information. Make sure to
communicate that all members of the organization are responsible for protecting patient
Step 2: Document Your Process, Findings, and Actions
Documenting the processes for risk analysis and implementation of safeguards is very
important, not to mention a requirement of HIPAA. The following are some examples cited by
the ONC of records to retain:
Policies and procedures
Completed security checklists (ESET, n.d.)
Training materials presented to staff members and volunteers and any associated certificates of
Updated business associate (BA) agreements
Security risk analysis report
EHR audit logs that show utilization of security features and efforts to monitor users’ actions
Risk management action plan or other documentation that shows appropriate safeguards are in
place throughout your organization, implementation timetables, and implementation notes
Security incident and breach information
Step 3: Review Existing Security of ePHI (Perform Security Risk Analysis)
Risk analysis assesses potential threats and vulnerabilities to the “confidentiality, integrity and
availability” (ONC, 2015, p. 41) of PHI. Several excellent government-sponsored guides and
toolsets available for conducting a comprehensive risk analysis are listed in Table 9.3 with a
corresponding web address.
Table 9.3 Resources for conducting a comprehensive risk analysis
OCR’s Guidance on Risk Analysis Requirements under the HIPAA Rule
OCR Security Rule Frequently Asked Questions (FAQs)
ONC SRA (Security Risk Assessment) Tool for small practices
National Institute of Standards and Technology (NIST) HIPAA Security Rule Toolkit
The three basic actions recommended for the organization’s first comprehensive security risk
analysis are as follows:
Identify where ePHI exists.
Identify potential threats and vulnerabilities to ePHI.
Identify risks and their associated levels.
Step 4: Develop an Action Plan
As discussed, the HIPAA Security Plan provides flexibility in how to achieve compliance, which
allows an organization to take into account its specific needs. The action plan should include five
components. Once in place, the plan should be reviewed regularly by the security team, led by
the security officer.
Policies and procedures
Table 9.4 lists common examples of vulnerabilities and mitigation strategies that could be
Table 7.4 Common examples of vulnerabilities and mitigation strategies
Security Component Examples of Vulnerabilities Examples of Security Mitigation Strategies
Administrative safeguards No security officer is designated.
Workforce is not trained or is unaware of privacy and security issues. Security officer is
designated and publicized.
Workforce training begins at hire and is conducted on a regular and frequent basis.
Security risk analysis is performed periodically and when a change occurs in the practice or the
Physical safeguards Facility has insufficient locks and other barriers to patient data access.
Computer equipment is easily accessible by the public.
Portable devices are not tracked or not locked up when not in use. Building alarm systems are
Offices are locked.
Screens are shielded from secondary viewers.
Technical safeguards Poor controls enable inappropriate access to EHR.
Audit logs are not used enough to monitor users and other HER activities.
No measures are in place to keep electronic patient data from improper changes.
No contingency plan exists.
Electronic exchanges of patient information are not encrypted or otherwise secured. Secure
user IDs, passwords, and appropriate role-based access are used.
Routine audits of access and changes to EHR are conducted.
Anti-hacking and anti-malware software is installed.
Contingency plans and data backup plans are in place.
Data are encrypted.
Organizational standards No breach notification and associated policies exist.
BA agreements have not been updated in several years. Regular reviews of agreements are
conducted and updates made accordingly.
Policies and procedures Generic written policies and procedures to ensure HIPAA security
compliance were purchased but not followed.
The manager performs ad hoc security measures. Written policies and procedures are
implemented and staff members are trained.
Security team conducts monthly review of user activities.
Routine updates are made to document security measures.
Step 5: Manage and Mitigate Risks
The security plan will reduce risk only if it is followed by all employees in the organization. This
step has four actions associated with it.
Implement your plan.
Prevent breaches by educating and training your workforce.
Communicate with patients.
Update your BA contracts.
Step 6: Attest for Meaningful Use Security Related Objective
Organizations can attest to the EHR Incentive Program security-related objective after the
security risk analysis and correction of any identified deficiencies.
Step 7: Monitor, Audit, and Update Security on an Ongoing Basis
The security officer, IT administrator, and EHR developer should work together to ensure that
the organization’s monitoring and auditing functions are active and configured appropriately.
Auditing and monitoring are necessary to determine the adequacy and effectiveness of the
security plan and infrastructure, as well as the “who, what, when, where and how” (ONC, 2015,
p. 54) patients’ ePHI is accessed.
Beyond HIPAA: Cybersecurity for Today’s Wired Environment
Clearly, HIPAA is an important legislative act aimed at protecting health data and information.
However, in today’s increasingly wired environment, health care organizations face threats that
were not present when HIPAA was enacted. In June 2016, 41 percent of all data breaches were
because of cybercrime—hacking. In July of the same year a single hacker was responsible for
30 percent of the health care data breached (Sullivan, 2016). Experts argue that health care
organizations are easy targets for cybercriminals because they are inadequately prepared. The
average health care provider spends less than 6 percent of its total IT budget on security,
compared to the government, which spends 16 percent, and the banking industry, which spends
between 12 and 15 percent. By one estimate the increase in cybercrime against health care
organizations is because of, at least in part, PHI’s value on the black market, estimating that
PHI is fifty times more valuable than financial information (Koch, 2016; Siwicki, 2016).
The reality of today’s environment is that there are more entry points into health care information
networks and computers than ever before. Mobile devices, cloud use, the use of smart
consumer products, health care devices with Internet connectivity, along with more employees
connecting to health care networks from remote locations create an increased need for
cybersecurity in health care organizations. One recent survey found that among medical
students and physicians 93.7 percent owned smartphones and 82.9 percent had used them in a
clinical setting. Perhaps the most surprising aspect of the survey was that none of respondents
believed using the devices increased risk of breaching patient information (Buchholz, Perry,
Weiss, & Cooley, 2016).
So-called mHealth technologies, which include entities that support personal health records and
cloud-based or mobile applications that collect patient information directly from patients or allow
uploading of health-related data from wearable devices, are also on the rise, as is the use of
health-related social media sites. These technologies were not addressed in HIPAA and,
therefore, do not meet the criteria as a CE (DeSalvo & Samuels, 2016).
To provide assistance to health care organizations to combat cyber attacks and improve
cybersecurity, the ONC (n.d.) published the Top 10 Tips for Cybersecurity in Health Care. The
first tip reminds health care organizations to establish a security culture, the same initial tip in
their guidance for developing a security plan, clearly emphasizing the importance of this aspect
of any security program. The other tips in the publication contain some more specific ways to
mitigate the threat from cyber attacks. These tips are listedwith specific checkpoints to ensure
security (ONC, n.d.). The full version of the top-ten document is available at HealthIT.gov.
Protect Mobile Devices
Ensure your mobile devices are equipped with strong authentication and access controls.
Ensure laptops have password protection.
Enable password protection on handheld devices (if available). Take extra physical control
precautions over the device if password protection is not provided.
Protect wireless transmissions from intrusion.
Do not transmit unencrypted PHI across public networks (e.g., Internet, Wi-Fi).
When it is absolutely necessary to commit PHI to a mobile device or remove a device from a
secure area, encrypt the data.
Do not use mobile devices that cannot support encryption.
Develop and enforce policies specifying the circumstances under which devices may be
removed from the facility.
Take extra care to prevent unauthorized viewing of the PHI displayed on a mobile device.
Maintain Good Computer Habits
Uninstall any software application that is not essential to running the practice (e.g., games,
instant message clients, photo-sharing tools).
Do not simply accept defaults or “standard” configurations when installing software.
Find out whether the EHR developer maintains an open connection to the installed software (a
“back door”) in order to provide updates and support.
Disable remote file sharing and remote printing within the operating system (e.g., Windows
Automate software updates to occur weekly (e.g., use Microsoft Windows Automatic Update).
Monitor for critical and urgent patches and updates that require immediate attention and act on
them as soon as possible.
Disable user accounts for former employees quickly and appropriately.
If an employee is to be involuntarily terminated, close access to the account before the notice of
termination is served.
Prior to disposal, sanitize computers and any other devices that have had data stored on them.
Archive old data files for storage if needed or clean them off the system if not needed, subject to
applicable data retention requirements.
Fully uninstall software that is no longer needed (including trial software and old versions of
Work with your IT team or other resources to perform malware, vulnerability, configuration, and
other security audits on a regular basis.
Use a Firewall
Unless your electronic health record (EHR) and other systems are totally disconnected from the
Internet, you must install a firewall to protect against intrusions and threats from outside
Larger health care organizations that use a local area network (LAN) should consider a
Install and Maintain Antivirus Software
Use an antivirus product that provides continuously updated protection against viruses,
malware, and other code that can attack your computers through web downloads, CDs, e-mail,
and flash drives.
Keep antivirus software up-to-date.
Most antivirus software automatically generates reminders about these updates, and many are
configurable to allow for automated updating.
Plan for the Unexpected
Create data backups regularly and reliably.
Begin backing up data from day one of a new system.
Ensure the data are being captured correctly.
Ensure the data can be quickly and accurately restored.
Use an automated backup system, if possible.
Consider storing the backup far away from the main system.
Protect backup media with the same type of access controls described in the next section.
Test backup media regularly for their ability to restore data properly, especially as the backups
Have a sound recovery plan. Know the following:
What data was backed up (e.g., databases, pdfs, tiffs, docs)
When the backups were done (time frame and frequency)
Where the backups are stored
What types of equipment are needed to restore them
Keep the recovery plan securely at a remote location where someone has responsibility for
producing it in the event of an emergency.
Control Access to PHI
Configure your EHR system to grant PHI access only to people with a “need to know.”
This access control system might be part of an operating system (e.g., Windows), built into a
particular application (e.g., an e-prescribing module), or both.
Manually set file access permissions using an access control list.
This can only be done by someone with authorized rights to the system.
Prior to setting these permissions, identify which files should be accessible to which staff
Configure role-based access control as needed.
In role-based access, a staff member’s role within the organization (e.g., physician, nurse,
billing specialist, etc.) determines what information may be accessed.
Assign staff members to the correct roles and then set the access permissions for each role
correctly on a need-to-know basis.
The following case on access control provides additional examples of access control.
Mary Smith is the director of the health information management department in a hospital. Under
a user-based access control scheme, Mary would be allowed read-only access to the hospital’s
laboratory information system because of her personal identity—that is, because she is Mary
Smith and uses the proper log-in and password(s) to get into the system. Under a role-based
control scheme, Mary would be allowed read-only access to the hospital’s lab system because
she is part of the health information management department and all department employees
have been granted read-only privileges for this system. If the hospital were to adopt a
context-based control scheme, Mary might be allowed access to the lab system only from her
own workstation or another workstation in the health information services department, provided
she used her proper log-in and password. If she attempted to log in from the emergency
department or another administrative office, she might be denied access. The context control
could also involve time of day. Because Mary is a daytime employee, she might be denied
access if she attempted to log in at night.
Use Strong Passwords
Choose a password that is not easily guessed. Following are some examples of strong
At least eight characters in length (the longer the better)
A combination of uppercase and lowercase letters, one number, and at least one special
character, such as a punctuation mark
Strong passwords should not include personal information:
Names of self, family members, or pets
Social Security number
Anything that is on your social networking sites or could otherwise be discovered easily by
Use multifactor authentication for more security. Multifactor authentication combines multiple
authentication methods, such as a password plus a fingerprint scan; this results in stronger
security protections. If you e-prescribe controlled substances, you must use multifactor
authentication for your accounts.
Configure your systems so that passwords must be changed on a regular basis.
To discourage staff members from writing down their passwords, develop a password reset
process to provide quick assistance in case of forgotten passwords.
Limit Network Access
Prohibit staff members from installing software without prior approval.
When a wireless router is used, set it up to operate only in encrypted mode.
Prohibit casual network access by visitors.
Check to make sure file sharing, instant messaging, and other peer-to-peer applications have
not been installed without explicit review and approval.
Control Physical Access
Limit the chances that devices (e.g., laptops, handhelds, desktops, servers, thumb drives, CDs,
backup tapes) may be tampered with, lost, or stolen.
Document and enforce policies limiting physical access to devices and information:
Keep machines in locked rooms.
Manage keys to facilities.
Restrict removal of devices from a secure area.
National Institute of Standards and Technology (NIST) Cybersecurity Framework
Recognizing the severity of the rise in cybercrime, President Obama issued an executive order
in February 2013 to “enhance the security and resilience of the Nation’s critical infrastructure”
(Executive Order 13636). As a result the National Institute of Standards and Technology (NIST)
was directed to develop, with help of stakeholder organizations, a voluntary cybersecurity
framework to reduce cyber-attack risks. The resulting NIST cybersecurity framework consists
of three components (NIST, n.d.):
The Framework Core consists of “five concurrent and continuous Functions—Identify, Protect,
Detect, Respond, Recover.” The functions provide “the highest level, strategic view of an
organization’s management of cybersecurity risk” (NIST, n.d., p. 4). The functions are divided
into categories and subcategories as shown in Exhibit 9.2.
The Framework Implementation Tiers characterize an organization’s actual cybersecurity
practices compared to the framework, using a range of tiers from partial (Tier 1) to adaptive (Tier
The Framework Profile documents outcomes obtained by reviewing all of the categories and
subcategories and comparing them to the organization’s business needs. Profiles can be
identified as “current,” documenting where the organization is now, or as “target,” where the
organization would like to be in the future.
Since its initial publication in 2014, the HHS, OCR, and the ONC have cited the framework as
an important tool for health care organizations to consider when developing a comprehensive
security program. In 2016, OCR published a crosswalk that maps the HIPAA Security Rule to
the NIST framework, which can be found at HHS.gov/hipaa (US Department of Health and
Human Services, n.d.a).
In this chapter we gained insight into why health information privacy and security are key topics
for health care administrators. In today’s ever-increasing electronic world with new and more
virulent threats, the security of health information is an ongoing concern. In this chapter we
examined and defined the concepts of privacy, confidentiality, and security and explored major
legislative efforts, historical and current, to protect health care information, with a focus on the
HIPAA Privacy, Security, and Breach Notification rules. Different types of threats, human,
natural and environmental, intentional and unintentional, were identified, with a focus on the
increase in cybercrime. Basic requirements for a strong health care organization security
program were outlined and the chapter ended with a discussion of the cybersecurity challenges
within the current health care environment.
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