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AMC/HIPAA Workgroup
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Purpose
These Guidelines provide a tool for developing policies, procedures, and best practices to assist
AMCs in efficiently and economically addressing the HIPAA security and privacy regulations.
They reference specific HIPAA regulations, provide interpretation, and make recommendations
for implementation and maintenance within healthcare organizations.
Scope
The intent of the workshop series was to provide guidance, within the context of the HIPAA
regulations, in the development of security and privacy policies and procedures that support all
activities of complex academic medical center environments. Depending on organizational
structure, this may include healthcare, research, teaching, learning, administration, and
associated interactions with external entities.
The results of these workshops will assist like-minded organizations in developing more efficient
and inclusive ways of implementing health care security and privacy arrangements. It is
intended that these guidelines be considered for adoption by relevant bodies beyond the covered
entities themselves. WEDI, as part of their role in advising HHS in matters related to HIPAA,
participated in the workshops and will take the final publication into consideration. The
combined talent and experience of the workshop participants have permitted the development of
a concise set of guidelines consistent with these purposes.
The intent of the workshop series was to provide guidance, within the context of the HIPAA
regulations, in the development of security and privacy policies and procedures that support all
activities of complex AMC environments. Depending on organizational structure, this may
include healthcare, research, teaching, learning, administration, and associated interactions with
external entities.
The results of these workshops will assist like-minded organizations in developing more efficient
and inclusive ways of implementing health care security and privacy arrangements. The
combined talent and experience of the workshop participants has permitted the development of a
concise set of guidelines to assist with HIPAA security and privacy regulations.
These guidelines recommend health information security and privacy mechanisms and strategies
for operational implementation of the HIPAA requirements. The recommended strategies are
intended to facilitate cultural change by building upon existing best practice, and are based upon
our common understanding of teaching hospital and medical school processes. This
collaborative effort also identifies implementation barriers that must be overcome, in addition to
benefits or incentives that may be leveraged to deploy adequate resources within teaching
hospitals and medical schools.
This document
does not
provide legal advice. Covered entities must work with their own legal
counsels to address appropriate institutional requirements. This document can provide
information to legal staff tasked with understanding the implications of the HIPAA regulation on
their organization. It may also serve as an aid to understanding the necessary legal actions
needed to address accreditation requirements, as well as federal and state legislation, as HIPAA
has an impact on many aspects of the organization.

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In addition, this document may be of value to other segments of the healthcare industry,
particularly consultants, payor organizations, general practitioners, group practices, suppliers,
financial organizations, and other organizations that regularly interact with teaching hospitals
and medical schools. Understanding the implications of the HIPAA regulations on AMCs will
be important to many aspects of the healthcare industry.
Background
Guidelines for Academic Medical Centers on Security and Privacy
was developed through a
series of monthly workshops involving the collaborative effort of several major academic and
healthcare related organizations. Several leading teaching hospitals and medical schools had
already developed individual security and privacy policies, as well as strategies to address the
impending HIPAA regulations. No process existed, however, to facilitate the benchmarking of
good practices, policies, and procedures among institutions. Academic Medical Centers needed
to join together and identify consistencies for reasonable HIPAA compliance. Teaching
hospitals and medical schools indicated their willingness and commitment to participate in this
process by submitting a Request for Information (RFI) that was developed by the steering
committee for this activity.
Information was gathered on current security and privacy practices via responses to the RFI.
This information, in addition to the HIPAA regulation, served as the basis for the initial draft.
Finally, individuals with substantial expertise were identified and asked to contribute to the
effort.
In addition to the teaching hospitals and medical schools, a number of industry organizations
joined the group. A series of workshops was identified as the best mechanism to create model
information practices and security guidelines, with a final document (this document) to
communicate the group's recommendations.
The workshops were held from Fall 2000 to Spring 2001. On December 20, 2000, the
Department of Health and Human Services Privacy Regulations were released. When the group
first met and planned its workshops, it was impossible to determine when the draft privacy
regulation would be made final, and how the final regulation might differ from the draft. Shortly
before the fourth workshop, the final privacy regulation was issued. The group opted to hold an
additional session to address any modifications to the guidelines as a result of the final privacy
regulation.
Acknowledgements
This guideline document is the result of many individuals, those who participated in the
workshops and others who helped to facilitate the process to make this document possible. A
group with diverse expertise in security and privacy found their way through a consensus based
process to produce these guidelines. Each participant in the workshops is commended for their
tireless devotion of time and enthusiasm.

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Special thanks are due to the organizations that hosted the workshops: Kaiser-Permanente, Duke
University, Texas A&M University, the National Library of Medicine, and the University of
Michigan. To all the individuals who coordinated the workshop logistics at each of the host
organizations, the participants in the workshops extend a thank you for creating extremely
productive working environments for this activity.
Thanks to the numerous individuals at each of the participating organizations who helped to
provide participants with input and content and kept the workshop participants on track, helping
its members to put their ideas and analyses into coherent prose. The workgroup is further
indebted to early reviewers of the draft guideline document. Thoughtful comments and
criticisms challenged members to strengthen and refine the guidelines.
Mike Ackerman, assistant director of the High Performance Computing Center at the NLM,
understood the need for this group to assemble. His support, dedication, and understanding
made this report a reality. Thanks to Morgan Passiment and the AAMC staff who provided
much time and attention to facilitating the production of the guidelines. Thanks also to Jim
Schuping at WEDI for help in getting the first set of interested parties together.
The guideline document is a much more readable document due to the efforts of Joseph Saul of
Communications Technology Consultancy, a security and privacy policy expert, who edited the
final version. Special thanks are due to Mike Davis for editorial leadership that kept everyone
organized and ensured that all input was incorporated into the final guidelines. Thanks are also
due to Bob Blakely, OMG, for his dedication to improving security and privacy practices. Bob's
enthusiasm, quick wit, and expert technical facilitation kept things on track, allowing discussions
to unfold when appropriate, and shutting us down when we needed to stop. Finally, Mary Kratz
and the Internet2 staff deserve praise for the great resources that they brought to this project.
The workgroup hopes that this guideline document will assist others in the healthcare industry
struggling with practical strategies for dealing with security and privacy issues and HIPAA
compliance.
Workshop Participants (alphabetical order by organization)
Duke University Health System
Dave Kirby*
Director of the Information Security Office
919-272-1157
Kirby001@mc.duke.edu
Duke University Health System
Lawrence H. Muhlbaier
Assistant Research Professor
Lawrence.muhlbaier@duke.edu
Emory University
Ron Palmich
404-727-4350
ron_palmich@emory.org
Johns Hopkins Medical Institutions
Bob Miller*
Department of Pathology
410-955-5429
rmiller@jhmi.edu
Johns Hopkins Medical
Bill Rider*
brider@jhmi.edu
Kaiser Permanente
Ted Cooper*
510-267-5659
ted.cooper@kp.org
Mayo Clinic
Lee Olson*
Information Security Officer
507-284-0594
olson.lee@mayo.edu
Oregon Health Sciences University
Jere Retzer*
Portland Research and Education Network
Chair
Internet2 Health Sciences Security Lead
503-494-3720
retzerj@ohsu.edu
Osaka Medical College
Ryuichi Yamamoto
Associate Professor Division of Medical
Informatics
+81-726-83-1221(x2265/2888)
yamamoto@art.osaka-med.ac.jp

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Texas A&M University System Health Science
Center
Larry Flournoy
Interim Chief Information Officer
713-677-7434
flournoy@isc.tamu.edu
Texas A&M University
Michael W. Buckley
Director, Compliance and Administration
Office of the Vice President of Research
979-845-8585
mwbuckley@tamu.edu
Tufts School of Medicine
Davis Damassa
617-636-6603
david.damassa@tufts.edu
University of Alabama at Birmingham
Mike Waldrum*
mwaldrum@uabmc.edu
University of Arizona Medical Center
Patti Redding
HIPAA Compliance and Information
Security
520-694-4760
predding@umcaz.edu
University of Michigan Health System
Leslie H. Kamil
Deputy Compliance Officer and Privacy
Officer
734-615-4400
lkamil@med.umich.edu
University of Pennsylvania
Mary Alice Annecharico
Executive Director, Information Services
215-898-9755
mannecha@mail.upenn.edu
University of Tennessee Health Science
Center
Jack Buchanan
Acting Director, School of Biomedical
Engineering
Internet2 Medical Middleware Lead
Jbuchanan@utmem.edu
North Carolina Healthcare Information and
Communications Alliance, Inc.
W. Holt Anderson
Executive Director
919-558-9258
holt@nchica.org
UT Southwestern Medical Center
Valerie D. Meyer
Information Resources
214-648-1718
Valerie.meyer@utsouthwestern.edu
Veterans Health Administration
Mike Davis (SAIC)*
VHA Security Architect
mikedatsd@home.com
Yale University School of Medicine
Stephen Rimar, MD
Medical Director, Yale Medical Group
stephen.rimar@yale.edu
Sponsoring Organizations
Association of American Medical Colleges
Morgan Passiment*
Staff Associate
202-828-0476
mpassiment@aamc.org
The AAMC (Association of American Medical Colleges) Group on
Information Resources has identified a need for collaboration in policy
development among Academic medical centers and agreed to
participate in the development of this policy framework as a key
component of its program to support the HIPAA implementation
activities of its members.
Internet 2
Mary Kratz*
Health Science Initiatives
734-352-7004
mkratz@internet2@edu
These guidelines serve as a basis for Internet2 Medical Middleware
requirements, ultimately folding into the larger fabric of advanced
services in the emerging common campus middleware infrastructure.
National Library of Medicine
Michael J. Ackerman, PhD*
Assistant Director
301-402-4100
ackerman@nlm.nih.gov
National Library of Medicine
Carol Haberman*
301-435-3267
carol_b_haberman@nih.gov
The National Library of Medicine (NLM)
views its support for this
workshop as part of its mission with the teaching hospital and medical
school community.
<www.nlm.nih.gov>
Object Management Group
Bob Blakley*
Chief Scientist for Security, Tivoli Systems Incorporated
512-458-4037
blakley@tivoli.com
The OMG's charter includes the establishment of industry guidelines
and specifications to provide a common framework for application
development that supports a heterogeneous computing environment
across all major hardware platforms and operating systems.
Supporting Organizations
CPRI-HOST
Pat Wise*
Executive Director
pat@digitalwise.com
North Carolina Healthcare Information and Communications
Association (NCHICA)
Holt Anderson

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919-558-9258
holt@nchica.org
Health Care Financing Administration
Barbara Clark
410-786-9937
bclark@hcfa.gov
Healthcare Computing Strategies, Inc.
John Parmigiani
Practice Director, Compliance Programs
410-750-2060
jcparmigiani@hcs-is.com
Southeastern University Research Association (SURA)
Sue Fratkin*
202-408-7872
sue@sura.org
Workgroup on Electronic Data Interchange (WEDI)
Jim Schuping*
Executive Vice President
703-391-2716
schups@aol.com
* Denotes members of the Steering Committee
Updates and Errata
For updates and errata, check the www.amc-hipaa.org website.
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tableofcontents.htm   start.htm   securitysectiontwo.htm   securitysectionthree.htm   securitysectionone.htm   securitycategories.htm   references.htm   privacysectiontwo.htm   privacysectionthree.htm   privacysectionone.htm   privacysectionfour.htm   privacysectionfive.htm   privacycategories.htm   jobdescriptions.htm   introduction.htm   index.htm   hipaatrifold.htm   hipaasuppliment.htm   hipaaresources.htm   hipaaexecsummary.htm   guidelinesorganization.htm   generalpolicyguidelines.htm   generalcategories.htm   definitions.htm   contractsandpolicies.htm   contact.htm   amchipaasecurityandprivacyguidelines.htm   acronyms.htm   acknowledgements.htm