Guard Glossary

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Activate
To provide access to The Guard for someone who had not had it previously. For Administrator use only.

Administrator
An individual who has increased access to The Guard in order to complete their compliance work. They will be able to access all aspects of The Guard, as opposed to a regular User who will only access the Main Screen.

Alerts
Relates to the dropdown beneath 'Administration' labeled 'Alerts.' Within this section you may review alerts in regards to pertinent reminders about your compliance work. The sections break down as follows; 'Compliance Alerts,' 'Remediation Alerts,' 'Incident Alerts,' 'Document Alerts,' 'Training Alerts,' 'Document Clarification Requests,' and 'Password Requests.' Please review each specifics term for further clarification.

Approved/Rejected By
Relates to the dropdown beneath Reporting labeled Remediation Summary. This filter is found within the field marked 'Order Report By.' It will show you who Approved or Rejected any given Remediation Plan.

Assigned To
Relates to the dropdown found beneath 'Reporting' labeled 'Remediation Summary.' This filter is found within the field marked 'Order Report By.' It will show you who was working on any given Remediation Plan, IE, who it was 'Assigned To.'

Attest/Attestation
Affirm in an official fashion. In regards to HIPAA Policy and Procedure(s) this means one has agreed to the terms set before them in writing and understands them.

Audit
An official examination and verification of accounts and records.

Audit Options
Relates to the dropdown found beneath 'Reporting' labeled 'Questionnaire Results.' This filter allows you to choose which of your previously completed self-audits you wish to review; Security Audit, Privacy Audit, or HITECH Act Audit.

Authorization Summary
Relates to the dropdown found beneath 'Reporting,' then 'Authorization Summary.' The filters you may add from this feature include, 'Status Options,' 'Requested By,' 'Revoked, or 'Order Report By.' Please review these specific terms for further explanation.

Business Associate (B.A.)
Anyone who you pay money to and their job specifically entails working with your patients' PHI would be considered a Business Associate. Examples of Business Associates include establishments such as a Clearinghouse, a Billing Service, a Collection Agency, 3rd Party Storage Companies, IT Servicers, EHR Platforms, Consultants, or Shredding Companies.

Business Associate Agreement (B.A.A.)
A written agreement between a Covered Entity and a Business Associate which states that both sides will do all they can to maintain safety of PHI and minimal information to complete job will be disseminated to the Business Associate. As per the Omnibus Rule, enacted in 2013 - The Business Associate agrees to also be HIPAA Compliant and the Covered Entity assumes risk if the Business Associate has a breach.

C.S./C.A. - Confidentiality Statement/Agreement
Any Vendor who is in your Employ but is not paid to directly deal with PHI should sign a Confidentiality Agreement. By signing one this Vendor is stating that they will not disseminate anything heard, seen, or touched which may contain PHI they were exposed to by chance. Also, each member of your direct Staff should sign a Confidentiality Agreement.

Completed/Open
Relates to the dropdown found beneath 'Reporting' labeled 'Remediation Summary.' This filter is found within the field marked 'Order Report By.' It will show you which of your Remediation Plans are Completed and which ones are still Open.

Compliance Alerts
Relates to the dropdown found beneath 'Administration' labeled 'Alerts.' Beneath 'Compliance Alerts' you will find your Organization's gaps (deficiencies) which are yet to be associated with a remediation plan.

Cost
Relates to the dropdown found beneath 'Reporting' labeled 'Remediation Summary.' This filter is found within the field marked 'Order Report By.' It will allow you to prioritize your search so that this option shows atop the report generated.

Covered Entity
Covered Entities Include - Doctors, Clinics, Psychologists, Dentists, Chiropractors, Nursing Homes and Pharmacies are all Covered Entities but only if they transmit any information in an electronic form in connection with a transaction for which HHS has adopted a standard.

 

Health Plans are also Covered Entities and include; Insurance Companies, HMOs, Company Health Plans, and Government Programs that pay for health care, such as Medicare, Medicaid and the Military/Veterans health care programs Also, a Health Care Clearinghouse would be considered a Covered Entity and includes establishments that process nonstandard health information they receive from another entity into a standard (i.e., standard electronic format or data content), or vice versa.

Date Started
Relates to the dropdown found beneath 'Reporting' labeled 'Remediation Summary.' This filter is found within the field marked 'Order Report By.' It will allow you to prioritize your search so this option shows atop the report generated.

Disclosure Summary
Relates to the dropdown found beneath 'Reporting,' then 'Disclosure Summary.' Within this feature you may filter your search by, ''Requested By,' and 'Order Report By.' Please review these specific terms for a more specific explanation.

Display Audit Notes
Relates to the dropdown found beneath 'Reporting' labeled 'Questionnaire Results.' With this check box you may filter your search to either contain or not contain the 'Auditor Notes' which you had inserted initially for any answers of 'Yes' filled in on your self-audits.

Doc(ument) Clarification Requests
Relates to the dropdown found beneath 'Administration' labeled 'Alerts.' Beneath 'Doc(ument) Clarification Requests' you will find who in your Organization's staff has requested explanation of a policy or procedure.

Document Alerts
Relates to the dropdown found beneath 'Administration' labeled 'Alerts.' Beneath 'Document Alerts' you will find your Organization's documents which have passed their review dates.

Document Repository
A storage engine for documents within The Guard.

Electronic Health Record (E.H.R.)
An electronic version of a patients medical history.

Employee Policy/Procedure Crosswalk
Allows an Administrator within The Guard to generate a report in regards to their Employee's attestations. From here, an Administrator can easily run a scan to see who amongst their Staff has read but not understood any given policy, who has not read any given policy, and who has wholly read/understood the policy. An Administrator may also choose 'All Types' to review all Staff members' Attestations.

Finalize
When completing the Self-Audits after your first session with your Compliance Coach you will be presented this option. This will set the answers in stone, so be sure to have answered all questions carefully and honestly. Utilize the 'Previous Question' button to review any answers prior to finalizing.

Gap
Upon completing your Self-Audits deficiencies, also known as gaps, will automatically populate based on your answers. These gaps are where your Organization's lacking elements necessary in order to be compliant.

Gap Analysis
The Guard allows you to generate reports at your leisure. Underneath the 'Reporting' tab select 'Gap Analysis' and you will be presented with options labeled 'Gap Options,' 'Remediation Options,' 'Risk Options,' and 'Order Report By.' Please refer to these individual terms within this glossary for a further breakdown of their functions.

Gap Options
Relates to the dropdown found beneath 'Reporting.' Within this feature you may filter your Gap Analysis search to show 'Both Resolved and Open Gaps,' 'Open/Unresolved Gaps,' and 'Resolved Gaps.'

Health Insurance Portability and Accountability Act (H.I.P.A.A.)
A regulation to guarantee patients new rights and protections against the misuse or disclosure of their health records.

Inactivate
To turn off access to someone who previously had the ability to log into The Guard. For Administrator use only.

Incident
The attempted or successful unauthorized access, use, disclosure, modification, or destruction of information or interference with system operations in an information system.

Incident Alerts
Relates to the dropdown found beneath 'Administration' labeled 'Alerts.' Beneath Incident Alerts you will find your Organization's incidents which are over 30 days old and are yet to be resolved.

Incident Options
Relates to the dropdown found beneath 'Reporting,' then 'Incident Summary.' Within this feature you may filter your search by, 'Both Resolved and Open Incidents,' ''Open/Resolved Incidents,' or 'Resolved Incidents.'

Incident Summary
Found beneath the dropdown for 'Reporting,' this 'Incident Summary' tab allows you to filter your search by 'Incident Options,' 'Vendor Association,' 'Incident Type,' or 'Order Report By.'

Incident Type
Relates to the dropdown found beneath 'Reporting,' then 'Incident Summary.' Within this feature you may filter your search by, 'Show ALL Incident Types,' 'Erroneous Release of Information by Fax,' Erroneous Release of Information by Mail,' 'Theft of Paper ePHI,' 'Theft of Device that Contained ePHI,' 'Lost Device (Laptop, Memory Stick, Blackberry, Etc.) that Contained ePHI,' 'ePHI sent Outside of Companies Protection and not Encrypted,' 'Unauthorized Individual Having Access to Company Protected Information,' 'Employees not Following Company Policy and Procedures in the Handling of ePHI,' 'Known Vendor Breach,' or 'Other Incident Type.'

Main Screen
Here you will find 'Assigned Tasks,' Important 'Documents,' and 'How to Report an Incident.' As an Administrator you will also see 'System Messages,' 'Notifications and Alerts,' and have the ability to Launch The Guard via the green button to the top-right of the screen.

Meaningful Use
An incentive program for Provider's accepting Medicare and Medicaid who are also using an EHR platform. To receive an EHR incentive payment, providers have to show that they are “meaningfully using” their certified EHR technology by meeting certain measurement thresholds that range from recording patient information as structured data to exchanging summary care records.

Order Report By
'Order Report By' will be seen many times throughout The Guard. Depending on the area which you see it, it will allow you to filter your inquiry/reports in a certain order for your convenience.

Password Requests
Relates to the dropdown found beneath 'Administration' labeled 'Alerts.' Beneath 'Password Requests' you will find who in your Organization requires/has requested a password reset.

Policies and Procedures
Standards that require a Covered Entity to adopt reasonable practices to comply with the provisions of the HIPAA Security Rule.

Privacy Rule
A set of national standards for the protection of certain health information. Goal of the Privacy Rule is to assure that individuals’ health information is properly protected while allowing the flow of health information needed to provide and promote high quality health care and to protect the public's health and well being.

Protected Health Information
Individually identifiable health information held or transmitted by a Covered Entity or its Business Associate, in any form or media, whether electronic, paper, or oral.

Questionnaire Results
By hovering over 'Reports' and selecting 'Questionnaire Results' you may review previously completed self-audits. Options for the reports include reviewing past answers to your Privacy, Security and HITECH audits. You may also choose to 'Show All Questions,' 'Incorrectly Answered Questions,' and 'Correctly Answered Questions.'

Questionnaires
Questionnaires provide us a jumping-off point for your compliance plan. When they are completed 'Gaps' will arise, making them immensely important to the beginning of the process.

Remediation
The act of fixing deficiencies (Gaps) found by The Guard after completing your self-audits.

Remediation Alerts
Relates to the dropdown found beneath 'Administration' labeled 'Alerts.' Beneath 'Remediation Alerts' you will find your Organization's remediation plans which have passed their due date or are still pending.

Remediation Options
Relates to the dropdown found beneath 'Reporting' labeled 'Gap Analysis.' Within this feature you may filter your Gap Analysis search to show 'Both Assigned and Unassigned Gaps,' '(Gaps) Assigned to a Remediation Plan,' '(Gaps) Not Assigned to a Remediation Plan.'

Remediation Summary
The Guard allows you to generate reports at your leisure. Underneath the 'Reporting' tab select 'Remediation Summary' and you will be presented with options labeled 'Remediation Options,' 'Status Options,' and 'Order Report By.' Please refer to these individual terms within this glossary for a further breakdown of their functions.

Reporting
The act of generating concise snapshots of work done previously. Options available within The Guard include 'Gap Analysis,' 'Remediation Summary,' 'Questionnaire Results,' 'Incident Summary,' 'Training History,' 'Authorization Summary,' 'Disclosure Summary,' 'Member Breakdown,' 'Vendor Breakdown,' and 'Employee Policy/Procedure Crosswalk.'

Requested By
Found beneath the dropdown labeled 'Reporting,' then 'Authorization Summary.' Within this 'Requested By' filter you may refine your search to see 'All Possible,' 'Organization,' 'Member,' 'Representative,' 'Legal Guardian,' 'Legal Entity (Law Enforcement, Etc.).'

Requested By (Disclosure Summary)
Found beneath the dropdown labeled 'Reporting,' then 'Disclosure Summary.' Within this 'Requested By' filter you may refine your search by, 'All Possible,' 'Organization,' 'Member,' 'Representative,' 'Legal Guardian,' or 'Legal Entity (Law Enforcement, Etc.).'

Revoked
Found beneath the dropdown labeled 'Reporting,' then 'Authorization Summary.' Within this 'Revoked' filter you may refine your search by, 'Both Revoked and Non-Revoked,' 'Revoked Authorizations,' or 'Non-Revoked Authorizations.'

Risk Options
Relates to the dropdown found beneath 'Reporting' labeled 'Gap Analysis.' Within this feature you may filter your 'Gap Analysis' search to show 'All Risk Levels,' '5 - Extremely High Risk (Requires Immediate Attention),' '4 - High Risk,' '3 - Moderate Risk (default level of risk),' '2 - Low Risk,' or '1 - Extremely Low Risk (needs to be resolved when time permits).'

Security Risk Analysis (S.R.A.)
Will guide you through a systematic examination of many aspects of your health care practice to identify potential security weaknesses and flaws.

Security Rule
The HIPAA Security Rule establishes national standards to protect individuals’ electronic personal health information that is created, received, used, or maintained by a covered entity. The Security Rule requires appropriate administrative, physical and technical safeguards to ensure the confidentiality, integrity, and security of electronic protected health information.

Status Options
Relates to the dropdown found beneath 'Reporting' labeled 'Remediation Summary.' Within this feature you may filter your search to show 'Approved, Pending and Rejected Recommendations,' items that were 'Approved,' items 'Pending Approval,' or 'Rejected' items.

Status Options (Authorization Summary)
Relates to the dropdown found beneath 'Reporting,' then 'Authorization Summary.' Within this filter you may refine your search to see, 'Pending, Approved and Rejected Authorizations,' 'Pending Authorizations,' 'Approved Authorizations,' and 'Rejected Authorizations.'

System Logs
Relates to the dropdown found beneath 'Administration,' then 'System Logs.' Within this feature you are able to track any/all changes made within your Organization's site.

Tracking
Beneath this tab you will find options for 'Training,' 'Authorizations and Disclosures,' and 'Documents (Version Control).' Tracking allows you to sort and organize various items within The Guard.

Training Alerts
Relates to the dropdown found beneath 'Administration' labeled 'Alerts.' Beneath 'Training Alerts' you will find your Organization's staff who has either not been trained, or whose training occurred over a year ago.

Training History
Relates to the dropdown found beneath 'Reporting,' then 'Training History.' You may filter your search via 'Training Options,' or 'Order Search By.'

Training Options
Relates to the dropdown found beneath 'Reporting,' then 'Training History.' You may filter your search by 'Training Options,' such as 'BOTH Scheduled and Completed Training,' 'Complete Training Courses,' or 'Scheduled Training Courses.'

Users and Access Control
This is found beneath the 'Administration' tab and allows an Administrator of The Guard to grant and deny access. It also is used to differentiate every day Employees (Users) from those completing the compliance work (Administrators).

Vendor (Regular)
A 'Regular' Vendor is someone in your employ who is not paid to directly handle PHI. Their job may have nothing to do with PHI at all. However, they may see it by chance. A good example of a Vendor who may potentially be exposed to PHI is someone who is a member of a Janitorial Staff, or a Copy Person.

Vendor Associations
Relates to the dropdown found beneath 'Reporting,' then 'Incident Summary.' Within this feature you may filter your search by, 'Both Assigned and Unassigned Incidents,' 'Incidents Assigned to Vendors,' or 'Incidents not Assigned to Vendor(s).'

Vendor Breakdown
Relates to the dropdown found beneath 'Reporting,' then 'Vendor Breakdown.' Within this feature you may filter your searches by, 'Vendor Options,' and 'Order Report By.'

Vendor Options
Relates to the dropdown found beneath 'Reporting,' then 'Vendor Breakdown.' Within this feature you may filter your search by 'BOTH Active and Inactive Vendors,' 'Active Vendors,' and 'Inactive Vendors.'


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