Requirement
164.308(a)(8) - Perform a periodic technical and nontechnical evaluation, based initially upon the standards implemented under this rule and subsequently, in response to environmental or operations changes affecting the security of electronic protected health information, that establishes the extent to which an entity’s security policies and procedures meet the requirements of this subpart [the Security Rule].
Explanation
It is important for a covered entity to know if the security plans and procedures it implements continue to adequately protect its EPHI. To accomplish this, covered entities must implement ongoing monitoring and evaluation plans. Covered entities must periodically evaluate their strategy and systems to ensure that the security requirements continue to meet their organizations’ operating environments. The purpose of the evaluation is to establish a process for covered entities to review and maintain reasonable and appropriate security measures to comply with the Security Rule. Initially the evaluation must be based on the security standards implemented to comply with the Security Rule. Subsequent periodic evaluations must be performed in response to environmental or operational changes that affect the security of EPHI. The on-going evaluation should also be performed on a scheduled basis, such as annually. The evaluation must include reviews of the technical and non-technical aspects of the security program.
