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This article is Part One of a Four-part Series on the HITRUST Framework

When you think of HITRUST, you probably think of healthcare. After all, HITRUST was originally created as the “Health Information Trust Alliance.” However, over the past few years HITRUST has evolved to serve as an industry-agnostic common security framework – such that any company in any industry can now pursue a HITRUST CSF certification.


First Introduced in HITRUST 1.0 September 2009 as a baseline of the hitrust requirements, but under HITRUST 9.2 – January 2019, HIPAA became an optional regulatory factor

The Healthcare Information Portability and Assurance Act (HIPAA) was enacted by President Clinton in 1996, making it one of the oldest and most influential information security and privacy regulations in the United States. In fact, HIPAA serves as a precursor to HITRUST, since HITRUST was conceived as a certifiable standard for HIPAA compliance. However, as HITRUST has transitioned from a specific healthcare-related standard into a more industry-agnostic framework, the HIPAA regulations were moved into separate optional regulatory factors.

HIPAA requirements focus on the Security Rule, Privacy Rule and Breach Notification. Several healthcare providers and insurance companies require their business partners to demonstrate HIPAA compliance as a pre-requisite to working together, and the HITRUST CSF is a certifiable and widely accepted framework to demonstrate HIPAA compliance.

The A-LIGN Bottom Line: Any organization that processes, stores or exchanges healthcare data should include HIPAA in its HITRUST assessment.

CMS Minimum Security Requirements (High)

First Introduced in HITRUST 3.0 – December 2010

The Centers for Medicare & Medicaid Services (CMS) Information Security and Privacy Acceptable Risk Safeguards (ARS) sets forth a set of guidelines for its contractors known as the CMS Minimum Security Requirements (CMSR). These requirements share a common heritage with HITRUST, since the CMS requirements are based on NIST (among others) and regulated by HIPAA, which both serve as authoritative sources for HITRUST. The purpose of the CMSR is to protect Medicare & Medicaid information and information services, including CMS Sensitive Information.

Systems Security Levels (Low/Moderate/High) are defined within the appendix of the ARS manual. The Moderate and High impact levels require an independent Security Assessment; therefore, HITRUST has incorporated CMSR (High) as one of the optional regulatory factors to be included in a HITRUST assessment.

The A-LIGN Bottom Line: CMS contractors may be required to demonstrate compliance, but any organization that handles Medicare or Medicaid data should be advised to include CMSR High in its HITRUST assessment.

MARS-E Requirements

First Introduced in HITRUST 7.0 January 2015

The Centers for Medicare & Medicaid Services (CMS) introduced its Minimum Acceptable Risk Standards for Exchanges (MARS-E) to address patient protection mandates and the Affordable Care Act. MARS-E applies to all “Administering Entities,” which are defined as state or federal exchanges and marketplaces, state Medicaid agencies, Children’s Health Insurance Program (CHIP) agencies, or state agencies administering the Basic Health Program. The purpose of MARS-E is to comply with the security and privacy standards and hitrust requirements of the Affordable Care Act.

The A-LIGN Bottom Line: MARS-E is primarily focused on the exchange of healthcare information related to Medicare and Medicaid. Whereas CMSR should be considered by any organization that handles this sort of healthcare information, MARS-E is more directly focused on the exchange of this information.

EHNAC Accreditation

First Introduced in HITRUST 9.0September 2017

The Electronic Healthcare Network Accreditation Commission (EHNAC) is similar to the Joint Commission Accreditation because it is also a non-profit organization, but whereas the Joint Commission is focused on accrediting healthcare providers, EHNAC is focused on accrediting health information exchanges and other electronic health services, such as payments and prescriptions. EHNAC develops standards for health information exchanges, and it serves as the accrediting body for these standards.

The A-LIGN Bottom Line: Pursuing EHNAC Accreditation is an extraneous activity, unless an organization is contractually obligated. Organizations involved with health information exchanges may find EHNAC Accreditation worthwhile, but would typically pursue it independently of a HITRUST assessment.

Texas Health & Safety Code, Section 181 (TX HB 300)

First Introduced in HITRUST 5.0 January 2013

The Texas House Bill 300 (TX HB 300) is a state-level healthcare regulation that is considered to be a more stringent version of HIPAA compliance, and section 181 deals specifically with Medical Records Privacy for residents of Texas. One of the primary differences between TX HB 300 and HIPAA is that TX HB 300 casts a much wider net in defining its covered entities. TX HB 300 includes any individual that possesses protected health information (PHI), even the academics, accountants, and lawyers that are precluded from HIPAA compliance. TX HB 300 introduces new standards for the handling of electronic health records (EHR), and it requires extensive, periodic employee training.

The A-LIGN Bottom Line: Any Organization (note extended definition of covered entity) that assembles, collects, analyzes, uses, evaluates, stores, or transmits PHI for a Texas resident should consider including this regulatory factor.

HITRUST De-ID Framework Requirement

First Introduced in HITRUST 8.0 February 2016

The HITRUST De-Identification Framework was developed to provide a program and methodology for anonymizing data so that it can be used for the purpose of comparative effectiveness research (CER), Health Economics and Outcomes Research (HEOR), early detection of disease outbreaks, reduction of medical errors, and so forth.

The A-LIGN Bottom Line: Organizations should balance the risk vs the reward of de-identifying protected healthcare information, since the penalty for errors can be significant. As a result, most organizations avoid the process of transacting anonymized healthcare data. But for those organizations that are willing to take the risk, the HITRUST De-ID Framework Requirement is a worthwhile inclusion to a HITRUST CSF Assessment.

Implement a Strategic Approach to HITRUST Compliance

The standardization of compliance regulations and the consolidation of audits are both tenets of a strategic compliance program. Adding the correct regulatory factors to a HITRUST assessment is a great way to start realizing the benefits of strategic compliance vs. handling each assessment individually. In fact, even the HITRUST mission statement seems to resonate with a strategic approach to compliance: One Framework, One Assessment, Globally.

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