Protected health information (PHI) can dwell anywhere, and there is always the danger of a security breach involved in such scenarios, especially considering today’s digitized healthcare environment. Due to the exponential increase in the value of electronic patient health information (e-PHI) over the last few decades, covered entities (C.E.s) and business associates (B.A.s) are required by the Health Insurance Portability and Accountability Act (HIPAA) Security Rule to conduct periodic security risk assessments.
Conducting routine HIPAA security risk assessments assists businesses in adhering to the administrative, technical, and physical precautions outlined in the law. It also helps identify potential vulnerabilities that could expose a company’s PHI. Healthcare organizations need to implement strict controls and governance in addition to completing assessments to reduce risks found during the security risk assessment. In this blog, we will discuss what a HIPAA risk assessment is, if your business needs one, and the steps and best practices you must follow to carry out a HIPAA security risk assessment seamlessly.
What is a HIPAA Risk Assessment?
Before we define a HIPAA risk assessment, it’s important first to understand what the HIPAA security standard entails. Risk assessment is mainly instrumental in helping companies comply with these two essential rules of the HIPAA framework:
- HIPAA Security Rule (45 CFR Part 160 and Subparts A and C of Part 164) — which mandates that covered businesses use the proper administrative, physical, and technical protections to protect ePHI; and
- Privacy Rule (45 CFR Part 160 and Subparts A and E of Part 164) — which governs access to PHI and determines how it can be used and when it can be shared.
A HIPAA risk assessment supports the implementation of suitable measures to reduce risks and vulnerabilities to the confidentiality, availability, and integrity of all PHI generated, received, retained, or transmitted by your organization.
In addition, conducting regular security risk assessments helps C.E.s stay prepared for unprecedented audits by the Office for Civil Rights (OCR) of the U.S. Department of Health and Human Services (HHS). In such scenarios, the OCR will ask to view some important records, such as:
- the most recent security risk assessment conducted under HIPAA;
- a list of hazards reduced in accordance with the risk level;
- a list of HIPAA guidelines or protocols installed;
- proof of records of important actions taken; and,
- a list of controls or procedures put in place to safeguard PHI in the future.
The main priority of HIPAA security risk assessments is to protect the confidential and sensitive information of patients for connected B.A.s as well as C.E.s.
But how important is a HIPAA security risk assessment for your business? Let’s find out.
Who Needs a HIPAA Risk Assessment?
Medical centers and health plans, among other covered entities (C.E.s), that generate, receive, store, or transmit PHI are required to do HIPAA risk assessments. Vendors, business associates, and subcontractors that deal with any ePHI are also required to perform these security evaluations.
HIPAA security assessments should be carried out whenever new work practices, technological advancements, or substantial updates to current I.T. systems are implemented, or at least once a year. It is a requirement that covered organizations must take seriously. Suppose your data infrastructure is compromised, and you suffer a security breach. In that case, the Office for Civil Rights (OCR) reserves the power to levy hefty fines, ranging from $100 to $50,000 per record or violation, with a cap of $1.5 million annually. This could debilitate a business.
Steps to Conduct a HIPAA Risk Assessment
There are seven steps you must follow in order to conduct a HIPAA risk assessment for your healthcare organization. These involve:
Step 1: Determine the Scope of the Assessment
Before starting your risk assessment, you need to decide the scope of your risk analysis. Your organization’s electronic patient health information (ePHI), regardless of its origin, location, or the electronic media used to create, receive, preserve, or transmit it, must be included in a HIPAA risk analysis.
The analysis must also cover all reasonable risks and vulnerabilities to the confidentiality, integrity, and availability of that ePHI. Reasonable refers to any known risks to HIPAA compliance, such as malevolent outside parties, hostile insiders, and unintentional human error brought on by ignorance or inexperience.
Step 2: Collect Data
Next, you have to compile accurate and comprehensive data regarding the use and disclosure of ePHI. To do this, you can check the list of completed and ongoing projects, conduct interviews, examine pre-existing documents, and use additional data collection methods where necessary.
Step 3: Identify Potential Vulnerabilities
Following this, you must examine the risks and vulnerabilities associated with every piece of regulated data. To that list, you should also add all disasters that can be reasonably expected.
Threats that have been identified ought to incorporate elements specific to your security setup. If you use Amazon Web Services (AWS) as your cloud solution, for example, you should be aware of the security concerns connected to AWS.
Step 4: Examine Current Security Posture
Next, you can go through the records of any precautions and actions you have previously taken to lessen the risk to your ePHI. You should make sure to incorporate the subsequent actions:
- Technical controls like audits, automated log-off, encryption, authentication, and access control, among other hardware and software safeguards; and,
- Non-technical measures, such as operational and managerial controls, including policies, processes, and environmental or physical security measures.
You must assess the setup and application of each security measure to ascertain its suitability and efficacy. In this way, you can lower the risks connected to each security measure.
Step 5: Determine the Likelihood and Potential Impact of Each Threat Occurrence
Following this, you must evaluate each possible risk and vulnerability combination and rate the likelihood that a threat will cause or take advantage of a particular vulnerability. A common method for conveying the probability of an event is to assign a precise numerical weight or use categories like High, Medium, and Low.
You also need to describe the potential consequences of any data threat, including unauthorized disclosure or access, irreversible loss or corruption, any transient absence or inaccessibility, financial cash flow or physical asset losses, etc. This stage also involves calculating each outcome’s influence and recording it. You can use quantitative or qualitative measures as required.
Step 6: Identify the Risk Level, Determine Accurate Security Measures, and Finalize the Documentation
Next, you have to examine the ratings given to each threat’s impact and likelihood. Once a probability and impact level have been assigned, you can determine the risk level.
Following this, you should determine the possible security precautions to bring each risk down to a manageable level. For this, you need to take into account the efficacy of the measure, any organizational policy and procedural requirements, and the regulatory constraints surrounding its execution. Last but not least, you need to record all results.
Step 7: Review and Update the Risk Assessment Criteria Regularly
Finally, you need to create a policy outlining the frequency of risk assessments. One should be done at least once a year. In addition, whenever your organization’s policies, authority and risk levels, or security systems change, you should update the evaluation as well. Lastly, you must keep track of every modification in the revision history after completing your risk assessment.
Best Practices for Conducting HIPAA Risk Assessments
Here are a few best practices to implement and maintain a consistent program for conducting HIPAA risk assessments:
- Create an accountability and transparency-mandated IT governance framework: Using an I.T. governance framework will make it impossible to overlook internal and external security risk assessments toward maintaining organizational accountability. The integrity of the governance structure should be preserved by rewarding the values of accountability and transparency.
- Enable the Chief Information Security Officer (CISO) as an Additional Resource: The right checks and balances should be provided by the CISO, an impartial resource. This holds for any possible conflict of interest or political pressure to hide the findings of security risk assessments conducted under HIPAA.
- Develop and implement a risk mitigation action plan: Once you mitigate the high-risk probabilities, you must attend to the low-risk ones. A clear owner and a deadline for completion should be included in the action plan. In addition to addressing any vulnerabilities, this action will prepare the company for the upcoming HIPAA security risk assessments.
- Establish a Plan for Managing Vendor Risks: Since HIPAA security risk assessments involve third-party suppliers and B.A.s, develop and implement a strict vendor risk management plan. You should also verify that each B.A. has a binding contract with the C.E. and that the B.A.s are carrying out their due diligence.
HIPAA Risk Assessment and Compliance Readiness with Akitra!
Establishing trust is a crucial competitive differentiator when courting new SaaS businesses in today’s era of data breaches and compromised privacy. Customers and partners want assurances that their organizations are doing everything possible to prevent disclosing sensitive data and putting them at risk, and compliance certification fills that need.
Akitra offers an industry-leading, AI-powered Compliance Automation platform for SaaS companies. Using automated evidence collection and continuous monitoring, together with a full suite of customizable policies and controls as a compliance foundation, our compliance automation platform and services help our customers become compliance-ready for the HIPAA compliance framework and other security standards like SOC 1, SOC 2, GDPR, PCI DSS, ISO 27001, ISO 27701, ISO 27017, ISO 27018, NIST CSF, NIST 800-53, NIST 800-171, FedRAMP, CCPA, CMMC, SOX ITGC, and more such as CIS AWS Foundations Benchmark, Australian ISM and Essential Eight etc. In addition, companies can use Akitra’s Risk Management product for overall risk management using quantitative methodologies such as Factorial Analysis of Information Risks (FAIR) and qualitative methods, including NIST-based for your company, Vulnerability Assessment and Pen Testing services, Trust Center, and AI-based Automated Questionnaire Response product to streamline and expedite security questionnaire response processes, delivering huge cost savings. Our compliance and security experts will provide customized guidance to navigate the end-to-end compliance process confidently. Akitra Academy provides easy-to-learn short video courses on security, compliance, and related topics of immense significance for today’s fast-growing companies.
The benefits of our solution include enormous savings in time, human resources, and cost savings, including discounted audit fees with our audit firm partners. Customers achieve compliance certification fast and cost-effectively, stay continuously compliant as they grow, and can become certified under additional frameworks using a single compliance automation platform.
Build customer trust. Choose Akitra TODAY!
To book your FREE DEMO, contact us right here.