Protecting patient data is crucial in the rapidly changing world of healthcare and digital information interchange. To fulfill that purpose, the Health Insurance Portability and Accountability Act (HIPAA) was released by the United States Department of Health and Human Services in 1996, and it has since then changed the way healthcare entities and organizations manage and safeguard sensitive patient data.
HIPAA was first created to streamline healthcare administration, reduce waste, prevent healthcare fraud, and ensure that employees could continue to access their health insurance after quitting their jobs. But as technology and the times changed, the law underwent a number of adjustments. Today, covered entities like healthcare providers, insurance providers, and third parties working with data from healthcare and insurance providers must comply with HIPAA’s privacy, security, and breach notification standards. Failure may result in severe consequences.
So how can your organization guarantee the safety of protected health information (PHI)? By conducting regular HIPAA risk assessments, of course.
Risk assessments can create a solid foundation for the organization’s security posture when done thoroughly. They can assist healthcare organizations in identifying weaknesses, enhancing their controls, preventing breaches, leaks, and revenue loss, and even preventing poor PR from happening! Therefore, risk evaluations and management should not be taken lightly. In this blog, we will discuss what a HIPAA risk and security assessment is and whether you should conduct one at your organization. Following that, we will take you through eight simple steps you can follow to implement one and even appraise you of some best practices for the same.
What is a HIPAA Risk Assessment?
The HIPAA risk assessment is an audit process through which an organization can confirm that it conforms to HIPAA’s administrative, physical, and technical safeguards. Performing a HIPAA risk assessment helps you find potential dangers to your organization’s protected health information (PHI).
The risks and vulnerabilities indicated in the risk assessment can impact the integrity and security of the electronic PHI (e-PHI) in your healthcare environment. To comply and maintain compliance with HIPAA, covered entities such as healthcare providers, health plans, clearinghouses, and business associates such as service providers and suppliers of covered entities that use or disclose PHI must periodically conduct risk assessments. In the face of new technology or substantial changes being introduced every year, such as modifications to your health information technology systems and procedures, it is recommended to perform risk assessments annually.
Why is it Important for Organizations Dealing with e-PHI?
HIPAA risk assessments are critical because they serve as the foundation for choosing and putting security measures that adhere to HIPAA Security Rule requirements. HIPAA mandates them, and failure to conduct them regularly could result in fines from the Office for Civil Rights (OCR) of $100 to $50,000 per violation, up to a maximum of $1.5 million per year for each violation.
Risk assessments are a key component of the HIPAA Security Rule, but there is no set way to conduct one. Instead, it specifies a number of goals you must meet regardless of the evaluation strategy. Organizations should be able to evaluate the appropriateness and reasonableness of an implementation specification or an equivalent metric with a HIPAA risk assessment.
How to Implement a HIPAA Risk Assessment?
HIPAA risk assessments are surprisingly easy to conduct. You can follow these eight steps to evaluate whether your organization adheres to HIPAA guidelines.
- Understand the Scope of the Assessment
As previously discussed, a HIPAA compliance risk assessment comprehensively examines the threats and weaknesses to the privacy, security, and accessibility of electronic protected health information (ePHI) in your environment.
This includes all e-PHI on hard drives, CDs, DVDs, smart cards, personal digital assistants, and portable electronic devices. Additionally, electronic media can consist of a single workstation or a complicated network connecting several sites. Therefore, regardless of the electronic medium or location of e-PHI, the scope of your organization’s security risk assessment must consider all of its e-PHI.
- Review Your Data
You must determine where e-PHI is kept, received, maintained, or sent within your company. To obtain all the data required for risk assessment, you could examine the organization’s previous and ongoing initiatives, conduct interviews, review documents, and employ other data-gathering strategies.
The Department of Health and Human Services (HHS) suggests entities and organizations ask the following questions to determine that they have proper knowledge of everything they need to proceed forward with the risk assessment:
- Have you determined where the e-PHI is located within your company? This includes any e-PHI produced, acquired, stored, or sent till the present date.
- What are the external sources for the e-PHI? For instance, any vendors or consultants who generate, receive, maintain, or transmit e-PHI for the entity?
It is also recommended that you remember that the collected e-PHI data must be documented.
- Detect and Document Potential Risks and Vulnerabilities
In this step, you must recognize and record any potential dangers to e-PHI, such as the hazards to information systems containing e-PHI from people, the natural world, and the environment. Moreover, you may also need to identify the many dangers that are particular to your location.
To acquire an overview of the potential dangers, you can speak with your staff members who deal with ePHI, examine the relevant documents, and consider any prior observations.
Here is a list of potential vulnerabilities your e-PHI may be at risk for —
- Natural threats: Floods, earthquakes, landslides, tornados, etc.
- Human threats (Intentional): Malicious software uploads, network, and computer-based cyber attacks, unauthorized access to PHI, etc.
- Human threats: Deletion of data, insertion of inaccurate data, etc., even unintentionally
- Environmental threats: Power failures, pollution, liquid leakages, chemical hazards, etc.
- Assess Current Security Measures
Now that you have security measures to protect ePHI, you must determine their efficacy and whether they are appropriate and effective. You must also decide whether or not they are configured and used properly if they are. These safety precautions will change based on the organization’s size and complexity. Remember to keep track of the measures you’ve already taken, including your evaluation.
To further elaborate, these measures can be both technical and non-technical:
- Technical measures: include access control, authentication, encryption, auto-logoff, auditing, and other hardware and software restrictions.
- Non-technical measures: include managerial and operational measures involving policies, processes, and environmental or physical security controls.
Examine each security measure’s implementation and configuration to ascertain its appropriateness and effectiveness.
- Determine the Possibility of Risk Incidents and Their Potential Impact
Once you have discovered the threats and vulnerabilities, you must ascertain how likely they will materialize. Consider assigning numbers 1, 2, or 3 or categorize the likelihood of occurrence as High, Moderate, or Low.
The confidentiality, integrity, and availability of e-PHI would be affected qualitatively and quantitatively if such a threat or vulnerability materialized. This stage should result in thorough documenting of a threat’s likelihood of happening and potential effects on the ePHI.
- Assess the Level of Risk and Corrective Actions Needed for Protection
The next step is to assign risk categories to each combination of a threat and a vulnerability. For instance, the level of risk might be ascertained by examining the values ascribed to the possibility of danger occurring and the consequence of that happening.
According to the HHS, you might calculate the risk levels by averaging the assigned likelihood and impact levels. The next step is to determine the potential security measures you can implement to bring each risk down to a manageable level.
Organizational policies, procedural regulations, and particular technical precautions like encryption, data backup, and others are all examples of security measures. Documentation of the assigned risk levels and a list of corrective actions you must take to mitigate each risk level are required, as is the outcome for each step.
- Audit and Finalize Documentation
The HIPAA regulations place a lot of focus on keeping records. Therefore, meticulously document your risk assessment process at each stage. The documentation proves that you completed the HIPAA risk assessments in good faith and could be useful if a breach or regulatory oversight is discovered during an audit of your compliance with HIPAA privacy risk and HIPAA security risk requirements.
- Update the Risk Assessment Information Periodically
Risk analysis is a multi-step process. Risk analyses should be carried out at least once a year or after significant organizational changes, including the inclusion of new technology or business activities, or even a security event, even if the Security Rules need to define how often they should be done.
For instance, you must modify your risk weights and implement security measures in response to a breach or change in ownership at your covered company to keep ePHI secure. You must quickly put additional security measures in place if the investigation reveals insufficient defense against the newly introduced hazards.
Best Practices for a HIPAA Risk Assessment
Here are five best practices for a successful HIPAA risk assessment:
- Designate a team member to oversee the assessment and instruct everyone on your staff on HIPAA compliance.
- Recognize that you can conduct the examination yourself or hire a HIPAA specialist. The planning and analytical duties might be completed more quickly by outsourcing the assessment.
- Keep in mind the purpose of the evaluation. Its objective is to assist you in identifying, prioritizing, and mitigating risks; it is not an audit.
- Make sure your paperwork complies with HIPAA requirements. All policies and processes should be written down, verified as accurate, and made centrally accessible.
- Remember that you must repeat the assessment procedure at least once a year.
- Use an automation platform such as Akitra Risk Management product.
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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 service help our customers prepare readiness for the HIPAA compliance standard, Risk Assessment, and Management along with other security frameworks 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, and more such as CIS AWS Foundations Benchmark, etc. In addition, companies can use Akitra’s Risk Management product for overall risk management for your company, 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.
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.
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