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How To Comply With the HIPAA Security Rule

With data breaches happening daily, protecting your patients' information has become the need of the hour. Here is how you can comply with HIPAA Security Rule.
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How to Comply with the HIPAA Security Rule

Data protection is one of the biggest concerns at the moment. A cyber attack happens every 39 seconds, posing security risks for 1 in 3 Americans yearly. According to the Pew Research Center, about 79% of Americans are concerned about how companies use their data.

The Health Insurance Portability and Accountability Act (HIPAA) Security Rule was formulated to counter this security concern for the healthcare industry. It requires professionals to protect their patients' digitally stored data from breaches, erasure, and other cyber threats. 

The rule encompasses three safeguards: physical, technical, and administrative. Complying with every security standard is crucial, or otherwise, you may have to face penalties by the federal institutions. HIIPA's law requirements may look overwhelming, so this post will make them easier for you.

Overview of the HIPAA Security Rule

Congress passed the HIPAA Security Rule in 1996 to help the American healthcare industry enhance its operations. The rule obliged the Secretary of the U.S. Department of Health and Human Services (HHS) to formulate rules that protect certain health information.

Since then, many rules have been added to the original act to protect patients' information or protected health information (PHI). To ensure their compliance, the HHS published the Privacy Rule and Security Rule.

Both of these rules work side-by-side to enhance the efficiency of the healthcare system. However, they serve different purposes. 

While the Privacy Rule encompasses standards for physical security and confidentiality of PHI, the Security Rule establishes standards for protecting certain health information being stored or transferred in digital form.

The electronic PHI is termed as "e-PHI". The HIPAA Security Rule applies to every health care provider and organization that stores the patients' health information electronically. 

It should be in connection with a transaction the Secretary of HHS has formulated standards for under HIPAA (covered entities) and to their business associates. The HIPAA Security Rule was implemented in 2004, followed by several other security rules, including the HITECH Act of 2009 and the Omnibus Rule of 2013.

What Does the Rule State?

Every healthcare providing firm has to stay compliant with HIPAA to ensure the protection of their patients. The HSS has given clear guidelines and standards so that organizations can follow them to prevent any potential risks for data breaches.

Generally, the Security Rule obliges covered entities to maintain appropriate administrative, physical, and technical safeguards for the protection of e-PHI. The covered entities are mandated to:

  • Ensure the integrity, availability, and confidentiality of all e-PHI they produce, receive, manage, or transfer.
  • Detect anticipated threats to the information security and protect against them.
  • Protect against impermissible or unauthorized uses or disclosures.
  • Convince their workforce to stay compliant with the rules.

The term "confidentiality" means that the e-PHI is neither exposed nor available to unauthorized persons.

The Three Safeguards for Health Data Protection

The HIPAA Security Rule requires healthcare organizations to implement three kinds of safeguards — including physical, administrative, and technical — to protect e-PHI. Let's discuss each of them briefly to understand what they entail for organizations.

Physical Safeguards

Physical safeguards prevent physical theft or misplacement of devices containing patients' information. Covered entities need to ensure physical safeguards in the below two ways:

  • Facility Access and Control. The organization must restrict the physical access of unauthorized persons to its facilities. Only authorized access should be permitted.
  • Workstation and Device Security. The covered entities must formulate and implement policies and regulations that explain the correct use of and access to workstations and electronic sources. Not only that, but the organizations must also develop policies and regulations related to the transfer, removal, and re-use of electronic media. This ensures full-proof protection of e-PHI. 

Administrative Safeguards

These rules make sure that the patients' data is valid and easily accessible to authorized persons. They include:

  • Security Management Process. The covered entities must identify and analyze any potential or existing risks to e-PHI. Once done, these entities have to implement security measures to mitigate the identified risks and threats.
  • Security Personnel. Organizations must recruit and designate a security official solely responsible for developing and implementing the security regulations according to the HIPAA rule.
  • Information Access Management. The Privacy Rule standard limits the use and disclosure of patients' information to the "minimum necessary." Complying with it, the Security Rule obliges covered entities to implement regulations for limiting access to e-PHI to only the appropriate user or recipient. 
  • Workforce Training and Management. The covered entities have to provide their workforce's authorization and supervision, particularly those who deal with e-PHI. In addition, organizations have to train their employees and staff members about their security policies and take appropriate actions against those who violate these rules and regulations.
  • Assessment. The covered entities also need to perform evaluations of the compliance of their security policies with the requirements of the Security Rule.

Technical Safeguards

These rules guard your networks and devices against cyberattacks and data breaches. Covered entities must ensure:

  • Access Control. They must implement technical rules and procedures to enable the access of only authorized persons to electronically protected health information (e-PHI). 
  • Audit Controls. Organizations must also implement hardware, software, and procedural techniques to record and assess access and other authorization activity in information systems that hold or use e-PHI.
  • Integrity Controls. They also have to implement policies and ways to ensure that no entity destroys or alters the e-PHI. For that, they need to develop electronic measures that confirm that e-PHI is safe and no one has changed it improperly.

Transmission Security. Organizations must also implement technical security measures to restrict any unauthorized or suspicious access to the e-PHI transferred through an electronic network.

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Risk Assessment and Management

The Administrative Safeguards require entities to perform a risk assessment to monitor and manage their security management processes. The risk analysis and management provisions of the Security Rule are usually addressed differently. 

Risk analysis allows covered entities to determine which security measures are appropriate and help them implement all the mandatory safeguards mentioned in the Security Rule. Generally, a risk assessment procedure includes:

  • Evaluating the impact and occurrence of potential risks to e-PHI's integrity
  • Implementing appropriate security measures to identify and address the identified risks
  • Documenting the selected security measures and determining the rationales for adopting and implementing those measures
  • Managing the consistency and relevance of the appropriate security protections

The risk analysis is an ongoing process that requires covered entities to periodically review its record to evaluate the effectiveness of their security measures. It allows healthcare organizations to track access to e-PHI, identify security incidents and threats, and reevaluate potential risks to e-PHI regularly. 

The Implementation of HIPAA

Every organization has different security concerns, so the HHS hasn't spelled out any specific recommendations for implementing the HIPAA Security Rule. In addition, the institution hasn't defined any particular technology or method that safeguards e-PHI for all covered entities equally. 

The rule allows several resources to be available due to the different natures of covered entities. For example, a small clinic operating in a rural area would have different security concerns than a renowned hospital in a major city's epicenter.

The HIPAA Security Rule is quite flexible and scalable. Typically, two major types of standards within the Security Rule exist:

Required Standards

These standards are essential. The covered entities have no way around implementing these rules or they'll be violating the HIPAA Security Rule.

Addressable Standards

These are mostly technical in nature. Unlike required standards, addressable standards are flexible in deciding how they should be implemented to fulfill the objectives of the security requirements. This doesn't mean that you can ignore them.

Simply put, it may not matter what procedures you choose to secure e-PHI as long as it is fully protected. If a covered entity doesn't implement any of the addressable standards, the Security Rule requires it to implement other safeguards as an alternative. Moreover, the entity also has to document the decision they took and why they did so.

What if a Covered Entity Violates the Security Rule?

There are consequences for every violation. Although the HSS obliges HIPAA on organizations, enforcing penalties on violations comes under the Office of Civil Rights (OCR). 

Thus, in the event of a HIPAA Security Rule violation, the OCR puts a fine of any amount ranging from $100 to $50,000 on the covered entity. However, the other HIPAA settlements may sum up over $1 million.

You may be wondering: Can you go to prison for HIPAA violations? Well, an organization and its employees may likely be held accountable for disclosing confidential PHI for any reason. 

If the HIPAA violations were done intentionally with malicious intent, they would be considered criminal and come under the jurisdiction of the department of justice. As a result, the individual at fault, rather than the organization leadership, may face prison along with fines.

How to Comply With the HIPAA Security Rule?

IBM estimated the average time taken by organizations to detect and contain a data breach is 279 days. Imagine the amount of data that could be exposed in such a duration. The HIPAA Security Rule is as complicated as it is, due to the flexible implementations.

So, how can you comply with the HIPAA Security Rule flawlessly and quickly? Simply use help of a compliance management platform like Accountable. It is an easy-to-use and simple software platform that helps organizations understand HIPAA rules and stay compliant. Get onboard with Accountable for free now!

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