What is a Risk Assessment?

As a reminder, one of the most important aspects of complying with the HIPAA Security Rule is to perform a Security Risk Assessment (also known as a Security Risk Analysis) to evaluate how an organization is protecting patient data.  Every organization covered by HIPAA (Covered Entities and Business Associates) must perform an SRA.  According to the Office for Civil Rights (OCR), the HHS division that enforces HIPAA, the SRA is THE most important document in HIPAA compliance.  It is the document that will first be looked at in any type of audit or investigation.

Why is a risk assessment so important?

Why is the SRA so important? Simply put, the output of the SRA will give you recommendations on how to reduce the risk of a data breach, which is what HIPAA security is all about.  

How does it work? The SRA looks at all systems that contain electronic protected health information (ePHI or patient information). It evaluates all the threats to ePHI,  looks at all vulnerabilities to the systems that contain ePHI and evaluates the current protections that are in place to protect ePHI. Based on all of the information that is gathered and evaluated the results of the SRA will show the areas of greatest risk of a breach, and provide a playbook (we call it the Work Plan) for how additional protections can lower the risk of a breach of patient information.

In addition to providing recommendations on how to reduce the risk of a data breach, the SRA process is widely considered to be a best practice in cybersecurity circles.  Cybersecurity is an issue for all organizations to deal with, not just HIPAA covered entities. Many organizations that are not in the healthcare field conduct regular SRAs as a way of reducing risk in their business and helping keep their business systems operational.

There are several methods used to perform an SRA.  Our partner, HIPAA Secure Now!, follows a process from the National Institute of Standards (NIST) called 800-30.  The 800-30 guideline is recommended by HHS/OCR for performing SRAs.  HIPAA Secure Now! has been involved in audits, investigations, and reviews with different regulatory bodies, and every time our SRA has been accepted as valid.

For many organizations, an SRA can be a time-consuming process.  Not so with HIPAA Secure Now! clients.  We have spent many years perfecting a process that minimizes the amount of time required to perform a comprehensive SRA.  

As mentioned above, the SRA will point out areas where the risk of a data breach can be reduced.   A key point is that it is not possible to eliminate all risks. No matter how much an organization spends to implement additional security measures, some risks cannot be completely eliminated. The goal of implementing the recommendations of a risk assessment is to lower risk to the point that it is acceptable to the organization.

Have questions? Need help?

Call us at 859-245-0582 or click here to reach out to us.

You might also be interested in our other article on HIPAA Compliance, “What are the HIPAA standards for IT”. Click here to read it now.

 

Next Century Technologies has teamed up with HIPAA Secure Now to bring comprehensive HIPAA compliance solutions and advice, at a reasonable price, to establishments that fall under HIPAA. We thank our partners at HIPAA Secure Now for providing the content for this article. 

 

What triggers a HIPAA audit?

What is HIPAA?

The Health Insurance Portability and Accountability Act, better know as HIPAA, was passed by Congress in 1996 and called for the protection and confidential handling of protected health information (PHI). HIPAA still exists today, aiming to protect patients and their information, but it’s important to think about how far we’ve come in the ways we handle patient data since its enactment.

Compliance is Non-Negotiable

One thing that has not changed since 1996 – HIPAA compliance is here, and it is not optional.  In fact, it’s arguably more important than ever before to have your HIPAA compliance program in order. With the healthcare industry being favored by cybercriminals, human error accounting for most data breaches, the ease in filing a complaint against an organization, and more, your compliance program could come under review at any given time – and you must be ready.

What triggers an audit?

The Office for Civil Rights (OCR), is the department responsible for enforcing HIPAA. It seems there is a common misconception that audits by the OCR happen at random when the department decides to “pop in” on organizations to check on their compliance state. The reality is, the OCR is not staffed to audit organizations without just cause, meaning when an audit occurs, something triggered it.

Common audit triggers

  • Patient complaints – Patients could file complaints for any number of reasons. Maybe a patient was denied access to their records, or perhaps they saw a picture on social media with their medical chart in the background.
  • Employee complaints – Often times, disgruntled employees may file a complaint following termination of employment, but that’s not always the case. If an employee feels there has been wrongdoing, they could certainly file a complaint.
  • Employee mistakes – Employee mistakes or human error account for many audits. An employee falling for a phishing email, using weak passwords, and sending a patient the incorrect records are all examples of human errors.
  • Insider wrongdoing – Sometimes employees violate company policies maliciously, and other times they may just be curious. Employees could steal patient records for personal gain or could peek at a patient’s records because they’re curious about their visit.
  • Third-party mistakes – Mistakes caused by a Business Associate (BA) could also lead to an investigation of your organization. If your (BA) suffers a data breach, you may be audited as well.
  • Security incident – Common security incidents include lost or stolen devices, especially those devices that are unencrypted, as well as unpatched software that led to malware or ransomware exploits.

Many times, whatever triggered the audit, to begin with, is not the biggest problem or finding by the OCR. This is why having your HIPAA compliance program in order and continuously working towards your compliance is critical.

What will OCR look for in an audit?

What OCR may be looking for in an audit situation will vary, dependent on what triggered the audit in the first place. Below are some common items that your organization could expect to show an auditor in the event of an audit, all of which, are key components of a HIPAA compliance program.

  • Security Risk Assessment – An absolutely critical part of your compliance program. The Security Risk Assessment (also referred to as the SRA, or Security Risk Analysis) will look for gaps in your organization’s administrative, physical and technical safeguards that could pose a risk for protected health information (PHI). You must have documented proof of your SRA.
  • Remediation/Risk Management Plan – Once you’ve conducted your SRA, you’ll need to have a process in place to begin addressing your deficiencies, often referred to as a Risk Management Plan. This plan should cover how you plan to remediate all the security gaps discovered in your SRA.
  • Policies & Procedures – Not only does your organization need to have policies and procedures in place, but you also must ensure that employees understand those policies and have signed off on them. Employees can’t be expected to follow the rules if they are unaware of them, and the documented proof that they acknowledged the policies is vital in the event of a security incident.
  • Security Officer – Every organization needs to have an appointed Security Officer. This individual is responsible for ensuring policies and procedures are created, understood by all employees of the organization, and acknowledged by them with documented proof. The Security Officer should also ensure employees are trained on HIPAA routinely.
  • Routine HIPAA Training – Not only is HIPAA training a requirement, but it is also necessary to reduce the chances of an employee-error. HIPAA and cybersecurity awareness training should be conducted routinely so employees are kept updated on the latest threats, and to keep security best practices top of mind.
  • Business Associate Agreements – You must have a Business Associate Agreement (BAA) with any and all vendors that handle your patient data. A data breach caused by a Business Associate will also affect your organization, so make sure you are working with vendors who take HIPAA compliance seriously.

Proof of network vulnerability scans, penetration tests, and breach notification (in the event of a breach) are also common requests by the OCR.

The Bottom Line

It’s safe to say that in this digital age, HIPAA could use a refresh, but despite its flaws, your adherence to it is not up for discussion. An audit could be triggered by anyone, at any time. If you had a complaint filed against you tomorrow, would you be confident in your compliance state? If you can’t answer yes, it’s best to get to work – before it’s too late.

Have questions? Need help?

Call us at 859-245-0582 or click here to reach out to us.

You might also be interested in our other article on HIPAA Compliance, “What are the HIPAA standards for IT”. Click here to read it now.

 

Next Century Technologies has teamed up with HIPAA Secure Now to bring comprehensive HIPAA compliance solutions and advice, at a reasonable price, to establishments that fall under HIPAA. We thank our partners at HIPAA Secure Now for providing the content for this article. 

 

 

What are the HIPAA standards for IT?

A HIPAA covered entity is more than just a doctor’s office or hospital – its any business that comes in direct contact with a patient’s PII (personally identifiable information). This includes not only medical providers but law firms dealing with medical cases, health insurance companies and medical billing services. HIPAA is a mindset, a set of policies and procedures that are followed for doing business. That being said, there are some areas in IT that a covered entity should focus on.

IT areas of focus for HIPAA compliance:

  • Risk Assessment. Have one. It is required. Without one you can’t identify your vulnerabilities and you can’t address those vulnerabilities. This is your foundation for the HIPAA mindset.
  • Archiving logs of user transactions and event notifications. Who did what, when and where? These are the questions that have to be answered! Staff is a lot less likely to steal PII if they think they are being watched. You know people are paid to steal PII, right?
  • Secure e-mail implementation. Does your staff know how to send PII securely via e-mail? Use encryption if you need to send PII. Use a system that’s easy to implement.
  • Regular operating system and application updates for all computers. Computers should be updated weekly, and servers at least monthly. Its best to automate this process so its not forgotten. This automated process should provide notifications of what updates were successful and which were missed.
  • Regularly scheduled vulnerability scans. Do them at least once a quarter and following any major IT changes. The vulnerability scan compares your IT environment to several reputable databases of vulnerabilities to identify issues that need to be addressed. Vulnerability software needs regular updates, so should be subscription-based.
  • Policies & Procedures. Do you maintain a set of policies and procedures for handling and protecting PII?  Although IT is included, it covers all aspects of the office right down to locking doors to sensitive areas and minimizing the view visitors have of your paperwork and computer screens.
  • Quality firewall device with intrusion prevention system (IPS).  IPS is subscription-based protection that is updated as new IT threats emerge.
  • Good password policy. So critical! This includes not only how complex the passwords are, but how they are stored and end-user training on how to manage them.
  • Internet restrictions. Keep the office computers focused on the business, not on games, shopping sites or social media. All of those sites are ripe with poor security that can lead to a breach of your data or a malware infection. 
  • Mobile device management. PII should not be on unsecured mobile devices. If you must use mobile devices, via technology,  they can be secured.
  • Laptop encryption. Windows 10 Pro includes encryption. A stolen or lost laptop is considered a breach. Even if you don’t think you store PII on that laptop, it is used to access email and cloud apps where PII is kept. So encrypt it.
  • Endpoint Protection. This includes your paid antivirus/antimalware, 2-factor authentication for e-mail and electronic records. Also encryption for e-mails. 
  • Physical security. Keep the server room locked! Desktops should be locked down with password protection if left unattended. Can patients wander behind the counter and have easy access to patient information laying around? 

Where can I find help with HIPAA?

Next Century Technologies has a dedicated team of HIPAA experts to assist with everything mentioned in this list. We have a cost-effective approach to HIPAA just for the budgets of the small and medium-sized covered entities. 

Call us at 859-245-0582 or click here to reach out to us.

About the Author

Tracy Hardin is President and founder of Next Century Technologies in Lexington, KY. She has a bachelor’s degree in computer science from the University of Kentucky and has earned certifications from Novell, Cisco and CompTIA. Her specialties in the field of IT are network design and security, project management and improving productivity through technology. She loves helping people by sharing her knowledge of tech.