Unlocking the Basics of HIPAA Audit Trail

Around 30 percent of the world data volume is generated by the healthcare industry. A variety of patient information is collected and stored in the system, from medical bills to treatment plans. This data is sensitive in nature and hence it needs to be protected from cyberattacks.

HIPAA (Health Insurance Portability and Accountability Act) rules and regulations ensure that ePHI (Protected Health Information) is safe and secure from potential hackers. These regulations mandate the BA (Business Associates) and CE (Covered Entities) to maintain the privacy and security of ePHI.

To comply with HIPAA regulations, CE and BA must adhere to certain requirements, and audit trail is one of them. HIPAA audit trails ensure that health information is tracked and monitored to maintain data security. The tracking system immediately alerts the authorities if there’s a data breach.

Learn about the nitty-gritty about HIPAA audit trails and log requirements in this article, which will help you to get started on your audit trails.

HIPAA Audit Trails and Logs: An Overview

Healthcare systems process thousands of activities each day ranging from user access to payments. These activities are recorded as audit logs and they are crucial for administrators because the logs show how and when events have occurred.

For a healthcare organization, HIPAA audit trails and logs can:

  1. Record details such as timestamps, username, and which patient data is accessed.
  2. Capture login, logout, and access to ePHI.
  3. Alert admins in case of security violations or unauthorized access.
  4. To demonstrate the organization’s compliance with HIPAA during audits.

HHS defines audit logs and audit trails as follows:

“According to the National Institute of Standards and Technology (NIST), audit logs are records of events based on applications, users, and systems, and audit trails involve audit logs of applications, users, and systems. Audit trails’ main purpose is to maintain a record of system activity by application processes and by user activity within systems and applications.”

Furthermore, audit logs are stored securely, in a tamper-proof location. Healthcare organizations are required to analyze and review log data periodically to check compliance and improve cybersecurity.

Benefits of HIPAA Audit Trails

Here are the three key benefits of implementing HIPAA audit trails and log requirements:

1. Forensic Analysis

According to an article published by Investopedia, ‘A forensic audit evaluates and examines an organization’s financial records to derive evidence to be used in the court of law. A forensic audit is conducted to prosecute a party for embezzlement, fraud, and other financial crimes.’

A HIPAA audit trail offers critical information on the nature of the security incident and the parties involved. By analyzing the logs, healthcare organizations can identify what went wrong and devise a solution for it.

2. Identify Security Defects and Incidences

HIPAA audit trails and log requirements allow healthcare organizations to detect security incidences beforehand. These incidences may include unauthorized access to ePHI, data breaches, system malfunction, or financial scam.

Continuous monitoring of audit trails and logs can help organizations to spot potential anomalies and respond swiftly, thereby mitigating damage and safeguarding ePHI.

3. Improve Operational Efficiency

With HIPAA audit trails and logs, organizations can improve operational efficiency as well. A well-structured audit trail helps medical and admin staff to comprehend their roles and the limits to access ePHI.

Moreover, system monitoring, regular risk assessments, and audit controls contributes to informed-decision making and risk management, thus streamlining healthcare workflows.

HIPAA Audit Trail Requirements

The CE and BA must maintain audit trails and audit logs, however the Security Rule doesn’t clarify which information needs to be tracked. With security and privacy of ePHI in mind, organizations can monitor the integrity and use of systems that transmit and store ePHI.

The three components of HIPAA audit trail requirements are: system, user, and application.

1. System Audit Trail Requirements

A system audit trail encompasses audit logs of time-stamps, logging credentials, and access attempts. The audit trail monitors the IP address, devices used for login, and location of the devices. Tracking these activities allow organizations to determine which actions are violating HIPAA regulations.

2. User Audit Trail Requirements

There’s an audit log for every user accessing the ePHI. User audit trail requirements includes information on login, users, logoff, password updates, and authentication attempts. Review of user audit logs can alert the organizations about breaches. It can also point out about a suspicious login activity, indicating that credentials have been stolen.

3. Application Audit Trail Requirements

Application audit trails track and log user activities in the application. This encompasses application files opened and closed, and reading, creating, deleting, and editing of application records associated with protected health information.

HIPAA Audit Log Requirements

The healthcare organizations are required to track the following requirements as part of the HIPAA audit log:

  1. Anti-malware logs
  2. Firewall logs
  3. Logins for operating systems
  4. File access
  5. Access level for every user
  6. Addition of new users
  7. Changes made to databases
  8. User login activities

For How Long to Retain Audit Logs?

According to the HIPAA Journal, ‘The HIPAA retention requirements are that certain documents must be maintained for six years from the date of their creation or from the date they were in effect, whichever is later.’

HIPAA classifies retention for two types of documents – HIPAA medical records retention and HIPAA retention for other documents.

The Privacy Rule doesn’t state for how long the medical records should be retained because each state has its own laws on medical records retention. So, BA and CE are bound by the state laws on how long the medical records must be retained.

There are requirements for how long other HIPPA documents must be retained. These requirements are stated in 45 CFR 164.530 and 45 CFR 164.316. Both of these rules state that CE and BA must document procedures and policies implemented to comply with HIPAA. Both the rules stipulate that the documents must be retained for the minimum period of six years from the date it was created or when it was last in effect. HIPAA audit trails and logs fall under the other document category, hence it should be retained for six years.

Getting Started with HIPAA Audit Trails

New to HIPAA audit trails, here’s how you can do it:

  1. Select the Technology: Select the technology for which you want to start audit trails and logs. For instance, in the case of EHR software ensure that it supports the essential audit trail functions as per the HIPAA regulations.
  2. Staff Training: Educate the staff on HIPAA audit trail requirements mentioned in the Security Rule. Provide hands-on training experience for accessing and checking audit trail data. Explain about the best practices for maintaining the integrity and confidentiality of ePHI.
  3. Continuously Monitor and Review the System: Implementing HIPAA audit trails is not a one-time task, it requires continuous reviewing and monitoring, to ascertain compliance. So, conduct regular audits to detect anomalies that may trigger data breach. Plus, conduct incident responsive exercises to test the organization’s capability to respond to security breaches.
  4. Connect With an Expert: Finding it hard to manage HIPAA audit trails? Just connect with a healthcare software development company who will help to conduct audits seamlessly.

Arkenea, a healthcare software development company promises to deliver HIPAA-compliant solutions for your organizations, so you never have to face anomalies during audit trails. Get a customized HIPAA compliant healthcare software developed today. Connect with us for a consultation call.