Key Takeaways
- To safeguard ePHI, understand the three rules: the Privacy Rule, the Security Rule, and the Breach Notification Rule. Having a profound understanding of the HIPAA rules puts you one step ahead in the healthcare sector.
- HIPAA risk assessment ensures that ePHI is protected from threats and vulnerabilities such as fraud, data breaches, financial scams, identity thefts, etc.
- In case of security issues file a Security Rule complaint on the OCR compliant portal. If considering faxing or mailing the complaint, then send it to the appropriate OCR regional office.
Cyber security continues to be the top priority for healthcare organizations owing to the rising number of thefts and data breaches. Nearly 45 million records were exposed or stolen in 2021. Stolen data is the leading cause of identity theft and credit card fraud. So, to safeguard ePHI (Protected Health Information) from cyber attacks, healthcare organizations and medical software development companies are imposing strict HIPAA compliance regulations.
To stay on top of protecting ePHI, ensure to run through the HIPAA compliance checklist covered in this article. But, before divulging it, let’s check:
Who is HIPAA Compliance Applicable for?
- Covered Entities (CE): These are involved in transmitting, storing, and creating ePHI, so they must follow HIPAA compliance rules. Covered entities include health insurance companies, health plans, healthcare programs by the government, healthcare providers, and healthcare clearinghouses.
- Business Associates (BA): These handle ePHI obtained from the covered entities, but don’t create medical data. CE have contracts with business associates, to ensure that they use and disclose medical data properly and also protect it. Business associates include billing and healthcare claims companies who help doctors get paid for offering their services. Companies that administer health plans and store or destroy medical records are also considered as BA. Along with this, lawyers, IT specialists, and accountants fall under BE too.
HIPAA Compliance Checklist
1. Understand HIPAA Rules
To safeguard ePHI, comprehend the three golden rules of HIPAA compliance: The Privacy Rule, the Security Rule, and the Breach Notification Rule. Having a profound understanding of the HIPAA rules puts you one step ahead in the healthcare sector. Chances of losing data decrease significantly, along with facing penalties for not imposing these regulations.
The Security Rule establishes standards for protecting health data that are created, transmitted, and stored. Whereas, the Privacy rule maintains the confidentiality of healthcare data by imposing encryption, assuring authorized access, allowing patients to review data, etc. The administrative, technical, and physical, safeguards are included in the Security Rule.
The Breach Notification Rule requires BA and CE to provide notification of a breach involving unsecured protected health information. A risk assessment is performed upon a breach to determine the scope of the incident.
2. Find the Right Security Vendors
Security vendors specialize in handling compliance for those who lack the resources to carry it out themselves. Companies that offer HIPAA compliance services provide software that adheres to all regulations. These companies are trained to handle risks, and security issues, and offer a solution to counter complaint problems. Collaborating with HIPAA compliance service providers can help to maintain the privacy and security of ePHI.
3. Conduct HIPAA Risk Assessment
HIPAA risk assessment ensures that ePHI is protected from threats and vulnerabilities such as fraud, data breaches, financial scams, identity thefts, etc. Risk analysis identifies current threats and vulnerabilities that may impact medical data, healthcare organizations, providers, and vendors in the future.
It is the first step before implementing the Security Rule, it forms a foundation for further data protection strategies. Based on HIPAA risk assessment, the security officer assigns risk levels for each electronic data, for instance high, medium, or low levels. The entire risk analysis is documented and reviewed periodically to prevent ePHI violations.
4. Prevent Compliance Violations
Once risk assessment is conducted, establish privacy and security rules to maintain compliance, and to prevent HIPAA violations. Have technical, physical, and administrative safeguards in place. Check for data encryption while exchanging ePHI and adhere to the authorized access rules to maintain data privacy. Avoiding HIPAA compliance violations saves healthcare organizations, vendors, business associates, and covered entities tons of money. Facilities can end up paying up to $50 million for violating compliance regulations.
Organizations with the least or no compliance violations are preferred by the patients as it reassures them that their data is in safe hands, thus building a reputation for organizations in the healthcare sector.
5. Plan for Emergencies
Emergencies can be of any type: technical, non, technical, natural, or accidental. So, before any emergency strikes, ascertain that there’s a robust healthcare data backup and recovery process in place. Also, an emergency can include compliance violations, so have enough financial support to pay off the penalties.
Moving on, in times of emergencies it may not be possible to save all data. So, sort out the most critical data right from the beginning. During the data backup process, the critical data can be moved first, followed by the rest of the data. Also, consider saving medical data at three different locations: two copies of media, and one offsite. Recovery solutions include cloud storage and physical data centers.
6. Report Security Issues Immediately
In case of security issues, report it as soon as possible, so the authorities can conduct their investigation and resolve the issue quickly. File a Security Rule complaint on the OCR compliant portal. If considering faxing or mailing the complaint, then send it to the appropriate OCR regional office.
Every regional office covers a specific state and sends the complaint to the OCR Regional Manager. It is also essential to conduct a risk assignment from your end before the investigation is conducted by the authorities.
7. Maintain Documentation
This probably one of the key factors in the HIPAA compliance checklist. It is essential to document diligently everything related to HIPAA compliance. Log and records help to keep policies and procedures transparent. HIPAA compliance documentation includes the following:
- Policies and procedures of HIPAA
- HIPAA risk analysis
- Actions to deal with vulnerabilities
- Privacy practices
- HIPAA risk management plan
- Employee sanction policy
- List of vendors
- Contracts
- Work desk processes
- Training logs
- Breach response plan
- Business associate agreements
- Media used to store ePHI records
- Password policies
- Disaster recovery plan
- Maintenance records
- Documentation of incidents
- Authorization for disclosing ePHI
- Physical security maintenance records
8. Monitor and Update Compliance Policies
There’s a constant change in the policies regarding the way healthcare data should be handled. Also, policies concerning the security and privacy of ePHI face alternations due to technological advancement.
As of today, new healthcare data policies regarding the use of the cloud as storage space and the use of artificial intelligence such as ChatGPT in healthcare are being made. So, healthcare organizations and vendors must consider revised rules and regulations concerning the healthcare industry. Updated policies can be put into action, to avoid violations in the future.
9. HIPAA Compliance Training
The last factor on the HIPAA compliance checklist is training of workforce. Both HIPAA Security Rule and Privacy Rule mention that training must be provided to the workforce. Security Rule states that all the staff has to participate in the awareness and training program. Covered Entities are required to train their workforce on policies and procedures on ePHI.
Also, the Business Associates are trained for reporting security incidences and breaches to the Covered Entities. HIPAA compliance training increases awareness amongst the staff about the importance of the ePHI, why it needs to be protected, and ways to protect it effectively.
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