The In’s and Out’s of HIPAA Risk Assessments
Keeping patients' sensitive medical information safe is a challenging task every medical practice must take seriously. Healthcare professionals (HCPs) are earnestly working hard to comply with HIPAA rules by safeguarding protected health information (PHI). A HIPAA risk assessment helps HCPs identify and plan how to eliminate threats to the safety and privacy of protected health information (PHI).
A HIPAA risk assessment is a requirement for covered entities and business associates in respective healthcare organizations. It guides them to remain compliant with HIPAA by implementing administrative, physical, and technical safeguards.
Let’s review what a HIPAA risk assessment is and how it works to benefit the healthcare system and patients.?
What Is HIPAA?
The United States Congress enacted HIPAA (Health Insurance Portability and Accountability Act) in 1996 to safeguard PHI from unauthorized access and disclosure that jeopardize its integrity and confidentiality. It is a set of rules for keeping health information safe while making it available to authorized individuals to advance the healthcare industry and improve patient care and outcomes. These rules serve as guideposts for HCPs for HIPAA compliance:
The HIPAA Privacy Rule covers how and when PHI can be used and disclosed. The Security Rule sets the minimum standards for protecting electronic PHI (ePHI). The Breach Notification Rule requires covered entities and their business associates to send notification letters to concerned parties and the Department of Health and Human Services (HHS) within a set period when a breach occurs. The Omnibus Rule contains changes to the law as a result of the enactment of the HITECH Act.?
For a HIPAA risk assessment, the HIPAA Security Rule that covers ePHI is the most important to understand.
The HIPAA Security Rule sets national standards in protecting the ePHI created, received, used, or maintained by covered entities. It requires them to establish appropriate administrative, physical and technical safeguards to ensure the integrity, confidentiality, and security of ePHI.
The HSS, through its Office for Civil Rights (OCR), takes charge of enforcing HIPAA and its rules. The OCR investigates filed complaints and reviews the compliance of covered entities and their business associates to determine possible HIPAA violations. The office also engages these entities to educate them on achieving and maintaining HIPAA compliance.?
Who Are the HIPAA-covered entities?
HIPAA covered entities include any organization, individuals, and agencies that fall under either of the following three categories:
In the healthcare system, these entities manage PHI electronically. They are subject to HIPAA violations when ePHI is compromised, resulting from a data breach, such as ransomware, malware, or a phishing attack. HIPAA violations may cost them penalties or criminal liabilities. In the healthcare business, such a predicament is undesirable and may result in lost patients and profit.?
Undoubtedly, any covered entity would rather learn how to establish and maintain HIPAA compliance than tarnish their professional reputation and lose the ability to deliver or assist in patient care. A HIPAA risk assessment is the first decisive step.
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How Can You Perform a HIPAA Risk Assessment?
Carrying out a HIPAA risk assessment to ensure HIPAA compliance is a fundamental step in safeguarding ePHI. It is a rigorous evaluation of HIPAA compliance to determine the most appropriate and adequate physical, technical, and administrative protection for ePHI.
However, even with sophisticated security measures to protect ePHI, reports on cybersecurity attacks and threats continue to rise. There is no single way of implementing an accurate HIPAA risk assessment. Regardless, the HHS wants HIPAA risk assessments in all healthcare systems. It helps HCPs chart out potential security risks to ePHI they create, collect, store, and share.?
The HSS recommends covered entities to do the following in a HIPAA risk assessment:
The HIPAA risk assessment process follows a specific guide. Covered entities, however, can expand, within the scope and structure of the assessment, to discover as many threats and vulnerabilities as possible in their different services and operations. A HIPAA risk assessment is not a one-time thing; covered entities must do it at least once a year.
If it’s beginning to sound laborious, it’s not a bad thing to ask for help. Anyway, there are tools to help you get through the job. You can choose between the government’s Security Risk Assessment Tool or third-party applications, such as Curogram.?
Use Tools to Assist with HIPAA Risk Assessments
The complexity of HIPAA risk assessments on the operations of a healthcare organization can be overwhelming enough to leave loopholes instead of tying loose ends, especially for small and medium practices. With their limited resources and inexperience with HIPAA, and its rules and required compliance, they need help with the task.
In 2014, the OCR and the Office of the National Coordinator for Health Information Technology (ONC) released the Security Risk Assessment (SRA) tool to help small and medium-sized medical practices with HIPAA risk assessments. The SRA tool serves as an instrument for covered entities, mapping out potential security risks and vulnerabilities to ePHI. It helps them go through the process as required by the HIPAA Security Rule.
The SRA tool stores the information that covered entities enter into it from their respective computers or gadgets. The HSS does not collect and share this information. However, it displays a report of the assessments to see the potential risks in a given practice's or companies policies, processes, and systems. The report helps the user to implement measures to mitigate any determined dangers.?
Although the SRA software covers 156 questions that assess ePHI's integrity, confidentiality, and availability, the tool itself does not guarantee HIPAA compliance, as stated in its accompanying User Guide. It does not, for example, suggest how to assign risk levels or recommend what policies and necessary procedures to carry out.?
Other third-party tools also help identify these vulnerabilities. But they do not provide a fully-compliant HIPAA risk assessment. It means they can assist in evaluating and determining the risks but do not offer complete solutions. Today, some software applications don’t provide HIPAA risk assessment but instead help avoid leaks of ePHI. These tools help resolve existing risks to comply with HIPAA and know that later assessments bring positive results.?
Let Curogram Help You Maintain HIPAA Compliance (at least when it comes to communication)
While third-party tools help covered entities with a HIPAA risk assessment, they do not offer solutions to keep ePHI safe. Curogram is a 100% HIPAA-compliant patient communication platform and front-desk suite.?
Curogram eliminates risks and vulnerabilities from cyberattacks by encrypting all medical information created and stored in computers and mobile devices. It also encrypts transmitted and received messages that contain ePHI. Its 2-way text messaging enables convenient communication between patients, staff, colleagues, and associates with full HIPAA compliance to deliver patient care more effectively.?
Using a practice management system like Curogram saves covered entities the time and effort of mapping out HIPAA compliance risks and working out the mitigation measures. Curogram has these vulnerabilities identified and addressed.
Demo Curogram now and discover how it can help you comply with HIPAA rules.?