My Proven HIPAA Security Strategy to Achieve Compliance

You know as well as I do that achieving and maintaining HIPAA compliance isn't always straightforward.

Over my 15 years of working in the cybersecurity...

And working with telemedicine, wearable, EHR, and other health tech companies, I’ve developed a proven strategy for fast-tracking HIPAA compliance!

Today, I’ll walk you through my step-by-step strategy for achieving and MAINTAINING compliance.

A strategy that’s designed to help you minimize risk, streamline your processes, and achieve customer trust!

Step 1: Discovery & Scoping

Before you can make any meaningful progress toward HIPAA compliance, you need to fully understand the scope of your efforts.

You don't understand how important this is!

This includes identifying all systems, processes, data flows, and individuals that interact with patient data.

Discovery and scoping ensure that nothing falls through the cracks, and it sets the security foundation.

How I Approach Discovery & Scoping

Discovery involves identifying all ePHI (electronic PHI) within your organization.

Think "where this data is stored, "how is data transmitted," and "who has access to it."

Scoping defines the boundaries of your efforts.

Determining which systems and processes should be included within your HIPAA compliance program.

Why is this important?

Because if you are a larger organization, all of your systems may not fall under HIPAA.

And this is why centralizing patient data is a game changer!

Key Actions:

1. PHI Data Mapping: Identify where ePHI is stored, accessed, and transmitted across your organization.
2. Identify Stakeholders: Determine all internal and external parties that interact with ePHI, including third-party vendors and contractors.
3. System Inventory: Create an inventory of all systems, software, and people that process, store, or transmit ePHI.
4. Define the Scope: Establish which systems, departments, and vendors fall within the scope of your HIPAA compliance efforts.

Step 2: Conduct a Thorough Gap Assessment

One of the primary differences of my HIPAA compliance strategy is performing a in-depth gap assessment.

But here's the KEY difference...

I don't just focus on the gaps.

I look at your entire cybersecurity infrastructure from a holistic perspective AND conduct a HIPAA compliance risk assessment too!

Why Gap Assessments are Critical

Before you implement any security measures, you need to understand what your gaps are!

This means going beyond just checking boxes for HIPAA.

You need to evaluate your data flows, access controls, business associate agreements (BAA), encryption standards, and incident response & continuity plans!

Adding a risk assessment is a cherry on top!

It will reveal the potential threats that could compromise patient data and violate HIPAA compliance requirements!

Key Actions:

1. Gap Analysis: Compare your current security posture against HIPAA requirements to identify areas that need improvement. Take it a step further and compare it to a framework, more on that soon!
2. Identify Risks: Highlight weaknesses in your existing security controls, especially around access controls, encryption, and audit trails.
3. Evaluate Vendor Compliance: Ensure that third-party vendors and business associates also adhere to HIPAA regulations, particularly through business associate agreements (BAAs).
4. Mitigation Strategy: Develop a detailed plan to address vulnerabilities in line with HIPAA's Security and Privacy Rules.

If you don't know how to do this part, I created a HIPAA Assessment tool to get you started!

Step 3: Selecting a Security Framework

While HIPAA provides guidelines, it doesn’t specify the BEST controls that need to be implemented.

That’s where a security framework comes in!

Selecting the appropriate framework sets the foundation of how your cybersecurity program functions.

It helps align organizational goals with security!

It helps with selecting security controls!

It increases your trust with customers!

How I Select the Right Framework

I guide organizations in selecting the security framework that best fits their long term goals.

Frameworks such as NIST (National Institute of Standards and Technology) and ISO/IEC 27001 provide solid foundations for building a security strategy that protects ePHI and ensures compliance.

Key Actions:

1. Framework Selection: Determine whether NIST or ISO/IEC 27001 is the best fit for your organization.
2. Tailored Implementation: Customize the security controls to align with HIPAA regulations while also addressing your organization’s unique security needs.
3. Ongoing Updates: Revisit the framework when you need ideas for advanced security controls to ensure ongoing compliance as regulations and threats evolve.

Step 4: Writing HIPAA Policies is Essential

Without clearly defined policies, even the best technology and security measures fall short.

Well-written policies help ensure that you're prepared for any situation.

Whether it’s responding to a data breach, training employees, or maintaining the privacy of patient data.

These documents also demonstrate compliance during audits.

Giving auditors and your CUSOTMERS concrete evidence that you're adhering to HIPAA requirements!

How I Approach Policy Writing

I draft policies that don't just meet regulatory requirements but achieve the following:

• aligned to a framework
• tailored to your business
• will pass auditor and customer assessments with flying colors

Key Actions:

1. Identify Required Policies: Ensure your organization has all the mandatory HIPAA policies, including Privacy, Security, and Breach Notification.
2. Tailor to Your Operations: Customize policies to fit your organization’s specific workflows, technologies, and personnel.
3. Create an Business Continuity Policy: Draft a detailed continuity policy outlining steps to take in the event systems go down.
4. Sanctions Policy: Write a policy that clearly defines the repercussions for security violations for your workforce.
5. Review and Update: Regularly review and update policies to reflect changes in regulations, technology, and your ecosystem.

Step 5: Prioritize Security Controls

The configuration of technical security controls is important when it comes to protecting patient data.

The HIPAA Security Rule mandates security controls such as encryption, access controls, logging, etc. as required safeguards.

However, every system isn't equal therefore some systems should have more controls than others!

How I Select HIPAA Technical Safeguards

One of the things that differentiates my approach is that I categorize systems based on the data they manage.

Once this is done, you should create a baseline of controls for each system according on their category.

Think HIGH, Medium, and Low.

This balances security with efficiency!

Key Actions:

1. Control Selection: Implement security controls that not only meet but exceed HIPAA standards. This includes servers, APIs, etc. AND workforce member workstations.
2. Role-Based Access Control (RBAC): Set up granular access controls that segment users based on their roles within the organization, minimizing the risk of unauthorized access.
3. Multi-Factor Authentication (MFA): Add an additional layer of security by requiring MFA for access to ePHI, whether remotely or internally.
4. Encryption: Ensure that all ePHI stored and in transit on servers, databases, or any other systems is encrypted using AES-256 or higher.
5. Separation of duties: Implement multi-approval processes for critical actions, such as granting access to or making significant system changes to systems with ePHI. This ensures that no single person has complete control over these processes. (This also helps thwart Ransomware)
6. Audit Logging: Ensure audit logs are active, reviewed regularly, and accessible during a potential breach investigation.

Step 6: Implement a Training Program

From preventing phishing attacks to ensuring proper data handling...

Employee awareness can make or break your compliance efforts.

A well-informed team reduces the likelihood of a breach.

And also fosters a culture of security throughout the organization.

In my strategy, training is key.

Your workforce is the first line of defense against breaches and violations so making a customized training program is an absolute necessity.

How I Approach HIPAA Compliance Training

I develop training programs that are tailored to the needs of the organization.

Rather than using generic, one-size-fits-all solutions,

I ensure the content is relevant to your specific workflows, systems, and potential risks.

I ensure that training is role specific, mimics current events, and increases your workforce's awareness.

The goal is to make training as engaging, applicable, and effective as possible!

Key Actions:

1. Annual HIPAA Training: Schedule annual HIPAA compliance training for all employees, focusing on data protection, proper use of ePHI, and recognizing potential threats.
2. Phishing Simulations: Conduct regular phishing simulations that emulate current events "think election time," to test staff awareness and readiness to respond to threats.
3. Real-World Scenarios: Provide training scenarios that simulate actual security incidents, helping employees understand the importance of proper response protocols.
4. Record-Keeping: Document all training activities to demonstrate compliance during an audit and for customer assessments.

Tip: Involve your marketing team!

Step 7: Monitor & Audit Regularly

Compliance isn’t a one-and-done process.

It requires regular monitoring and auditing to ensure your organization is compliant and safe!

This requires actively looking for threats in your environment and auditing your controls.

My strategy involves setting up continuous monitoring systems that give you real-time insights into threats and your compliance posture.

How I Monitor for Ongoing Compliance

I help implement automated auditing tools that do the following:

• identify threats in real-time
• continuously scan systems for vulnerabilities
• document compliance activities

Audits are setup on an annual basis to identify and close gaps.

This approach ensures that you're always one step ahead and improving security every year.

Key Actions:

1. Automated Monitoring Systems: Use technology to automatically monitor your infrastructure for HIPAA compliance, including logs, security events, and data flows.
2. Regular Audits: Conduct audits to identify areas that may require attention before they become larger issues.
3. Incident Response & Business Continuity: Test your incident response and business continuity plans out annually to ensure effectiveness.

Bonus: How To Prove Compliance to Customers

Achieving HIPAA compliance is critical for protecting patient data and avoiding legal penalties.

But for the success of your organization, proving your compliant to customers is just as important.

For health tech leaders demonstrating compliance is essential in earning customer trust securing new contracts, and maintaining existing relationships.

Here's how you can effectively prove compliance to customers:

• provide customers with a HIPAA compliance summary
• make sure documentation is available if requested (but don't share everything!)
• Provide redact copies of your audits and assessments
• Showcase your cybersecurity certifications
• include security topics in your webinars

Beyond Compliance, Cultivate Trust

By following my proven strategy, you can achieve HIPAA compliance with confidence.

My approach not only ensures that your organization remains HIPAA compliant but also enhances your overall marketability.

I hope this helps!

Feel free to reach out if there's a topic you'd like to see covered in my next newsletter.

Until next time, stay secure and keep innovating.

Thanks for reading and subscribing!

Larry

P.S. If you don't know where to start on your HIPAA journey, head over to my helpful free HIPAA compliance assessment tool.

As Founder of Inherent Security, Larry Trotter II is responsible for defining the mission and vision of the company, ensuring execution aligns with the business.?Larry has 15 years of cybersecurity experience including industry recognized certifications (e.g., CISM, ISO 27001.) His healthcare expertise includes working with health tech EHR, telemedicine, mobile, medical device, and behavioral health organizations. He has helped both Business Associates and Covered Entities, giving him a deep understanding of your patient security challenges, allowing him to offer solutions that are tailored for your unique needs.