Organizations operating in and adjacent to healthcare need to be HIPAA compliant, and that includes having an incident response plan in place. There are many approaches that work, but tailoring government-recommended best practices to your needs is a near-foolproof option.
Is your organization fully compliant with HIPAA? Schedule a consultation to find out.
The Why and How of HIPAA-Compliant Incident Response
The Health Insurance Portability and Availability Act of 1996 (HIPAA) requires healthcare providers and other organizations to safeguard protected health information (PHI). One critical part of that protection is having contingency plans in place such that impacted individuals are protected even in the event of a cyberattack or other incident. Creating such a plan requires:
- Understanding the intersection of HIPAA rules and incident response
- Following government-provided best practices, tailored for HIPAA
- Accounting for post-incident recovery, including breach notification
Working with a quality compliance partner is the best way to implement and manage incident response policies that meet and exceed the requirements of HIPAA and other regulations.
Why You Need HIPAA-Compliant Incident Response
HIPAA, which is governed by the US Department of Health and Human Services (HHS), explicitly requires incident response planning by way of the Security Rule. In fact, all three prescriptive HIPAA rules relate to incident response planning in one way or another.
The HIPAA Privacy Rule mandates safeguarding PHI and preventing any unauthorized uses or disclosures thereof. In practice, cybersecurity incidents might directly cause a breach or render PHI susceptible to one, so incident response needs to include special attention to PHI privacy.
The HIPAA Security Rule extends these protections, requiring specific infrastructure to prevent such disallowed PHI access and to prevent the possibility of a breach. In particular, the HIPAA Security Rule calls for Administrative, Physical, and Technical Safeguards to be implemented, one of which is establishing a “Contingency Plan” that includes backing up and restoring PHI while also ensuring business continuity and security while “emergency mode” is activated.
The third rule, on breach Notification, will be touched on in a dedicated section below.
Simply put, the HHS requires organizations governed by HIPAA to create, implement, and manage incident response plans to ensure PHI is safeguarded even in the event of an attack.
Who Specifically Needs to Have HIPAA Incident Response
Another part of the “why” is determining whether or not the HIPAA law protections apply to your organization or to a specific business segment therein. While the framework primarily targets the healthcare industry, its effects are felt by any other organizations that work alongside it.
The parties to whom HIPAA most directly applies are covered entities, including:
- Healthcare providers, such as private practices, group care facilities, and pharmacies
- Health plan administrators, including both insurance companies and intermediaries
- Healthcare clearinghouses that process nonstandard or standardized health data
Beyond these parties, HIPAA also applies to covered entities’ business associates, such as professional service providers, so long as they come into contact with PHI. In practice, most organizations that collect, process, or otherwise contact PHI need to comply with HIPAA. That means all these kinds of organizations need to implement HIPAA-compliant incident response.
If you come into contact with PHI, you likely need a HIPAA-compliant incident response plan.
The Phases of HIPAA-Compliant Incident Response
One thing that makes HIPAA unique as a regulatory framework is that it gives organizations flexibility in terms of how to meet its standards. Rather than prescribing specific tools or means, HIPAA mandates thresholds to be met (i.e., definitions of unauthorized uses to prevent) and lets applicable parties decide how to meet them. The same goes for incident response planning.
The HHS does not mandate a particular kind of incident response plan. It just mandates that organizations have one in place. It does, however, provide guidance and recommendations.
In a joint publication with the National Institute of Standards and Technology (NIST), the HHS outlined several approaches to cybersecurity incident response plans that healthcare and related organizations can use. While HIPAA and the HHS are not strictly prescriptive, they do strongly suggest using NIST’s guide to incident response, Special Publication (SP) 800-61.
What follows is a breakdown of the four phases of the incident response life cycle, per NIST SP 800-61, with specific recommendations and considerations for compliance with HIPAA’s rules.
Phase 1: Preparation and Preemptive Protections
The first and most fundamental step toward incident response is preventive preparation. NIST recommends accounting for incident handler communications and facilities independently of incident analysis infrastructure. For the former, organizations should index contact info for all parties that could be impacted internally by an incident, create on-call protocols, and establish the “war room” that will centralize and secure communication in the event of a cyberattack. For the latter, NIST recommends installing protections such as packet sniffers across all devices and creating exhaustive inventories of devices, secure baselines, and cryptographic hashes.
The other side of preparation is prevention proper. This includes conducting risk assessments and ensuring network and host security, along with providing regular training to keep staff both informed and vigilant. For covered entities, risk analyses are another critical part of the HIPAA Security Rule and HIPAA compliance more broadly. Tailoring risk assessments to broader incident response and readiness is one way to optimize your overall compliance process.
Phase 2: Detection, Analysis, and Identification
Preparation is an ongoing practice. The second phase has an ongoing component, as incident monitoring should similarly be running at all times to ensure attacks are detected as swiftly as possible. But then, once an incident is spotted, the reactive portion of this phase commences.
In terms of detection, NIST recommends attuning organizational monitoring to specific attack vectors common in its business environment. Constantly searching for these and other incident indicators, like irregularities or unauthorized access attempts, will lead to swift identification.
Analysis is also critical to effective incident response, and it’s a process that continues on into the following phases and long after the incident has been resolved. Initial analysis should be focused on determining causes and solutions, while longer-term forensic analysis should generate threat intelligence to bolster incident prevention efforts in the future. For HIPAA purposes, compliant incident analysis should also determine the extent of PHI leakage to ensure accurate reporting and assistance for individuals to whom the PHI refers (see below).
Additionally, conducting annual tabletop exercises is an essential practice to enhance preparedness. These exercises simulate potential incidents in a controlled environment, allowing teams to practice detection, response, and resolution strategies without real-world consequences. Regularly engaging in these exercises ensures that staff remain well-versed in incident response protocols, helps identify gaps in current processes, and may be a requirement for compliance under certain regulatory frameworks.
Phase 3: Containment, Eradication, and Recovery
This next phase is where the incident is dealt with most actively. It comprises active hunting and elimination tactics to sequester and remove all traces of the attack or issue (aside from any kept for forensic analysis) while also recovering and ensuring continuity across non-impacted areas.
The three sub-phases to account for are all equally critical to overall incident response:
- Containment – Intruders or elements of the attack need to be confined to a limited area, such that any areas not yet impacted do not become infected. This involves both closing off pathways attackers could use and removing untouched data from vulnerable spaces.
- Eradication – All traces of the attack and any malicious code left behind need to be removed completely. Samples may be retained for follow-up reporting and analysis.
- Recovery – Wherever possible, systems and data need to be backed up so that they can be restored to pre-breach status. This can happen as soon as threats are cleared.
However, these should not be seen as linear or finite, as though eradication and recovery can only happen once an incident is fully contained. Instead, the first two should be engaged at the same time, and recovery proper can commence once threat levels are sufficiently lowered.
Phase 4: Post-Incident Activities
At this stage, incident response moves from triage to recovery and preparation to avoid any other similar attacks in the future. NIST recommends a wide variety of data gathering and analytical practices here, beginning with collecting exhaustive information on the kind of incident that occurred, the number of attackers or vulnerability points, the efficacy of existing defense mechanisms and teams, and the extent of long-term damage that might have been sustained.
However, there is an additional layer of infrastructure needed in HIPAA contexts. Covered entities and business associates need to provide specific forms of HIPAA breach notification.
Post-Incident Recovery and Breach Notification
Beyond the Security and Privacy Rules, the HIPAA Breach Notification Rule can be easy to overlook. Nevertheless, it’s a critical part of HIPAA compliance. It requires sending specific forms of notification to impacted parties to minimize the harm that a breach of PHI could cause.
The three kinds of breach notification that need to be provided if a breach occurs are:
- Individual Notice – Parties to whom PHI refers need to be notified if PHI that identifies them has been breached. Notice must go out within 60 days of the breach’s discovery.
- Secretary Notice – The Secretary of the HHS must be notified of a breach within 60 days if it impacts 500 or more individuals or annually if it impacts fewer than 500 people.
- Media Notice – Similarly, if a breach impacts 500 or more people within a given location, notice must be sent to a media outlet serving that area within 60 days of the breach.
An incident response plan needs to account for these notification requirements proactively, with communication channels and infrastructure in place and ready to activate when the time comes.
How to Streamline Compliance and Incident Response
HIPAA incident response is one of the more complicated parts of overall HIPAA compliance. It can be difficult for organizations to manage these requirements, especially if they normally operate outside of a healthcare context and are only subject to HIPAA because of a business relationship with a covered entity. Equally challenging is the fact that these requirements will often apply simultaneously with other regulatory frameworks (i.e., PCI, GDPR, etc.).
One of the best ways to streamline compliance across multiple rulesets is implementing an omnibus framework such as the HITRUST CSF. HITRUST compliance allows for a single installation of controls and a single assessment that satisfies compliance conditions for HIPAA regulations and many others. This minimizes costly overlap and maximizes security, efficiently.
Optimize Your HIPAA Compliance Process Today
Ultimately, incident response planning is crucial to HIPAA compliance and avoiding potential HIPAA violations. You need to have plans in place to address and recover from any attacks or other emergencies that happen and ensure the privacy and integrity of PHI along the way.
RSI Security has helped countless organizations achieve HIPAA compliance. We know that the right way is the only way to safeguard PHI, and we’ll help you rethink your incident response plan to assure seamless, long-term compliance with HIPAA laws (and other regulations).
To learn more about our HIPAA compliance services, contact RSI Security today!
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