To safeguard patient data security and privacy, organizations within and adjacent to healthcare must implement the Health Insurance Portability and Accountability Act (HIPAA) safeguards stipulated by the US Department of Health and Human Services (HHS). Compliance with HIPAA enables organizations to methodically secure protected health information and achieve a high standard of patient data security. Read on to learn more.
Critical Aspects of HIPAA Patient Data Security
To achieve ongoing patient data security and privacy, organizations both within and adjacent to the healthcare field must develop a deep and practical understanding of:
- The HIPAA Rules and the requirements they stipulate
- Common HIPAA patient data security challenges
- Best practices for strengthening HIPAA patient data security
Even with an understanding of HIPAA patient data security requirements, challenges, and best practices, your organization may still need to leverage the expertise of a HIPAA compliance partner to optimize HIPAA controls and fully ensure patient data security and privacy.
Breakdown of the HIPAA Rules
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) was enacted to improve the standards of healthcare delivery by safeguarding the privacy and security of patient data. To help organizations within and adjacent to healthcare achieve patient data security and privacy, HIPAA requires these organizations to comply with the four main Rules—securing healthcare transactions and protecting the integrity of sensitive patient data.
The HIPAA Privacy Rule
Compliance with the HIPAA Privacy Rule enables organizations to safeguard all types of patient medical data classified as protected health information (PHI). The Privacy Rule also provides conditions to govern the use and disclosure of PHI, called “permitted uses and disclosures.”
Organizations that must safeguard PHI are classified as “covered entities,” which include:
- Health plans – Organizations that cover the costs of medical care, including:
- Insurers of medical, dental, vision, or prescription drug services
- Employer-, government-, or church-sponsored health plans
- Healthcare providers – Organizations that transmit PHI during healthcare transactions, including:
- Claims and benefits inquiries
- Referral authorization requests
- Billing services
- Healthcare clearinghouses – Organizations that standardize PHI for a health plan or healthcare provider for transactions, including:
- Medical billing services
- Healthcare repricing
- Management of community health information systems
- Business associates of covered entities – Any organization that conducts transactions on behalf of a HIPAA covered entity in which the said transactions involve the use and disclosure of PHI, including:
- Analysis of data related to healthcare transactions
- Processing of insurance claims
- Billing of medical services
As a basic principle, the HIPAA Privacy Rule requires covered entities to limit any instances in which they use or disclose PHI. As such, covered entities can only use or disclose PHI:
- Under the Privacy Rule’s permitted uses and disclosures
- Following the written authorization of the data subject
Further, to protect patient data security and privacy, Covered Entities must only implement the HIPAA Privacy Rule’s permitted uses and disclosures under the following conditions:
- For use and disclosure of PHI to the individual who is the data subject
- For healthcare-related purposes such as treatment, bill payment, or other healthcare operations
- To provide the opportunity for a data subject to agree or object to the use of the subject’s PHI
- In incidental cases directly related to other permitted uses and disclosures
- For activities of public interest and benefit
- For academic or other research, within a limited dataset
Compliance with the HIPAA Privacy Rule enables healthcare organizations to identify and safeguard various types of PHI throughout processing and protect patient data security.
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The HIPAA Security Rule
While the HIPAA Privacy Rule establishes PHI as a sensitive form of data, the Security Rule provides organizations the tools to implement patient data security. This enables organizations to optimize the technologies used in healthcare transactions and reduce data breach risks.
The HIPAA Security Rule comprises three safeguards to secure electronic PHI (ePHI):
- Administrative safeguards – To achieve HIPAA compliance at an enterprise level, the administrative safeguards help organizations implement processes that address patient data security, including:
- Management of security risks and vulnerabilities
- Delegation of security personnel to implement security policies and procedures
- Access-based control of environments containing PHI
- Training and management of workforce security
- Physical safeguards – To secure facilities or physical locations containing sensitive PHI, physical safeguards help healthcare organizations:
- Control access to physical facilities containing PHI
- Safeguard the use and access of devices and workstations containing ePHI
- Technical safeguards – Beyond administrative and physical controls, the Security Rule also helps healthcare organizations implement technical controls to safeguard ePHI, including:
- Controlled access to ePHI environments or systems via technical policies and procedures
- Use of audit controls to record access events to ePHI environments
- Minimizing the alteration of ePHI via integrity controls
- Securing the transmission of ePHI across electronic networks
Compliance with the HIPAA Security Rule will help you secure data environments containing ePHI and maintain a high standard of HIPAA patient data security. While these safeguards are designed for ePHI specifically, they may also protect any non-digitized (legacy) records, as well.
The HIPAA Breach Notification and Enforcement Rules
HIPAA also provides guidance for organizations to report data breaches, should they occur. The Office of the Secretary of Health and Human Services (HHS) oversees the process for reporting PHI breaches, which are loosely defined as any breakage of the Privacy or Security Rules.
Should you experience a data breach, the HIPAA Breach Notification Rule lists the procedures for reporting the incident. If it affects 500 or more individuals, covered entities must:
- Notify the Security of HHS immediately, no later than 60 days from breach discovery.
- Submit the breach notice electronically.
If the data breach affects fewer than 500 individuals, covered entities must:
- Notify the Security of HHS within 60 days of the end of the calendar year of breach discovery.
- Submit a separate notice for each breach incident.
Enforcement of the HIPAA Privacy and Security Rules is overseen by the Office of Civil Rights (OCR), which conducts investigations into complaints of HIPAA non-compliance. In some cases, the Department of Justice (DOJ) may be involved in investigating HIPAA violations.
Patient Data Security Challenges in Healthcare
Although today’s rapid technological advancements improve the speed and efficiency of healthcare transactions and overall healthcare delivery, there remain high risks of data breaches—most of which exploit gaps in patient data security.
The healthcare industry is a frequent target for cyberattacks, with upwards of 45 million individuals being affected by PHI breaches in 2021. The gaps in patient data security and privacy that often result in data breaches can be attributed to several challenges.
Healthcare Security Staffing Burdens
Cybersecurity staffing remains a challenge within, adjacent to, and beyond healthcare. It’s most often a result of budget constraints or deprioritized security initiatives. For organizations within a high cyber risk industry like healthcare, IT security teams should be adequately staffed to minimize the risks of data breaches.
For a healthcare organization to achieve HIPAA-standard patient data security, an understaffed IT security team presents several challenges, including:
- Limited visibility into imminent cyber threats
- Reduced capacity to detect breaches promptly
- Shortfalls in cyber threat detection routines
- Gaps in HIPAA compliance
A more effective alternative to alleviating healthcare security staffing burdens and maintaining robust patient data security is to outsource IT security to a managed security services provider (MSSP), who can oversee the security of your entire IT infrastructure.
Sophisticated Threats to Patient Data Security
Another gap in protecting patient privacy and data security is the fast-changing cybersecurity threat landscape. Cybercriminals are consistently devising new ways to breach healthcare IT systems utilizing vectors such as social engineering.
For example, phishing—the most common form of social engineering—can be tailored to exploit gaps in cybersecurity awareness at all levels within a healthcare organization. A senior-level employee can fall prey to a phishing attack just as often as an entry-level employee.
Sophisticated threats also extend to other factors often beyond the control of most healthcare organizations’ IT security efforts:
- High employee turnover contributes to gaps in access control and strain efforts to protect sensitive PHI environments.
- Vulnerabilities in the compliance and security processes used by third-party vendors working with healthcare organizations also compromise patient data security.
- The use of outdated, difficult-to-replace security systems to monitor cybersecurity threats and vulnerabilities creates gaps in patient data security.
Regardless of the types of challenges your organization may face, complying with the HIPAA Requirements is an effective way to start protecting patient data security and privacy—especially with the help of a HIPAA compliance partner.
HIPAA Patient Data Security Best Practices
For HIPAA compliance to be effective, it must meet your organization’s patient data security needs and safeguard PHI at all stages of processing. It is always best to mitigate threats or risks to the privacy and security of PHI once they are identified rather than dealing with the aftermath of a data breach.
As you optimize your compliance with HIPAA, certain best practices will help your organization maintain HIPAA compliance year-round, streamline enterprise patient data security and privacy, and ultimately strengthen your cybersecurity posture.
Risk Management
To achieve patient data security efficiently and consistently, you need to understand the unique risks faced by your organization. Each organization within or adjacent to healthcare faces specific risks, which must be managed via a comprehensive risk management approach in order to achieve patient data security and privacy.
Based on the guidance provided in the HIPAA Privacy and Security Rules, you can adopt a risk management approach to securing the privacy of patient data by:
- Assessing the likelihood of threat risks to PHI
- Defining the potential impact of a threat to patient data security
- Establishing risk levels for threats to PHI
A comprehensive risk assessment of the potential threats to patient data security and privacy will help define which areas of your cybersecurity program require security optimization to match HIPAA standards.
Security Monitoring
Although security threats evolve rapidly, implementing robust security monitoring tools will help identify these threats swiftly and mitigate potential compromises to PHI and patient data security. Three commonly used security monitoring tools include:
- Penetration testing – Also called “ethical hacking,” penetration testing will help identify gaps in the infrastructure used to process PHI, including:
- Networks that transmit PHI across organizations
- Applications used for conducting healthcare transactions
- Systems that support and connect hardware devices (e.g., workstations)
- Identity and access management – Controlled access is critical to mitigating unauthorized access and intrusion into PHI environments. By employing an identity and access management (IAM) system, you can easily:
- Track login attempts to systems or databases containing PHI
- Monitor unusual access events (e.g., escalation of privileges outside of business hours)
- Delegate role-based privileges to users across the organization
- Security awareness training – Ultimately, HIPAA patient data security comes down to training your employees on cyber vigilance skills that will enable them to:
- Identify phishing attempts and report them to a dedicated IT security team
- Develop secure password use practices (e.g., using complex, hard-to-decipher passwords) on all devices
- Comply with security policies
If your organization has a limited bandwidth, outsourcing security to a managed security services provider (MSSP) can help you achieve robust patient data security at minimum cyberdefense spend, maximizing overall cybersecurity ROI.
Implementing a Security Policy
A highly effective way to standardize patient data security best practices is to establish a security policy that lists processes and procedures for protecting patient privacy and data security for all transactions involving PHI. A compliant patient data security policy should be:
- Updated periodically (at least annually) to align with current data security needs
- Comprehensive, covering data security requirements across your IT infrastructure
- In alignment with changes and updates to the HIPAA Rules and related requirements
Working with a HIPAA compliance partner such as RSI Security will help you get started on implementing a patient data security policy to streamline HIPAA compliance across your organization.
Achieve and Maintain HIPAA Patient Data Security
In spite of the challenges faced by organizations within and adjacent to healthcare in securing PHI, HIPAA compliance can help mitigate pressing patient data security gaps and vulnerabilities and safeguard the privacy of sensitive patient data.
Furthermore, HIPAA compliance will help mitigate costly data breaches and the legal, financial, and reputational consequences of breaches to patient data. As an experienced HIPAA compliance partner, RSI Security will help you optimize HIPAA compliance and develop best practices to achieve ongoing patient data security.
Contact RSI Security today to learn more and get started!
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