For organizations within and adjacent to healthcare, safeguarding patient health information, also known as protected health information (PHI), is critical. These organizations must comply with HIPAA stipulations to maintain the security of electronic health records and avoid the consequences of non-compliance violations. Read on to learn more.
Best Practices to Implement the Security of Electronic Health Records
Of the four primary HIPAA Rules, the HIPAA Security Rule addresses the security of electronic health records, also known as electronic PHI (ePHI). The Security Rule comprises:
- Administrative-level safeguards to secure ePHI across various departments
- Physical safeguards to protect ePHI within an organization’s physical infrastructure
- Technical safeguards to mitigate threats to ePHI within IT systems and components
With the help of an experienced HIPAA compliance advisor, your organization can implement appropriate HIPAA safeguards, ensuring the security and privacy of electronic health records.
But first, you’ll need to understand if and how the Security Rule applies to you.
Security Rule and HIPAA Applicability
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) was established to secure all PHI transactions, providing organizations within and adjacent to healthcare a set of recommended safeguards with which to comply. The Security Rule broadly describes technical and non-technical controls that organizations must implement to protect electronic records like:
- Physical or mental health records (past, present, or future)
- Details of healthcare service provision
- Payment information for health services
The scope of Security Rule safeguards aligns with the Privacy Rule, which establishes PHI as a sensitive type of information. Additionally, the Privacy Rule defines HIPAA covered entities as:
- Health plans, which finance medical services
- Healthcare providers, which provide medical services
- Healthcare clearinghouses, which standardize PHI transmission across entities
Covered entities and select business associates must establish HIPAA safeguards in compliance with both the Privacy and Security Rules. Other applicable rules include:
- The Breach Notification Rule, which outlines the reporting responsibilities for covered entities and business associates following the discovery of a breach.
- The Enforcement Rule, which stipulates the penalties associated with compliance violations.
For your organization to ensure the security of electronic health records, you must implement the recommended HIPAA Security Rule administrative, physical, and technical safeguards.
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Security Rule Administrative Safeguards
The Security Rule administrative safeguards help align the permitted uses and disclosures outlined in the Privacy Rule with the physical and technical safeguards stipulated in the Security Rule. Establishing policies and processes to govern HIPAA compliance based on administrative safeguards will help maintain—and strengthen—your overall cybersecurity posture.
Administrative Safeguards and Risk Management
It is critical to manage all possible risks to ePHI by addressing any vulnerabilities promptly and with the appropriate controls. Risks to the security of electronic health records are constantly changing and must be addressed relative to your organization’s infrastructure and environment.
Common risks and vulnerabilities to ePHI include:
- Insider threats involving malicious exposure of health records
- Access control gaps that compromise PHI environments
- Poor management of risks, especially during enterprise growth and expansion
An effective risk management strategy is to designate a security team to address ePHI risks.
You can also benefit from outsourcing risk and security management to an experienced managed security services provider (MSSP).
Administrative Safeguards and Access Control Management
In many cases, ePHI is compromised due to gaps in access control. A HIPAA-compliant policy to secure electronic health records should ensure that access to ePHI is:
- Provisioned according to roles and strictly for a business need to meet mission-specific goals
- Removed from users who no longer need access to ePHI
- Restricted for third-party service providers to the minimum necessity
The physical and technical safeguards also cover some aspects of access control.
Administrative Safeguards for Workforce Training and Development
Maintaining the privacy of electronic health records also requires developing your workforce to minimize risks to ePHI during creation, processing, transmission, or disposal. You’ll need:
- Cybersecurity awareness training to implement secure practices for handling ePHI
- Documentation of all training processes for organization-wide dissemination
- Onboarding training for all newer staff, in alignment with existing security policies
Robust cybersecurity awareness training programs will help secure electronic health records.
Security Rule Physical Safeguards
The physical safeguards listed in the Security Rule address risks to physical access to ePHI, regardless of the size or location of the physical ePHI infrastructure. The requirements include:
- Processes to manage access to facilities containing ePHI, including:
- Key card access to server rooms
- Barriers (e.g., secured door access) to ePHI environments
- Role-based access to ePHI storage environments
- Device security for ePHI-containing infrastructure, including:
- Alignment of workstation use with HIPAA security policies
- Monitoring of the transfer, removal, or disposal of electronic health records from workstations
- Asset risk assessment by conducting an inventory of all assets containing ePHI, including:
- Shared workstations
- Non-shared computers (desktops or laptops)
- Mobile devices
- Media storage devices
Securing electronic health records with physical safeguards will minimize the likelihood of ePHI breaches from devices and other infrastructure containing ePHI.
Security Rule Technical Safeguards
The technical safeguards in the Security Rule include any IT processes that help maintain the security of electronic health records. Compliance requires implementing controls to address:
- Identity and access management of electronic health records storage (e.g., databases, cloud storage) that includes:
- Limiting access to ePHI storage to only authorized individuals
- Establishing policies to guide access to ePHI during emergencies
- Implementing automatic account log-off procedures on all devices left idle
- Designating unique IDs for all user accounts with access to ePHI
- Evaluation of technical access controls, including:
- Monitoring use of privileged user accounts
- Tracking access events for all forms of ePHI storage
- Record-keeping of all events to access ePHI
- Implementing change management processes
- Assessment of the integrity of electronic health records by:
- Establishing processes to prevent any modifications of ePHI
- Periodic audits of ePHI to confirm that it has not been altered
- Implementation of processes to secure the transmission of electronic health records:
- Assessing network security components (e.g., firewalls)
- Use of industry-standard encryption for all electronic health records transmission
Note that the effective combination of some safeguards will prevent unauthorized ePHI use or disclosure should one fail. For example, even if an employee’s device containing ePHI is stolen, encryption prevents thieves from accessing the data. Without the cryptographic key, the ePHI can’t be “read” or interacted with.
For robust establishment and implementation of controls, working with a leading HIPAA compliance advisor will help you streamline all aspects of HIPAA-related controls.
Additional Consideration: HITRUST Certification
Many organizations in and adjacent to healthcare are adopting a more robust cybersecurity framework—the HITRUST CSF. HITRUST is not a federally mandated regulation, like HIPAA. However, it is increasingly becoming a de-facto requirement for organizations in the industry because payers require it explicitly or implicitly favor CSF-certified business partners.
But beyond requirements, organizations are moving toward HITRUST as a gold standard because it streamlines all other compliance regulations into one centralized implementation.
The HITRUST CSF is a robust, flexible framework. It comprises 14 Control Categories and hundreds of Controls that scale up to different Implementation Levels. These cover all of the HIPAA rules’ requirements, along with other commonly applicable regulations (e.g., PCI DSS).
The breadth and depth of security the HITRUST CSF ensures far surpasses HIPAA Privacy and Security Rule protections. Certification is the best assurance of your commitment to PHI safety.
Robust Electronic Health Records Security
As cybersecurity threats evolve and become more sophisticated, it is critical for organizations within and adjacent to healthcare to maintain the security of electronic health records.
RSI Security’s team of qualified HIPAA compliance advisors and security assessors will help you identify gaps in cybersecurity controls and guide you on best practices to secure all forms of electronic health records. Contact RSI Security today to get started with HIPAA compliance!
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