Encrypting personal and personally identifiable information (PII) is critical for organizations in industries prone to cybersecurity threats, such as healthcare. Data encryption in healthcare is one essential part of compliance with regulatory frameworks such as HIPAA and HITRUST CSF, and it can be optimized by following some cutting-edge best practices. Read on to learn more.
Optimizing Data Encryption in Healthcare via Regulatory Compliance
Organizations within and adjacent to healthcare can effectively safeguard protected health information (PHI) by complying with widely-recognized compliance frameworks, such as HIPAA and HITRUST CSF. To strengthen encryption practices and secure PHI against cybersecurity threats, organizations should focus their efforts on the two frameworks’ respective aims:
- Implement data encryption in healthcare to safeguard PHI per HIPAA’s definitions
- Optimize data encryption in healthcare using HITRUST CSF’s scalable controls
Optimized data encryption in healthcare will help you secure data and mitigate the risks of breaches, especially when working with an experienced HITRUST CSF compliance advisor.
Data Encryption in Healthcare Using HIPAA
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) outlines compliance requirements to help organizations secure the sensitive protected health information (PHI) that they create, process, store, transmit, or otherwise contact. HIPAA was developed and is overseen by the Department of Health and Human Services (HHS).
HIPAA stipulations are broken into four primary Rules, including:
HIPAA sets national standards to govern and secure healthcare transactions and can help guide healthcare data encryption processes. Implementing effective data encryption in healthcare starts with understanding the scope and requirements outlined under the primary HIPAA Rules.
HIPAA Privacy Rule
The Privacy Rule establishes the sensitivity of PHI by defining permitted uses and disclosures of PHI by covered entities. Any organization in or adjacent to the healthcare industry that comes into contact with PHI—in any way—may be a covered entity. Specific covered entities include:
- Health plans and plan administrators, which cover the costs of medical services
- Healthcare providers, such as doctors and clinics, who deliver medical services
- Healthcare clearinghouses, which process PHI in nonstandard or standard forms
The Privacy Rule guidelines also extend to select business associates of covered entities, which provide specific services to or on behalf of covered entities. These business associates need to follow HIPAA guidelines as well and guarantee compliance in contracts with covered entities.
Covered entities are prohibited from all use or disclosure PHI outside the following conditions:
- Permitted uses and disclosures, including:
- Disclosure to the subject of the PHI or at their formal request
- Select healthcare operations (e.g., treatment, payment processing)
- Use or disclosure after the subject’s opportunity to agree or object
- Incidental uses during the course of other permitted or required ones
- Activities of public interest and benefit (e.g., research, public health)
- Written authorization by the subject of the PHI
Covered entities are also required to disclose PHI under two specific situations:
- Disclosure is requested by the subject or a representative thereof
- The HHS’s Office for Civil Rights (OCR) requests access for:
- Compliance investigations or reviews
- Enforcement actions
Compliance with the HIPAA Privacy Rule requirements for permitted uses and disclosures helps covered entities and their business associates define best practices for safeguarding PHI. The provisions and definitions in the Privacy Rule align with the more specific controls of the Security Rule to help you develop HIPAA-compliant data encryption in healthcare.
HIPAA Security Rule
The Security Rule helps covered entities and their business associates implement processes to safeguard the integrity, confidentiality, and availability of electronic PHI (ePHI) specifically. Still, its protections should also be applied to all non-electronic PHI at all lifecycle phases.
The Security Rule consists of three essential classes of cybersecurity controls:
- Administrative safeguards to implement enterprise-level security, including:
- Management of security risks and vulnerabilities
- Development of security processes and policies
- Building infrastructure to secure access control processes
- Security training and management of workforce
- Evaluation of security processes and compliance with Security Rule provisions
- Physical safeguards to secure access to physical locations containing ePHI, including:
- Controlling physical access to facilities with ePHI storage
- Securing devices and workstations with access to ePHI
- Technical safeguards to minimize the risks of ePHI exposure, including:
- Establishing user access controls to ePHI environments
- Auditing the hardware, software, or systems involved in processing ePHI
- Instituting controls to prevent unauthorized modification or disposal of ePHI
- Securing the transmission of ePHI using industry-recommended healthcare data encryption tools
When it comes to data encryption in healthcare, the Security Rule safeguards—specifically the administrative and technical safeguards—will help optimize and strengthen your overall medical data encryption. Working with a HIPAA compliance partner will ensure they’re followed to a T.
HIPAA Breach Notification and Enforcement Rules
While the Privacy and Security Rules provide guidance on best practices for safeguarding paper and electronic PHI, the Breach Notification and Enforcement Rules enforce HIPAA compliance.
Specifically, the Breach Notification Rule provides covered entities with mechanisms to report data breaches based on the number of individuals affected (i.e., 500 or fewer). The Secretary of the HHS oversees the enforcement of breach notification guidelines. Encryption helps ensure that breached data is illegible to attackers, but breaches still need to be reported accordingly.
The Enforcement Rule stipulates guidelines for the enforcement of HIPAA compliance, including fines and penalties for non-compliance violations. HIPAA enforcement is overseen by the OCR and, in the most serious cases involving criminal penalties, the Department of Justice (DOJ).
How to Optimize Data Encryption in Healthcare Using HITRUST CSF
As technology advances and cyber threats evolve, data encryption in healthcare is critical to protect organizations within and adjacent to healthcare against breaches to PHI. HIPAA does provide guidelines to help healthcare organizations safeguard the privacy and confidentiality of PHI, and HIPAA compliance can be challenging for many entities—especially those newer to it or those with large, complex infrastructure and risk profiles. Even so, it’s often not enough.
Compliance with the HITRUST CSF, a comprehensive, risk-based framework, helps streamline healthcare data encryption by standardizing HIPAA compliance to other regulatory frameworks.
What is the HITRUST CSF?
The CSF is a complex framework encompassing HIPAA and various other regulatory codes. By integrating the broad security requirements addressed by multiple frameworks into one, the HITRUST CSF streamlines compliance for organizations within and adjacent to healthcare.
The HITRUST CSF framework consists of:
- Control Categories (14), which are high-level cybersecurity aims that roughly correspond to the “Domains” or Families” in other common regulatory frameworks (i.e., Access Control)
- Control Objectives (49), which are lower-level aims or sub-categories that substantiate the Categories’ aims and break down further into individual practices to achieve them
- Control References (155), which are the specific practices entities can use to achieve the aims above—and break down further into Specifications and Implementation Levels
Compliance with the HITRUST CSF helps optimize data encryption in healthcare by:
- Implementing standardized and industry-accepted assessment and reporting processes for healthcare data encryption
- Providing trust and assurance of healthcare data encryption for transactions between healthcare organizations, their business associates, and stakeholders that involve PHI
- Reducing the overall time and financial costs of implementing cumbersome processes for medical data encryption
- Creating more realistic and manageable expectations for healthcare data encryption
When implemented via the HITRUST CSF Assurance Program, HITRUST CSF compliance will help you optimize data encryption in healthcare and enact robust safeguards for PHI.
Optimized Data Encryption with the HITRUST CSF Assurance Program
The HITRUST CSF Assurance Program provides a standard approach to help organizations develop robust safeguards for PHI via:
- Self-Assessments to identify risks to PHI, including gaps in:
- Security controls (e.g., poor medical data encryption tools)
- Compliance with critical frameworks (e.g., HIPAA, PCI DSS)
- Reporting on risk and vulnerability management
- CSF-Validated Assessments—conducted by HITRUST CSF Assessors—that involve:
- Onsite interviews to determine the robustness of existing encryption processes
- Documentation reviews of healthcare data encryption policies
- System testing to validate the performance of data encryption tools
- CSF-Validated Assessments with Certification to provide stakeholders assurance of:
- Risk management to industry-defined and accepted standards
- Adherence to standards of data encryption in healthcare
- Presence of critical security controls (e.g., industry-standard healthcare data encryption)
Compliance with the HITRUST CSF will assure stakeholders (e.g., business partners, customers, third-party vendors) of your commitment to implementing and optimizing data encryption in healthcare, especially with the help of a HITRUST CSF Assessor.
HITRUST CSF Control Maturity Assessment
HITRUST CSF compliance requires healthcare organizations to assess the maturity of CSF security controls, as defined by the National Institute of Standards and Technology (NIST) Program Review of Information Security Management Assistance (PRISMA).
Assessment of control maturity will help you assess and optimize data encryption in healthcare, especially for those controls used to encrypt PHI at rest and in transit.
For an organization to achieve HITRUST CSF compliance for healthcare data encryption, controls must meet the following maturity levels:
- Policy – Controls must address data encryption policies, ensuring:
- Documentation of up-to-date policies
- Ongoing encryption risk assessment and monitoring
- Coverage of all data encryption systems and operations
- Approval of all data encryption policies
- Definition of the security management structure for all data encryption methods
- Procedure – Controls must support effective data encryption procedures, ensuring:
- Data encryption practices are up-to-date and well-defined by security policies
- Procedures for data encryption clearly outline workflows and step-by-step encryption design
- Clearly defined roles and responsibilities of all involved security personnel
- Established guidelines for individuals to be contacted for guidance about data encryption
- Communication of procedures to the individuals that implement data encryption
- Documentation of the rigor with which encryption is applied
- Implemented – Controls must streamline data encryption implementation, ensuring:
- Consistent implementation of encryption procedures and controls
- Training of individuals involved in medical data encryption
- Initial testing and validation of data encryption controls
- Measured – Controls must measure outcomes of data encryption, ensuring:
- Routine testing of data encryption to evaluate effectiveness and security robustness
- Validation of data encryption policies, procedures, and controls to verify alignment with intended purposes
- Independent audits to assess the organization-wide performance of data encryption
- Assessment of security incidents to identify gaps and vulnerabilities in data encryption
- Re-evaluation of threats to develop internal threat intelligence
- Documentation of evaluation requirements used to validate data encryption methods
- Establishment of status metrics for the assessment of data encryption and overall security program effectiveness
- Managed – Data encryption controls must be managed to ensure:
- Implementation of corrective action plans to address gaps and vulnerabilities in healthcare data encryption
- Ongoing evaluation, testing, and improvement of data encryption policies, procedures, and processes
- Integration of data encryption security into the capital budget and expense planning process
- Optimized internal threat intelligence benchmarked against widely-used threat databases
- Development of data encryption alternatives that are more cost-effective
- Achievement of data encryption and security program effectiveness
Assessment of HITRUST CSF control maturity will help optimize data encryption in healthcare and strengthen your security posture against cyber threats.
Specific features of the MyCSF tool that can optimize data encryption in healthcare include:
- Corrective Action Plans (CAPs) are centralized, enabling organizations to manage all aspects of HITRUST assessments, including:
- Validation of data encryption controls
- Identification of security gaps and vulnerabilities
- Remediation of gaps in healthcare data encryption
- Tracking of HITRUST CSF assessment and reporting, enabling organizations to interface with HITRUST CSF Assessors
- Tailoring of assessments to organization-specific needs and assessment of compliance with frameworks, including:
- Compliance and reporting support for HIPAA, which includes:
- Collection of evidence to demonstrate HIPAA compliance
- Reporting of consolidated compliance documentation
- Formatting of HIPAA controls (e.g., healthcare data encryption) for submission to the HHS OCR, if requested
- Simplified sharing of risk assessment data
- Support for the inheritance of control scores from internal and external HITRUST CSF assessments
- eSignature support removes the burden of time-consuming tasks, such as scanning and uploading multiple PDF files
The MyCSF Tool will help you optimize healthcare data encryption tools and prepare for HITRUST CSF self-assessment, validated assessment, and certification. With the help of a HITRUST CSF Assessor, you will improve internal assessment of gaps in HITRUST CSF compliance, mitigate threat risks, and simplify the overall HITRUST CSF certification process.
Optimize Data Encryption in Healthcare with HITRUST CSF
Compliance with the HITRUST CSF framework will help you optimize and standardize data encryption in healthcare—regardless of your organization size or infrastructure—to that required by HIPAA, especially in consultation with a HITRUST CSF compliance advisor.
Contact RSI Security today to rethink your healthcare data encryption practices.