Organizations within and adjacent to healthcare must establish processes to restore assets to their original state and safeguard sensitive healthcare data if a disaster occurs. By implementing a disaster recovery plan for HIPAA compliance, you will respond faster to security incidents and minimize downtime across your organization. Read on to learn more.
How to Implement a Disaster Recovery Plan for HIPAA
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) was established to safeguard the privacy and sensitivity of protected health information(PHI). To effectively mitigate potential disasters and other related contingencies, organizations must implement a disaster recovery plan for HIPAA, which requires an understanding of:
- The primary HIPAA Rules and how they apply to organizations in healthcare
- The HIPAA disaster recovery requirements and how they inform contingency planning
Working with a HIPAA compliance specialist will help you optimize HIPAA disaster recovery planning and ensure your organization’s data is secure, whether at rest or in transit.
Breakdown of the HIPAA Rules
Before creating and implementing a disaster recovery plan for HIPAA, it is critical to understand how the HIPAA Rules may apply to your organization. HIPAA provides a framework for optimizing compliance across any organization that handles PHI, whether physically, electronically, or in both forms.
HIPAA comprises four primary Rules:
- Privacy Rule – By outlining the conditions for the use and disclosure of PHI, the Privacy Rule standards safeguard its privacy when processed by covered entities, including:
- Health plans, which pay for the costs of healthcare services
- Healthcare providers, who provide or facilitate the delivery of healthcare
- Healthcare clearinghouses, which convert PHI from one form to another
- Security Rule – Throughout its processing by covered entities electronic PHI (ePHI) is protected by the Security Rule, which contains three types of safeguards:
- Administrative safeguards, which provide oversight for all HIPAA security controls implemented across your organization
- Technical safeguards, which ensure that security controls for ePHI are functioning optimally
- Physical safeguards, which prevent unauthorized entry into physical environments containing ePHI
- Breach Notification Rule – Should a breach of PHI occur, covered entities and their business associates must promptly report the breach to parties, including:
- The individuals whose data is compromised
- The Secretary of Health and Human Services (HHS)
- Enforcement Rule – Under the Enforcement Rule—which is overseen by the HHS Office of Civil Rights (OCR)—HIPAA-related complaints are reviewed and evaluated for potential violation of HIPAA.
For the majority of their day-to-day operations handling PHI, covered entities will leverage the safeguards listed in the HIPAA Privacy and Security Rules to protect the PHI from data breaches. When implemented hand-in-hand, the Privacy and Security Rule requirements will help you mitigate the security risks associated with data breaches.
Compliance with HIPAA will also help optimize HIPAA disaster recovery and minimize any security risks to the physical or electronic PHI you handle.
What are the HIPAA Disaster Recovery Requirements?
When it comes to mitigating security risks and surviving a disaster that may affect sensitive PHI or disrupt business operations, advance planning is critical. Most disasters are abrupt and often find organizations ill-prepared to handle them, resulting in a higher risk of business disruption.
A disaster can be defined as any circumstance or event that occurs outside your control, with the potential of inflicting significant damage to your IT infrastructure and compromising sensitive data. For organizations within and adjacent to healthcare, a disaster can be:
- Cyber attacks which lock users out of computer systems or networks
- Extreme weather (e.g., hurricanes) that results in prolonged power outages
- System downtime resulting in reduced or non-existent IT availability
Compliance with the HIPAA disaster recovery requirements will help you achieve a robust and effective disaster recovery plan for HIPAA and minimize disruptions to business operations.
HIPAA Contingency Planning
The requirements for creating and implementing a HIPAA disaster recovery plan are listed under those for HIPAA contingency planning. A HIPAA contingency plan helps keep operations online and increases the availability of PHI during emergency situations.
Beyond safeguarding the accessibility and sensitivity of PHI during disaster scenarios, a contingency plan helps minimize any disruptions to business operations.
A HIPAA contingency plan typically includes five implementation specifications:
- A data backup plan to ensure that PHI can be retrieved without compromising its integrity
- A disaster recovery plan to restore lost data to its original state
- An emergency mode operation plan to maintain business continuity during emergencies
- Testing and revision procedures to pressure test disaster recovery and broader contingency plans
- Application and data criticality analysis to identify the most critical assets to keep in operation during emergencies
Implementation of a HIPAA disaster recovery plan is not an independent process; it happens in tandem with the remaining four specifications to achieve a fully functional contingency plan.
Inventory of HIPAA-Critical Assets
HIPAA disaster recovery and contingency planning cannot be fully effective if your asset inventory is incomplete, inaccurate, or poorly documented. Should a disaster strike, there are high chances that asset users will be panicking to manage the ramifications of the disaster.
An up-to-date asset inventory will aid HIPAA disaster recovery by streamlining processes for:
- Identifying asset types across your organization, such as:
- On-premise assets (e.g., workstations, servers)
- Cloud-based assets (e.g., applications, databases)
- Endpoints (e.g., mobile devices)
- Backing up on-premise and cloud-based assets
- Phasing asset recovery and restoration efforts
- Meeting compliance requirements for other wide-reaching standards such as:
A carefully planned and well-maintained asset inventory will minimize delays in identifying critical assets during HIPAA disaster recovery and prevent unexpected sensitive data losses.
Disaster Recovery Processes and Procedures
Developing a disaster recovery plan for HIPAA-subject data requires clear documentation and dissemination of the processes and procedures that your organization will follow when managing a disaster, should one occur. Disaster recovery scenarios can range anywhere from situations involving severe weather to full-blown cyber attacks. When developing a HIPAA disaster recovery plan, examples of potential disasters will help optimize disaster recovery planning to the unique complexity of your organization’s IT infrastructure.
Critical processes and procedures for managing disaster recovery scenarios include:
- Informing employees across the organization about impending disasters
- Designating disaster response roles and responsibilities for employees across the organization, including:
- Notifying dedicated IT teams about signs of a disaster
- Initiating storage backups for critical data files
- Relaying updates about disaster management to employees
- Monitoring the disaster scenario
- Escalating disaster recovery processes to experts like managed security service providers (MSSPs)
- Defining the limits for asset downtime
When creating and implementing a HIPAA disaster recovery plan, it is critical to consider the factor that may affect business continuity when a disaster occurs.
Although some disasters—such as system downtime due to a technical issue—are easily managed, others may be more challenging to resolve. For example, sophisticated malware or ransomware attacks may shut down your entire infrastructure and prevent business continuity.
Ultimately, the effectiveness of a disaster recovery plan for HIPAA is best optimized in partnership with a HIPAA compliance expert.
Manage and Optimize HIPAA Disaster Recovery
Establishing a fully operational HIPAA disaster recovery plan is a critical step in ensuring your organization’s sensitive data will not be compromised if you are affected by a disaster. The most effective way to optimize your disaster recovery plan for HIPAA is to work with a HIPAA compliance partner, who will advise on the best strategies to minimize downtime for your organization. To learn more and get started, contact RSI Security today!