HIPAA Risk Assessment Options

If you work in the healthcare or business industry, you’re probably familiar with HIPAA. HIPAA is a set of federal guidelines set forth to ensure healthcare organizations and their technological associates meet a specific set of standards in regards to how they protect and handle their patients’ personal health information. Many businesses also ascribe to the same rules for their clients.

One of the factors that make HIPAA so successful is the risk assessment portion, which mandates that HIPAA compliance consist of not only putting strict security measures in place to protect sensitive information, but also testing those security measures. Testing HIPAA security measures involves looking for potential loopholes or weak spots in the protection of personal health information, which could be thwarted by hackers, malware, and so on. Without a regular, thorough risk assessment, it would be impossible for an organization to be sure their patients’ or clients’ information is as highly protected as possible.

However, assessing the risk is not all HIPAA compliance requires. According to section 164.308 of the HIPAA bylaws, compliance requires that organizations also “implement security measures sufficient to reduce risks and vulnerabilities to a reasonable and appropriate level…” In short, any problems the risk assessment finds need to be immediately resolved and further assessed to be certain the fixes hold up. HIPAA’s guidelines do not specify how exactly risk assessment and repair must be performed, as that is up to the individual organization to decide the most effective method for them. What is specified is that doing the assessment and repair in some form must be adhered to the best capability of each HIPAA-compliant organization.

Choosing how to manage the risk assessment and repair or remediation portion of HIPAA can be complex for any organization due to the number of options available and the generalized nature of HIPAA guidelines. One of the newest and strongest options is software designed with the goal of compliance to this section of the HIPAA laws in mind. The software follows a simple process of testing the organization’s security and either repairs the problems or gives guidelines about the next steps the organization should take to make sure they can become HIPAA compliant or maintain current HIPAA compliance. These software programs are ideal because they are designed by leading experts in technology whose specialty is security. This knowledge allows for the design of software that is truly exceptional in terms of helping an organization be certain any risks can be modified and safeguarded to protect sensitive information now and in the future.

There are many companies who design leading edge software to help organizations become HIPAA compliant. The ideal company has excellent reviews and holds a HIPAA Seal of Compliance from the HIPAA Compliancy Group.

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Know about HIPAA risk assessment

One of the primary functions of the Health Insurance Portability and Accountability Act (HIPAA) is to guarantee security and protect the confidentiality of health information. Covered Entities such as doctor’s offices, hospitals and pharmacies, as well as any third party Business Associates are responsible for compliance with HIPAA guidelines. Risk assessment plays a vital role in compliance and the Department of Health and Human Services (HHS) has established steps to help Covered Entities apply the HIPAA risk assessment or security rule to their daily business practices.

The purpose of the Security Rule is to evaluate risks, threats and vulnerabilities, and outline policies and procedures that should be implemented to address any issues that could cause a security breach. In order to secure Protected Health Information (PHI) and identify any possible threats, all CoveredEntities are required to implement appropriate security processes. A threat can be intentional or unintentional and must be addressed for a Covered Entity to remain compliant with HIPAA regulations.

Steps have been developed to help Covered Entities maintain security and compliance. The initial step should be identification of any areas needing to be analyzed and to begin collecting data to provide structure for a risk analysis. Once data has been collected, a risk analysis will help document any threats, risks or vulnerabilities, which then allows the Covered Entity to evaluate current security measures to determine the possibility of a security breach. Once current security measures have been examined, it is time to determine the potential impact of any risk and what areas need stronger security measures.

After the completion of the risk analysis, a risk management strategy has to be developed to address any issues found during the investigation. A risk management plan must be created to provide structure through the process of implementing any new or updated security measures. When the risk management plan is in place, the necessary security measures can be employed, along with a plan for continuous evaluation to ensure ongoing security of data.

 All Covered Entities must establish a process for risk analysis and management to guarantee HIPAA compliance. Basic steps have been outlined for the evaluation of any vulnerability, risks or threats, as well as a process to address any problems that could result in a breach or HIPAA non-compliance. By following these basic steps a Covered Entity can manage any risk they may discover and quickly respond to potential threats.

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Get to know about the HIPAA risk assessment

The Health Insurance Portability and Accountability Act of 1996, better known as HIPAA, affects more than just insurance companies. Several establishments, including doctors, hospitals and pharmacies, must conformto HIPAA guidelines. One of the most important aspects regarding HIPAA is a risk assessment. This is why the Centers for Medicare & Medicaid Services (CMS) has developed a rule titled “Security Standards for the Protection of Electronic Protected Health Information”, commonly known as the Security Rule.

All Electronic Protected Health Information (ePHI) is subjected to the Security Rule and companies who are required to follow HIPAA guidelines must implement security practices to protect this information. The Security Rule requires the evaluation of risks, threats and vulnerabilities, and the implementation of policies and procedures to address them. In order to identify the areas that pose a threat, organizations must develop the proper security processes.

Whether a threat is intentional or unintentional is irrelevant, the main focus should be compliance with HIPAA regulations. CMS developed basic steps to help with risk analysis and risk management. While this approach is not required, the following steps can help organizations develop a basic risk analysis. First, it is important to pinpoint the areas to be analyzed and begin gathering relevant data. This will provide structure to the analysis. Next, it is time to recognize and document any risks, threats, or vulnerabilities; once this is completed it’s time to evaluate security measures already in place. This will help to determine the likelihood of a security breach. The final steps include discovering the potential impact and level of risk, and deciding where to implement security measures.

Once a risk analysis has been completed, it’s time to develop a risk management strategy. Common steps to address risk management include creating a risk management plan to provide structure when implementing security measures. Once the plan is in place, it’s time to employ the necessary security measures. Finally, continuous evaluation of these measures is vital in maintaining security.

Risk analysis and management is an integral part of HIPAA risk assessment and compliance. CMS has provided extensive information on their website to help companies develop a plan of action specific to their own individual needs, while at the same time following the Security Rule to protect all ePHI and other documents falling under HIPAA guidelines. The steps recommended by CMSprovide a basic approach to effectively manage any threats or risks a company may encounter.

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Introducing the HIPAA Omnibus Rule

New standards have been added to HIPAA regulations through the Omnibus Rule. These new additions address holes in the ability to access PHI (Protected Health Information) by those that are non-privy to such data. These standards ensure that "Covered Entities" follow these rules or deal with significantly harsher penalties.Covered Entities, Business Associates and their subcontractors are more liable for compliance lapses under the Omnibus Rule. Enacted on September 23, 2013,the Omnibus Rule has led to a dramatic increase in the cost and complexity for the maintenance of healthcare documentation, requiring even more precise auditing of systems and policies.

There are a variety of points that make up the new HIPAA Omnibus Rule, which include additional HITECH Act enhancements. During a breach of PHI the Covered Entity must notify eachindividual party whose information was breached, the Dept. of Health and Human Services, and media sources. The definition of a secure system is not simply having access or login protection. It requires the data to be thoroughly encrypted when breached, or automatically destroyed before it is accessed. In addition, the Omnibus Rule expanded the scope of what constitutes a breach to even limited sets of data that might contain certain fields.

The Omnibus Rule is an update to the Interim Final Rule published in August 2009 and involves the discarding of a 'harm threshold'. This threshold analyzed the risk of a potential breach's impact in determining the potential recourse for a Covered Entity. However, the Omnibus Rule voided this threshold, but instead presumes a breach unless certain specific factors are taken into account. This includes who the unauthorized person is, whether the PHI was viewed, and how it was acquired.

Sanctions for not providing the required notice are severe, with some state law requirements even more severe than federal laws. Thus, potential breach and all follow-up protocols should include a full analysis of both state and federal regulations.

The Omnibus Act also expands the definition of a Business Associate. Thus, the new BAA (Business Associate Agreement) must specify the general arrangement of data being exchanged in addition toaddressing the repercussions of a potential breach in the transfer of information between Covered Entities and Business Associates. The NPP (Notice of Privacy Policies) has beenmodified to include provisions for distribution, sale, and notification of breach to patients including special provisions for psychotherapy notes.

Penalties for lack of compliance to these rules include $100 per violation and $25,000 if the violation is identical in one calendar year. Privacy breaches have a far greater consequence, including penalties up to $1.5 million.

With the HIPAA Omnibus Rule in effect, it is even more imperative that Covered Entities and Business Associates take active steps in ensuring that their systems are protected, with protocols and audit tools in place to prevent even a seemingly minor PHI breach from occurring. To comply with these changes, both Covered Entities and Business Associates must make updates to their privacy practices, as well as perform an audit of all their policies and procedures on a regular basis.

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The Important of Risk Assessment Tracking and Proof of Efforts

Meaningful use stage two is an important way for healthcare providers too ensures patients receive the best care. Meaningful Use Stage 2 utilizes many of the healthcare initiatives beginning with stage one, but includes some important updates that you will want to know about. Tracking and recording are vital when you are want to provide proof of risk assessments in a hospital or other medical establishment in order to qualify for incentive payments.

Getting Started

You will need to develop a solid, clear plan for tracking and recording risk assessment in order to reach meaningful use standards. Your staff should be aware of any new processes that will be implemented, which processes will be stopped and how long the new practices will be used in the workplace. Offering a training seminar can be an ideal solution to training staff in new recording and tracking methods used by your organization.

Why is Tracking and Recording Important?

The goal of meaningful use stage two is to provide electronic medical records that are accurate, up to date and relevant to the care of patients. The ability to prove that you have use established risk assessment guidelines according to the meaningful use regulations is vital when working with Medicaid and Medicare clients. Your organization will need to use EHRs, or electronic health records, to meet specific goals in order to qualify for state funded incentives. You can satisfy the need for proof by using the EHRs according to regulations and working with your local Regional Extension Center.

The goals of meaningful use are designed to provide a more comprehensive health care system to the public. One of the goals is to share more information with patients to promote a better understanding of medical conditions and treatments. You will need to supply proof that you have been utilizing the EHRs to achieve meaningful use stage two guidelines. Your local Regional Extension Center representative can help you get started on implementing the guidelines in your organization and assist you with learning more about the measures that are used to prove that the guidelines have been used.

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HIPAA, Security, and the Mobile Device

With the inclusion of Biometrics to the IPHONE 5, as seen in this article, http://secureidnews.com/news-item/analysis-biometrics-and-the-iphone/, there are many pros and cons that will affect how to be hipaa compliant.

Awesome that you can use your own identification to open you mobile device but it also comes with organizations and individuals who think this is not such a great thing.

For many years putting sensitive information on your mobile device was a no no, it can be stolen and access easily gained.  That is evident in the rules the Government puts forward like the Health Information Portability and Accountability Act, HIPAA.  A HIPAA Risk assessment requires you to encrypt and safeguard data at rest and in motion, and focus a lot on mobile devices.  So you would think this type of encryption and access would be welcome, well it is in and it isn’t.

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