What are HIPAA network compliance requirements, rules, and violations?
The advancement in data management technology has revolutionized how healthcare providers offer their services. Digital or electronic solutions are integrated into healthcare processes to improve productivity, enhance efficiency, and meet patients’ demands.
Before digital transformation swept across the healthcare industry, healthcare providers at all levels relied upon manual methods and traditional data processing to carry out their day-to-day activities. Today, modern solutions, like computerized physician order entry (CPOE) and electronic health records (EHR), have replaced them, streamlining repetitive tasks, encouraging collaboration, and improving data sharing.
Even though using computerized systems and other medical record management systems is very helpful, the security of confidential healthcare information has been a major challenge. To ensure that the privacy and security of patients’ information are maintained, the government created a law to enforce compliance (by organizations) with security best practices. This is where HIPAA comes in!
What is HIPAA compliance?
This refers to compliance with regulatory standards that outline what organizations that handle protected health information (PHI) must do to ensure the privacy and security of patients’ data. The U.S. Health Insurance Portability and Accountability Act (HIPAA) requires healthcare providers and their business associates to implement physical, network, and process security measures to ensure the security of PHI.
HIPAA regulations set clear standards that health organizations must meet when managing patients’ sensitive data, like patient medical records, health insurance information, and other personally identifiable information.
Who needs to be HIPAA-compliant?
According to the HIPAA, the Privacy Rule covers:
- Health plans
- Health care clearinghouses
- Healthcare providers who execute certain financial and administrative transactions electronically.
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What are HIPAA compliance requirements?
There are some measures organizations are required to implement to protect patients’ sensitive data. If your company is a “covered entity”, it is expected to meet the following compliance requirements:
1. Have a dedicated HIPAA privacy officer
There is a need for a professional who understands HIPAA and how to comply with the regulations. The officer will guide your organization on the right path and implement necessary measures to avoid HIPAA violations. And when a data breach or violation happens, the officer should restore order following the provisions of the act.
2. Identify and classify sensitive data
Does your organization manage data that is not subject to HIPAA regulations? If that is the case, identify and classify sensitive information that should be handled according to HIPAA requirements. This helps you to implement security measures with little or no ambiguity.
3. Staff training
Malicious actors usually target employees of organizations they want to attack. To equip your staff with the ability to spot attacks from a distance, you need to institute staff training. Your employees need to learn how to implement physical, administrative, and technical safeguards to protect PHI.
4. Institute strict data management policies
Getting your staff trained on HIPAA laws and regulations is not enough. They need good leadership to uphold data security standards. Establish data management policies to enforce best practices and regulate access privileges.
5. Equip your facilities with security solutions
Access control is a significant part of HIPAA compliance. Ensure unauthorized users don’t have access to computers, documents, or sensitive parts of workstations. You can achieve this by implementing security measures that regulate access to data and notify you when someone trespasses.
6. Install encryption software where necessary
Data encryption solutions make files inaccessible to cybercriminals. Cloud solutions and other digital methods of storing data have increased the surface area for attacks. Malicious cyber actors are relentlessly scouring the internet for security vulnerabilities. Safeguarding patients’ data with encryption software is the way to go.
7. Enforce common best practices
Visiting a malware-compromised website or clicking an ‘infected’ link can make your organization prone to a security breach. Encourage safe browsing and adopt security solutions, like email security software and antivirus systems.
8. File disposal policy
Don’t dispose of documents or storage devices without rendering them unreadable. The best way to dispose of documents and records is to destroy them – by shredding or burning them.
9. Establish procedures for handling data breaches
The primary goal is to prevent a security breach. However, the undesirable happens, and you need to be ready for the worst-case scenario. Establish and maintain procedures for managing security challenges. Ensure you appoint well-trained security experts who can respond swiftly when a breach occurs.
10. Monitor & review your assets & procedures regularly
Keep an eye on your data assets and management policies. This helps you to identify inefficiencies and adopt measures to plug loopholes. Regular review is necessary to ensure you are keeping up with best practices. Remove outdated solutions and procedures to stay a thousand steps ahead of criminals.
11. Implement a strict backup policy
Implement a backup strategy that conforms with the dictates of HIPAA. That said, having a good backup policy helps you clean up a data breach quickly. The general backup best practice is to have three copies of data at three different premises – on-site, off-site, and cloud locations.
12. Establish and maintain a disaster recovery plan
A disaster recovery plan outlines how your organization will restore operations and manage stakeholders after a security breach. It details how your security team will respond to emergencies or the aftermath of security problems. Remember, your disaster recovery system should comply with the provisions of HIPAA.
What are the four main HIPAA rules?
The major HIPAA rules are the Privacy Rule, Security Rule, Breach Notification Rule, and Omnibus Rule. Let’s take a look at each rule.
The HIPAA privacy rule
The HIPAA Privacy Rule is a regulatory framework that mandates covered entities and their business associates to uphold patients’ rights to data privacy. The privacy rule states what constitutes electronically protected health information, how it should be safeguarded, and the DOs and DON’Ts of PHI management.
In a nutshell, this rule establishes how patients’ sensitive information should be protected, stored, used, shared, and disclosed. Any identifiable patient data is subject to the Privacy Rule.
The PHI includes:
- Any past, present or future documentation on physical or mental conditions
- Healthcare records of the patient
- Records showing past, present, or future healthcare payment information
According to the Privacy Rule, covered entities and their business associates are responsible for protecting PHI. There are cases where organizations can disclose private health information. But such scenarios are strictly defined by the rule and subject to legal interpretation.
The HIPAA security rule
While the Privacy Rule defines what privacy and ePHI (electronic PHI) are, the Security Rule is a framework that outlines the standards required to ensure the security of electronically protected health information. The security rule covers every aspect of your organization’s operations, from administration and physical processes to computers and technology equipment.
The security rule has five sections: general rules, administrative safeguards, physical safeguards, technical safeguards, and organizational requirements.
The General Rules
The General rules mandate organizations to:
- Protect ePHI from reasonably anticipated threats or hazards
- Prevent any reasonably anticipated uses or disclosures of PHI that are not in line with the provisions of the Privacy Rule
- Enforce compliance with the security rule by the employees
The Administrative Safeguards
The Administrative Safeguards require the implementation of security policies and procedures. It dictates that the Security Officer should be responsible for conducting risk analyses, staff training, adopting risks and vulnerability management measures, and other administrative measures.
The Physical Safeguards
The physical safeguards outline how physical access to ePHI should be regulated. Whether the ePHI is stored in the cloud, in a remote data center, or on on-premise servers, there should be a strict policy that regulates access. This section of the security rule also states how access to workstations and devices should be safeguarded.
The Technical Safeguards
This part of the security rules focuses on ensuring that every person accessing ePHI is legitimate and does exactly what they are supposed to do. The technical safeguards help to ensure that security challenges are identified and rectified timely. The safeguards cover access controls, audit controls, integrity controls, transmission security, and any person or entity authentication.
This section states the things business associate agreements must cover. Organizational Requirements stipulate that:
- Business associate agreements must provide that the business associates comply with the relevant parts of the security rule.
- Business associates must ensure compliance with subcontractors by entering into an Agreement with them.
- Business associates will report any security breach to the concerned covered entity.
The HIPAA breach notification rule
As much as organizations strive to comply with the requirements of HIPAA, security breaches still happen. It’s difficult, if not impossible, for covered entities and business associates to protect data with 100% effectiveness.
Organizations must notify the public and the data subjects about a breach and disclose the steps they are taking to contain the problem. The Breach Notification Rule outlines what covered entities need to do when a breach occurs.
Organizations are required to:
- Notify the people affected by the breach
- Inform the affected people within 60 days of the discovery of the security incident
- Provide a public notice if more than 500 individuals are impacted
- And more!
The HIPAA omnibus rule
According to the Omnibus Rule, organizations outside of covered entities (business associates and contractors) must meet compliance obligations. This rule states that covered entities are responsible for ensuring that business associates and contractors are compliant. Consequently, covered entities have to implement compliance measures to avoid any violations.
What are HIPAA violations and how to avoid them?
Violation is said to have occurred when an organization fails to comply with or meet the requirements of HIPAA. There are two major categories of violations: civil and criminal violations.
Civil violations are committed accidentally or without malicious intent. On the other hand, criminal violations are done with malicious intent. As expected, penalties for civil violations are less than that for criminal violations.
Here are some examples of violations and tips on how to avoid them:
Illegal exposure of patients’ data
Disclosing patients’ data to unauthorized parties accidentally or on purpose violates HIPAA provisions. There is a guideline for disclosing sensitive healthcare information. When due process is not followed, a violation occurs. And the penalty for unlawful disclosure of medical records depends on a range of factors, including whether it’s a civil or criminal violation.
To avoid this type of violation, implement strict administrative policies. Allow only a few well-trained administrators to have the privilege to access or disclose data. When data access is strictly regulated, you can easily prevent unauthorized access and keep tabs on data management.
Failure to implement proper security best practices
The HIPAA security rule outlines the security protocols covered entities are required to implement. Given the complexity of data protection today, it’s easy to leave important things undone. You can avoid this by appointing an experienced security officer. You should also set up a committee of security professionals responsible for ensuring the proper implementation of security protocols.
Lack of a consistent training policy
It takes consistent staff training to meet the requirements of HIPAA. Both old and new employees need to be trained from time to time on how to protect healthcare data. Make training an integral part of your administrative policy. Non-compliance to security regulations is mainly caused by people.
No matter the type of access management or security risk mitigation software you implement, you need an informed workforce to ensure compliance.
Lack of proper notification after a security breach
The HIPAA breach notification rule states how healthcare service providers should notify affected data subjects and public officials after a security incident. Failure to do so accordingly results in HIPAA violation. To avoid this, appoint a HIPAA compliance officer to monitor compliance gaps and ensure that requirements are met at every point in time.
In addition, your contingency plan or disaster recovery system should contain a guideline on how to notify impacted parties when things go wrong.
Lack of measures to address existing compliance gaps
Neglecting existing compliance gaps or not doing the needful to avoid potential security problems violates HIPAA. Healthcare organizations are expected to act proactively, leveraging risk assessment and risk management policy to protect PHI.
To close compliance gaps, do the following:
- Establish a HIPAA compliance enforcement team and a compliance officer
- Keep all software updated
- Conduct HIPAA audits regularly
- Work with a health information technology and security company that offers HIPAA compliance services.
How can your network become HIPAA compliant with AlgoSec?
HIPAA compliance requirements can be challenging to meet. The requirements are many, and you need teams of dedicated experts to interpret and design compliance strategies. Managing in-house teams of compliance experts is capital-intensive and time-consuming. Therefore outsourcing compliance duties to a technology and security vendor is the way to go.
AlgoSec provides comprehensive network security solutions you need for your organization to become HIPAA compliant. AlgoSec automatically identifies compliance gaps and provides remediation guidance. It also allows you to easily generate daily audit and compliance reporting across your entire network – whether the data is in the on-premise data center, in the private cloud or in the public cloud.
Best of all, AlgoSec generates pre-populated, audit-ready compliance reports that help reduce HIPAA audit preparation efforts and costs. Contact us today to learn more about how we can help you comply with HIPAA provisions.