There is a lot to know about HIPAA but let’s take a look at 6 things that you must know.
HIPAA is not optional
A lot of practices feel they are exempt from the HIPAA regulations. This may stem from the fact that “small practices” were granted a 1 year extension to comply with the HIPAA Security Rule. According to Wikipedia
The Final Rule on Security Standards was issued on February 20, 2003. It took effect on April 21, 2003 with a compliance date of April 21, 2005 for most covered entities and April 21, 2006 for “small plans”
So if you are a covered entity or healthcare provider (click here to see if you are a covered entity) then HIPAA regulations apply to your practice or organization and MUST be implemented.
Encryption is your friend
Although encryption is not a requirement under the HIPAA Security Rule, it does provide a “safe harbor” in the event of a security incident. If a device (laptop, desktop, USB drive, DVD, etc.) that contains ePHI (electronic protected health information) is lost or stolen and the device is encrypted, the covered entity does not have to report the breach. Encryption dramatically reduces the liability of storing ePHI on desktops, laptops and portable devices. Just remember to keep the encryption password separate from the device. In other words, don’t put the password on a sticky note on the laptop or DVD.
You must perform a Risk Assessment
The HIPAA Security Rule mandates that all covered entities perform a Risk Assessment to determine how ePHI is being protected and to recommend additional safeguards. A Risk Assessment is the foundation of the HIPAA Security Rule. By doing a Risk Assessment an organization is forced to analyze where ePHI is stored and how it is currently protected. The output of a Risk Assessment provides valuable insight into vulnerabilities to ePHI and how ePHI can be better protected. If an organization is to get audited, one of the first questions is going to be “where is a copy of your latest Risk Assessment?”. You don’t want to respond “we don’t have one”.
You must train your employees on HIPAA Security
The HIPAA Security Rule also mandates that covered entities setup a security awareness / training program and all workforce members (employees, contractors, etc.) go through security training. Training is not optional. The only way employees will understand how to protect ePHI is through training. In addition, the HIPAA Security Rule requires that employees be provided with ongoing security reminders. In other words, all workforce members must receive training and after training they need reminders on security so they are aware of how to effectively protect ePHI.
You must have written policies and procedures
The HIPAA Security Rule requires written policies and procedures on how ePHI is to be protected. A few things to take into consideration here is that the policies and procedures need to be written. It is not good enough to have policies and/or procedures but these policies and procedures must be documented. Another important aspect is that the written policies and procedures must be distributed and implemented by the organization. In other words, having a binder with written policies and procedures that sits on a Practice Administrator’s bookshelf and has never been read, will not satisfy the HIPAA requirement.
You must have an incident response procedure
To be compliant with the HIPAA Security Rule and HITECH Act, you must have a security incident response plan in place. An incident response plan (IRP) is a predefined plan that guides an organization through what to do in the event of a security breach or incident. The IRP determines roles and responsibilities of the incident response team, the steps required to handle the breach, steps required to determine the risk to patients / individuals affected by the breach, notification steps, etc. The key point here is that if you plan the steps to respond to a breach prior to the breach occurring, your organization will be much better prepared when the breach occurs.
Now that you know these 6 things about HIPAA Security how prepared is your organization?