Many people ask us what is needed for an Incident Response Plan (IRP). It seems to be one of the HIPAA requirements that people have a hard time putting their arms around. So let’s take a practical look at what is needed.
Incidents will happen
The first thing that must be accepted and understood is that security incidents will happen. It is not a matter of if, but more a matter of when the incident will happen. With the use of EMRs, portable devices, smartphones, internet access and the abundance of computer viruses and spyware, it is only a matter of time before a security incident will occur.
Have a team in place before an incident
If you accept the first point, that incidents will happen, then the next step is to plan in advance on how to handle an incident when it occurs. Incidents are very stressful events. Imagine your organization loses an unencrypted laptop with 10,000 patient records. You are easily looking at $250,000 to over $1,000,000 of breach expenses and fines. If that is not enough to give you palpations nothing will. The point is that under that sort of pressure it is difficult to think clearly and rationally. That is why you need to have a team in place that is ready to handle the situation BEFORE the incident occurs.
The Incident Response Team (IRT) should be selected and needs to understand their role. Teams could be made up of senior people, administrators, IT people, etc. There is no requirement in terms of size of the team. The team should be represented by individuals that are empowered to react to an incident when it occurs.
Incidents usually occur at the worst times
For some reason it seems that incidents usually occur at the worst times whether that be a weekend, when you have a family function, etc. For this reason, it is important to ensure that all the members of the IRT have contact information of each team member. That includes home phone numbers, cell phone numbers, work emails, personal emails, etc. In the scramble to react to an incident, it is important for the team members to be able to easily contact each other.
Have a plan in place
Once you have selected the Incident Response Team, it is important to have the team define how they will react to incidents. At first this may seem hard to understand because there is no clear description of the incident. You may ask yourself how can you define a plan to react to something you don’t know. Think of the fire department, they are ready to react to all types of emergencies whether it is a small kitchen fire, complete house fire, hotel fire, car crash or terrorist threat. The point is that the IRT should have a plan that defines what steps should be taken no matter what the actual incident is.
Some steps of the IRP may include the following:
- Define the incident – what happened? When did it happen? Who was involved? When was it discovered?
- Stop the incident – if a smartphone is lost take the steps to disable the access, if a breach is found take the steps to prevent further access, etc.
- Document the incident – fill in all the details of what occurred from step 1 (define the incident) and step 2 (steps taken to stop the incident). Clearly document all aspects of the incident.
- Determine who has been affected by the incident – which patient records have been affected?
- Notify appropriate individuals / agencies –the amount of patient records affected will determine what notification steps are needed. Individual patients and Health and Human Services (HHS) will need to be notified. In addition, local media may need to be notified as well.
- Provide guidance to prevent the incident from occurring again – an important aspect of an incident response is to ensure that the same incident does not happen in the future. Recommendations to increase security and reduce the risk of an incident are essential.
Hopefully you have a better understanding of what an incident response plan is. The next step is to implement the incident response plan. Give yourself two weeks and get it done!