A Risk Assessment is required in order to comply with the HIPAA Security Rule.
The Security Management Process standard in the Security Rule requires organizations to “[i]mplement policies and procedures to prevent, detect, contain, and correct security violations.” (45 C.F.R. § 164.308(a)(1).) Risk analysis is one of four required implementation specifications that provide instructions to implement the Security Management Process standard. Section 164.308(a)(1)(ii)(A) states:
RISK ANALYSIS (Required).
Conduct an accurate and thorough assessment of the potential risks and vulnerabilities to the confidentiality, integrity, and availability of electronic protected health information (ePHI) held by the [organization].
But being required under HIPAA is not the reason to perform a Risk Assessment. A Risk Assessment, if performed correctly, will give you the insight into what you need to do to better protect electronic protected health information (ePHI aka patient information). Let’s take a look at the process for performing the Risk Assessment and then look at how this can help you.
The basic steps of a Risk Assessment are:
- Identify all systems and devices that contain ePHI. This might be your EMR, email, file server, spreadsheets, USB drives, etc. The key here is that you can’t protect ePHI / data if you don’t know where it is residing. The inventory is very important.
- Once you have completed the inventory, the next step is to look at potential threats to the ePHI / data. Some common threats including mother nature. The data can be destroyed in a fire or flood. Other threats include viruses, hackers and spyware could steal or destroy the data. An employee that was recently terminated could try to access the systems and destroy or steal data. These are just a few of the potential threats to ePHI / data. It is important to list all of the potential threats. Again, you can’t protect data if you don’t know what you are protecting it against.
- Now that you have inventoried the systems and identified potential threats to ePHI / data, the next step is to identify the current protections you have in place to protect the data. Some protections including doing a nightly backup of the data. If data is destroyed at least you will have a backup of it. Other protections including having a network firewall to protect against hackers. Using anti-virus software to protect against viruses and spyware. Other protections may include implementing employee termination procedures that ensure a terminated employee’s access to the network is removed immediately. It is important to list all the current protections that you have in place.
- The fourth step of the Risk Assessment process is to determine the impact to your organization if something happens to the ePHI / data. The impact would be high if a fire destroyed all your systems containing ePHI. It would also be high if a hacker stole your patient data and posted it on a public website. On the other hand, the impact might not be that high if an employee accidentally deleted a spreadsheet with patient information if you had a current backup of the file. A simple restore of the file and you are off and running again. As you can see it is important to understand the impact of the threats to your data so you can focus on protecting against the threats that have the largest impact.
- As I just eluded to, the next step is to look at all your systems that contain ePHI, analyze the threats to each system (step #2), look at the current protections you have in place (step #3) and determine the impact if something was to happen to each of these systems (step #4). Putting each of these steps together, you determine the risk level to each system. Risk can be identified in various ways but for simplicity lets say risk is determined as High, Medium and Low. Some examples might be that your systems are at high risk from a hacker because you do not have a network firewall in place to protect from intrusions. Or your risk level from a flood is low because your systems are located on the 5th floor in an office building. For each system that contains ePHI, you want to determine the risk level to that system.
- One of the last steps and most important is to identify additional security measures that should be implemented to further protect the systems and data. So if your systems are at high risk from hackers and network intruders then one of the additional protections would be to implement a network firewall. Or if you are at medium risk from a terminated employee gaining access to data then implementing formal termination procedures will help lower the risk. It is important to identify the new level of risk that each system would have after you have implemented the additional protections. You want to understand your current risks, what things you can do to lower your risks and then what the new risk level would be to your systems.
- The final step is to document each of the above steps so you have a record of the process and you can start to implement additional safeguards to protect ePHI and patient data.
HIPAA Secure Now! uses the above process in performing a HIPAA Security Risk Assessment. Let us help you protect your systems and ePHI.