Introduction to HIPAA Security Rule
The Health Insurance Portability and Accountability Act (HIPAA) of 1996 introduced the Security Rule to establish national standards for protecting certain health information that is held or transferred in electronic form. The Security Rule operationalizes the protections contained in the Privacy Rule by addressing the technical and non-technical safeguards that organizations called “covered entities” must put in place to secure individuals’ electronic protected health information (ePHI).
Understanding the Scope of the Security Rule
The Security Rule is applicable to all sizes and types of covered entities that handle ePHI, including:
- Health plans
- Health care clearinghouses
- Health care providers who conduct certain billing and payment transactions electronically
Moreover, business associates that perform services on behalf of these covered entities that involve the use or disclosure of ePHI must also comply with the Security Rule.
Administrative safeguards are administrative actions, policies, and procedures to manage the selection, development, and execution of security measures. They aim to protect ePHI and to manage the conduct of the workforce in relation to the protection of that information. To stay compliant with the Security Rule, healthcare IT should:
- Conduct risk analysis to identify potential risks and vulnerabilities to the confidentiality, integrity, and availability of ePHI.
- Implement risk management policies to reduce risks to a reasonable and appropriate level.
- Develop and enforce sanctions policies to hold the workforce accountable for non-compliance.
- Implement procedures to regularly review records of information system activity, such as audit logs and access reports.
- Assign a security official responsible for developing and implementing the entity’s security policies and procedures.
- Train the workforce on security policies and procedures.
Physical safeguards involve the physical measures, policies, and procedures to protect a covered entity’s electronic information systems and related buildings and equipment from natural and environmental hazards, and unauthorized intrusion. Measures include:
- Facility access controls to limit physical access to the location of ePHI, while ensuring that properly authorized access is allowed.
- Policies to safeguard workstation and device security so that unauthorized users cannot access ePHI.
- Device and media controls to manage the movement, removal, and disposal of electronic media containing ePHI.
Technical safeguards concern the technology and the policy and procedures for its use that protect ePHI and control access to it. They typically include:
- Access control measures to ensure that only authorized individuals can access ePHI.
- Unique user identification to track identity and actions of users who access electronic systems containing ePHI.
- Transmission security to protect ePHI while it is being transmitted over an electronic network.
- Automatic log-off to terminate sessions after a specified period of inactivity.
- Encryption and decryption processes to protect ePHI especially when transmitted over networks or stored on portable devices.
To assure HIPAA compliance, covered entities and their business associates must enter into contracts that hold the business associates to the same standards as the covered entities. This includes:
- Ensuring Business Associate Agreements (BAAs) are in place.
- Oversight of business associates to verify that they are appropriately safeguarding ePHI.
- Establishing policies for responding to a breach of unsecured PHI.
Policies, Procedures, and Documentation Requirements
Healthcare IT must:
- Implement reasonable and appropriate policies and procedures to comply with the provisions of the Security Rule.
- Maintain written (which may be electronic) documentation of all policies and procedures.
- Retain the documentation for six years from the date of its creation or the date when it last was in effect, whichever is later.
- Review and update documentation periodically to respond to environmental or operational changes affecting the security of ePHI.
Summary and Compliance Tips
Staying compliant with the HIPAA Security Rule requires a thorough approach that integrates administrative, physical, and technical safeguards. Compliance tips include:
- Risk assessments: Regularly conduct and document risk assessments to stay aware of potential vulnerabilities.
- Training programs: Develop ongoing training programs for staff to understand their role in maintaining compliance.
- Incident response plan: Create an incident response plan to address any security breaches promptly.
- Audits and reviews: Perform periodic audits of security policies and procedures to identify areas needing improvement.
- Vendor management: Diligently manage business associates and ensure all parties adhere to HIPAA rules through BAAs.
By rigorously implementing these safeguards and continually assessing their efficacy, healthcare IT can maintain compliance with the HIPAA Security Rule, thereby helping to protect the ePHI of their patients and preventing costly data breaches.