Following the aftermath of cyber incidents like Change Healthcare’s recent cyberattack, it’s become undeniable that the healthcare industry’s cybersecurity practices need to be taken more seriously. The Health Insurance Portability and Accountability Act (HIPAA) Security Rule aims to do just that, playing an important role in safeguarding electronic protected health information (ePHI).
This blog will explore what the HIPAA Security Rule is, the specific cybersecurity requirements it entails, whom it applies to and how RapidFire Tools’ Compliance Manager GRC can help manage and ensure compliance with these requirements.
What is the HIPAA Security Rule?
The HIPAA Security Rule is a group of standards designed to protect ePHI created, received, used or maintained by a covered entity. Part of the broader HIPAA framework, this rule focuses specifically on the electronic aspects of health information. It establishes a set of security standards for protecting certain health information that is held or transferred in any digital capacity across the nation. Essentially, the Security Rule ensures that healthcare providers, health plans and healthcare clearinghouses implement appropriate administrative, physical and technical safeguards to protect ePHI.
What are HIPAA Security Rule requirements?
The HIPAA Security Rule outlines specific requirements to guarantee the confidentiality, integrity and availability of ePHI. These requirements are divided into three major categories: administrative safeguards, physical safeguards and technical safeguards. Each category encompasses various components that collectively ensure comprehensive protection of ePHI.
Administrative safeguards
Administrative safeguards are essential policies and procedures that healthcare organizations must implement to comply with the HIPAA Security Rule. These safeguards ensure that ePHI is adequately protected through various management processes and workforce protocols.
Security management process
The security management process is critical for maintaining the integrity and confidentiality of ePHI. Organizations must conduct thorough risk analyses to identify potential threats and vulnerabilities to ePHI. This involves assessing the chances, and impact, of various risks and implementing measures to mitigate them. Additionally, organizations must establish a workforce sanctions policy to address non-compliance with security policies. Procedures must also be in place to regularly review system activity to detect and respond to security incidents. The key components of this process are:
- Risk analysis: Identifying potential risks to ePHI.
- Risk management: Implementing measures to reduce identified risks.
- Sanctions policy: Enforcing penalties for non-compliance.
- Activity review: Monitoring system activities to detect security breaches.
Assigned security responsibility
Organizations must designate a specific individual or team to oversee the security of ePHI. This person, often referred to as the HIPAA security officer, is responsible for developing, implementing and enforcing the organization’s security policies and procedures. The role may be combined with the HIPAA privacy officer, depending on the organization’s structure. The key components here include:
- Policy development: Creating security policies and procedures.
- Implementation: Ensuring policies are put into practice.
- Enforcement: Overseeing compliance with security measures.
Workforce security
Workforce security focuses on ensuring that employees have appropriate access to ePHI based on their roles. Organizations must have procedures in place to verify that only authorized personnel can access ePHI. This includes measures to grant access to new employees, modify access when roles change and terminate access when employees leave the organization. The main aspects of workforce security are:
- Access authorization: Granting access to ePHI based on job roles.
- Access modification: Adjusting access when roles change.
- Access termination: Removing access when employment ends.
Information access management
This standard ensures that ePHI is accessible only to authorized personnel. Organizations must implement policies to authorize access to ePHI based on the concept of “minimum necessary” use. This means that employees should have access only to the information they need to perform their job duties. The main components of this process are:
- Authorization: Granting access based on job requirements.
- Minimum necessary use: Limiting access to only what is necessary.
Security awareness and training
Security awareness and training are vital for ensuring that all employees understand the importance of ePHI security. Organizations must provide ongoing training programs that educate employees about security policies and procedures. This involves training on identifying and responding to various security threats, managing passwords, and maintaining security awareness. Key training topics include:
- Security policies: Understanding organizational security measures.
- Threat recognition: Identifying potential security threats.
- Password management: Creating and maintaining secure passwords.
Security incident procedures
Organizations must have formal procedures in place to address security incidents involving ePHI. This includes protocols for reporting incidents, responding to them and documenting the outcomes. These procedures help organizations manage and mitigate the impact of security breaches effectively. More concisely, these procedures include:
- Incident reporting: Documenting and reporting security incidents.
- Response: Addressing and mitigating security incidents.
- Documentation: Keeping records of incidents and responses.
Contingency plan
A contingency plan is essential for responding to emergencies that affect systems containing ePHI. Organizations must establish and regularly test policies and procedures for data backup, disaster recovery and emergency mode operations. These plans ensure that ePHI remains accessible and secure during and after an emergency.
- Data backup: Regularly backing up ePHI.
- Disaster recovery: Restoring data and systems after an incident.
- Emergency operations: Maintaining operations during emergencies.
Evaluation
Periodic evaluation of security policies and procedures is necessary to ensure ongoing compliance with the HIPAA Security Rule. Organizations must conduct regular assessments to review the competency of their security measures and make adjustments wherever required.
- Policy review: Assessing the effectiveness of security policies.
- Procedure review: Evaluating the implementation of security procedures.
- Compliance check: Ensuring continued compliance with HIPAA standards.
Physical safeguards
Physical safeguards are critical components of the HIPAA Security Rule designed to protect electronic systems, equipment and the data they hold from physical threats, environmental hazards and unauthorized intrusion. They ensure that sensitive health information remains secure and inaccessible to unauthorized individuals. Physical safeguards encompass various measures and controls to protect the physical premises and the devices that store and transmit ePHI.
Facility access controls
Facility access controls are measures that limit physical access to buildings, facilities and equipment where ePHI is stored. These controls are essential to prevent unauthorized individuals from entering areas where sensitive information is kept, while ensuring that authorized personnel can access these areas as needed.
- Access authorization: Implement policies to verify and authorize individuals entering secure areas. This may include using identification badges, key cards, biometric scans or security personnel to control access points.
- Visitor management: Establish procedures to monitor and manage visitors to facilities. This can include sign-in logs, visitor badges and escorting visitors within secure areas.
- Monitoring and surveillance: Use surveillance cameras and security systems to monitor access points and detect unauthorized access attempts. Regularly review footage to identify potential security breaches.
- Access logs: Maintain detailed logs of who accessed secure areas, when they accessed them and for what purpose. Regularly review these logs to detect any anomalies or unauthorized access.
Workstation and device security
Workstation and device security policies ensure that workstations and devices with access to ePHI are used and secured appropriately. These policies help protect sensitive information from being accessed by unauthorized users and ensure that devices are used in a secure manner.
- Workstation use policies: Define the appropriate use of workstations that access ePHI. This includes specifying which activities are permitted against those prohibited, such as restricting the use of workstations for personal activities.
- Physical security: Implement physical safeguards to protect workstations and devices from unauthorized access. This may include locking devices when not in use, using privacy screens and positioning workstations in secure areas.
- Device management: Establish procedures for managing devices that access ePHI. This includes securing mobile devices, using encryption and ensuring that devices are only used by authorized personnel.
- Regular inspections: Conduct regular inspections of workstations and devices to ensure compliance with security policies. Address any vulnerabilities or non-compliance issues promptly.
Device and media controls
Device and media controls are procedures for managing the receipt, removal, and disposal of hardware and electronic media containing ePHI. These controls help safeguard against unauthorized access, use, or disclosure of sensitive information.
- Receipt and removal: Establish protocols for the secure receipt and removal of devices and media. This includes tracking devices entering and leaving secure areas and ensuring that only authorized personnel handle them.
- Disposal: Implement procedures for the secure disposal of devices and media containing ePHI. This may involve data wiping, degaussing, or physical destruction to ensure that information cannot be recovered.
- Reuse: Ensure that devices and media are securely cleared of ePHI before reuse. This includes reformatting storage media and verifying that no residual data remains.
- Backup: Regularly back up ePHI stored on devices and media to ensure data can be restored in the event of loss or damage. Store backups in a secure location with access controls.
Technical Safeguards
Technical safeguards are the technology and related policies and procedures that protect ePHI and control access to it. These safeguards ensure that only authorized individuals can access ePHI, monitor access and protect the integrity and confidentiality of the data.
Access control
Access control measures ensure that only authorized individuals can access ePHI. These measures involve implementing technical solutions to manage user permissions and verify identities.
- User identification: Assign unique identifiers to each user to track access and activity. This helps ensure accountability and enables the tracking of user actions.
- Password management: Implement strong password policies to protect access to ePHI. This includes requiring complex passwords, regular password changes and preventing the reuse of passwords.
- Role-based access control (RBAC): Assign access permissions based on user roles and responsibilities. This ensures that employees can only access the information necessary for their job functions.
- Automatic logoff: Configure systems to automatically log off users after a period of inactivity. This prevents unauthorized access if a workstation is left unattended.
Audit controls
Audit controls are mechanisms that record and examine activity in information systems containing ePHI. These controls help organizations monitor access to ePHI and detect potential security incidents.
- Logging: Enable logging of all access and activity involving ePHI. This includes recording user logins, data access and changes to ePHI.
- Audit trails: Maintain detailed audit trails to track the actions taken by users. This helps identify who accessed ePHI, what actions were performed and when they occurred.
- Regular audits: Conduct regular audits of system logs and audit trails to identify any suspicious activity or potential security breaches. Investigate and address any anomalies promptly.
- Compliance monitoring: Use automated tools to monitor compliance with security policies and detect deviations. This helps ensure that security measures are consistently applied.
Integrity controls
Integrity controls are measures designed to protect ePHI from being improperly altered or destroyed. These controls ensure that data remains accurate and reliable throughout its lifecycle.
- Data validation: Implement mechanisms to validate the integrity of ePHI during storage and transmission. This may include using checksums, digital signatures or hash functions to verify data integrity.
- Data protection: Use encryption to protect ePHI from unauthorized alteration during storage and transmission. This ensures that data remains secure and unaltered.
- Change tracking: Track changes to ePHI to identify any unauthorized modifications. This includes maintaining records of data edits, deletions and additions.
- Regular integrity checks: Conduct regular integrity checks to verify that ePHI has not been altered or corrupted. Address any discrepancies promptly to maintain data accuracy.
Transmission security
Transmission security measures protect ePHI from unauthorized access during electronic transmission. These measures ensure that data is securely transmitted over networks and prevent interception or tampering.
- Encryption: Use encryption to protect ePHI during transmission. This ensures that data is unreadable to unauthorized individuals if intercepted.
- Secure protocols: Implement secure communication protocols, such as HTTPS, SSL/TLS and VPNs, to protect data during transmission. These protocols provide encryption and secure data exchange.
- Transmission monitoring: Monitor network transmissions to detect any unauthorized access or anomalies. Use intrusion detection systems (IDS) and intrusion prevention systems (IPS) to enhance security.
- Endpoint security: Ensure that both sending and receiving endpoints are secure. This includes securing devices, networks and applications involved in data transmission.
Authentication
Authentication measures ensure that individuals or entities seeking access to ePHI are who they claim to be. These measures verify identities and prevent unauthorized access to sensitive information.
- User authentication: Implement multi-factor authentication (MFA) to verify user identities. MFA requires users to provide multiple forms of identification, such as passwords, security tokens or biometric data.
- Entity authentication: Verify the identity of systems and applications accessing ePHI. This includes using digital certificates and secure authentication protocols.
- Access controls: Combine authentication with access controls to ensure that only authorized users can access ePHI. This includes role-based access and permissions management.
- Regular authentication updates: Regularly update and review authentication methods to ensure they remain effective and secure. Address any vulnerabilities or outdated methods promptly.
Organizational requirements
Organizational requirements include ensuring that contracts or other arrangements are in place with business associates who will have access to the ePHI to ensure that they will appropriately safeguard the information.
- Covered entity responsibilities: Entities covered by HIPAA must ensure that their own activities comply with the Security Rule.
- Business associate contracts: Agreements must be in place with business associates that outline their responsibilities for protecting ePHI.
Who does the HIPAA Security Rule apply to?
The HIPAA Security Rule applies to covered entities and their associates. Covered entities include healthcare providers, health plans, and healthcare clearinghouses. This also extends to business associates — any organization or individual that offers or performs services for a covered entity and has access to ePHI. For example, a third-party billing company for a hospital would be subject to the HIPAA Security Rule. It’s essential to determine if your organization falls under these compliance categories.
How does RapidFire Tools help address HIPAA security compliance?
RapidFire Tools’s Compliance Manager GRC is built to help organizations manage HIPAA compliance effectively. Compliance Manager GRC is designed to simplify the process of meeting HIPAA security requirements by providing a comprehensive framework for managing risks and compliance activities.
Manage HIPAA cybersecurity with Compliance Manager GRC
Compliance Manager GRC automates the compliance process by providing a clear framework for managing all HIPAA cybersecurity requirements. It simplifies the assessment of administrative, physical and technical safeguards, ensuring that all aspects of HIPAA security are covered. This tool not only identifies gaps in compliance but also provides actionable recommendations to address these issues, reducing the risk of non-compliance penalties.
The powerful compliance management platform includes customizable templates for policies and procedures that align with HIPAA standards, which makes it easier for businesses to adopt compliant practices. Moreover, it generates audit-ready reports that can be used to prove compliance to auditors, saving healthcare organizations valuable time and resources during audit periods.
Compliance Manager GRC understands that the landscape of threats is ever-changing and is continually updated to reflect the latest regulatory changes and cybersecurity best practices, which ensures that your compliance efforts are always up to date.
For IT professionals looking for an effective way to manage HIPAA cybersecurity requirements, Compliance Manager GRC offers a purpose-built solution. Download our eBook, “HIPAA Compliance: An Rx for IT Professionals,” to learn more about how Compliance Manager GRC can facilitate your compliance efforts and streamline your cybersecurity management
To see Compliance Manager GRC in action and discover how it can help your organization meet its compliance goals, request a demo today.
