To comply with HIPAA, it’s best to follow a roadmap of the most important aspects of compliance. Below is a checklist of what you can do for your organization to maintain security and ensure compliance.
HIPAA's administrative simplification provisions apply to many entities, including health plans, healthcare clearinghouses, and healthcare providers that transmit health information electronically in connection with specific transactions. These entities are classified as covered entities under HIPAA.
Additionally, business associates – organizations that create, receive, maintain, or transmit PHI on behalf of covered entities – are subject to specific HIPAA requirements.
To determine your organization's HIPAA status, conduct a self-assessment to review your operations, identify the health information you handle, and assess whether you qualify as a covered entity or a business associate.
Once you've established your organization's HIPAA status, the next step is to assess your specific compliance obligations. HIPAA comprises several interconnected rules and regulations, each with its unique set of requirements and standards.
Achieving and maintaining HIPAA compliance is an ongoing process that requires a well-organized program. Here are the components to consider:
The first step in establishing a HIPAA compliance program is to designate qualified individuals to oversee and manage the process. These roles typically include:
Regular risk assessments are necessary for identifying potential vulnerabilities and threats to the privacy and security of PHI within your organization. These assessments should:
Well-documented policies and procedures form the backbone of an effective HIPAA compliance program. These guidelines should cover various aspects of HIPAA compliance, including:
HIPAA compliance requires organizations to implement safeguards to protect PHI. These safeguards encompass administrative, physical, and technical aspects, such as:
A knowledgeable and properly trained workforce helps maintain HIPAA compliance. Training programs should include various aspects, such as:
Ongoing monitoring and regular audits are necessary for maintaining HIPAA compliance and finding areas for improvement. This process may involve:
Use secure messaging, video conferencing, and file-sharing tools designed for healthcare to protect PHI. These tools offer encryption, access controls, and audit trails to secure communication.
Implement IAM solutions to control access to PHI. These tools provide role-based access, strong authentication, and audit logs to protect sensitive information.
Encrypt PHI and use pseudonymization to enhance data privacy. Encryption protects data during storage and transmission, while pseudonymization replaces identifiable data with codes to protect privacy.
Use risk management platforms to streamline HIPAA compliance tasks such as risk assessments, policy management, and incident reporting. These platforms offer centralized dashboards and automated workflows to manage compliance efficiently.
Cloud services and managed IT functions can support compliance efforts. Ensure that providers are HIPAA compliant and enter into business associate agreements (BAAs) to secure data and services.
Keep thorough records of HIPAA compliance efforts and have protocols to respond to audit requests. Designate a contact person and ensure timely responses to inquiries.
Fully cooperate during audits to show your commitment to compliance. Provide clear responses, address deficiencies quickly, and maintain open communication.
If issues are identified during an audit, address them promptly. Update policies, enhance training, and implement new safeguards as needed. Develop a corrective action plan with specific steps, responsibilities, and timelines.
Related: How to prepare for a HIPAA audit
In a recent interview, OCR Director Melanie Fontes Rainer revealed that the HHS has proposed regulatory revisions related to the HIPAA security rule. These updates are modernizing the 20-year-old regulation and address changes in healthcare, including reliance on online services and the need for encryption. According to Rainer, the security rule's technology-neutral and scalable nature has allowed for its continued enforcement, but the proposed changes seek to reflect the current state of healthcare delivery.
Rainer said the OCR plans to reinitiate the HITECH audit program, which will focus on the security rule and target security risk analyses and risk management. With limited resources, OCR is trying to drive voluntary compliance, and these audits will serve as an educational tool for HIPAA-regulated entities. Healthcare providers should be prepared for the possibility of a HITECH audit in the coming year, as OCR seeks to ensure that organizations have an understanding and implementation of the security rule's requirements.
HIPAA applies to covered entities, which include healthcare providers, health plans, and healthcare clearinghouses. It also applies to business associates of these covered entities. These are entities that perform certain functions or activities on behalf of the covered entity.
There are various tools available to assist with HIPAA compliance, including HIPAA compliance software, secure email solutions, encryption technologies, and training programs. Choose tools that align with your organization's specific needs and requirements.
Learn more: HIPAA Compliant Email: The Definitive Guide