Organizations often combine the roles of Security and Privacy officers because the organization is too small to facilitate separate roles or to streamline compliance efforts in larger organizations. The main consideration when combining these roles is maintaining a clear delineation of the responsibilities to prevent potential overlapping.
HIPAA and the compliance officers
The requirement for a Privacy officer is provided for within Section 164.530 (a) of the Privacy Rule it specifically states “A covered entity must designate a privacy official who is responsible for the development and implementation of the policies and procedures of the entity.” The role exists to ensure that patient's privacy rights are upheld through proper policies and procedures. A Perspectives in Health in Health Information Management study expands on the specification of their role stating, “If a privacy breach occurs, privacy officers make critical choices about reporting that may have lasting impacts on the healthcare organizations…”
In relation to the implementation of a Security officer, the Security Rule Section 164.308 (a)(2) states organizations need to, “Identify the security official who is responsible for the development and implementation of the policies and procedures required by this subpart for the covered entity or business associate.” The officer oversees the implementation of security measures necessary to protect electronic protected health information (ePHI), including decisions related to implementation and alterations.
The reason behind dual roles for compliance officers
HIPAA allows for one person to fulfill the roles of both Security and Privacy officers. Organizations therefore have a choice in how they address this requirement. By merging these positions organizations often create a unified approach to HIPAA compliance that ensures privacy and security measures remain aligned. Integration has its benefits when it comes to communication and collaboration, reducing the risk of gaps in compliance that might occur if the roles were separate.
Best practices for handling dual roles in healthcare organizations
Have clearly defined responsibilities:
- Establish clear and distinct responsibilities for both security and privacy functions.
- Document the responsibilities attached to each role in policy manuals to avoid overlaps.
Develop integrated policies and procedures:
- Create comprehensive policies that address both privacy and security needs.
- Make sure that these policies are harmonized to facilitate a unified approach to protecting ePHI.
Make sure training remains regular:
- Provide training on an ongoing basis so that officers remain informed about the latest regulations and technology.
Improve communication and collaboration:
- Create open lines of communication between privacy and security functions even in combined roles.
- Regular meetings and communication with heads of departments and management through means like HIPAA compliant email help compliance officers remain knowledgeable about the challenges and upcoming risks.
Conduct comprehensive risk assessments:
- Regularly perform risk assessments that encompass both security and privacy aspects.
FAQs
What is the Security Rule?
A set of HIPAA regulations that establishes the standards for protecting ePHI by requiring appropriate administrative, physical, and technical safeguards.
What is the purpose of a risk assessment?
To identify potential vulnerabilities and threats to any PHI.
How often do risk assessments need to take place?
While HIPAA does not provide set periods for risk assessments, they should occur at least annually.
Kirsten Peremore
