To meet HIPAA standards when dealing with protected health information (PHI), you need a comprehensive framework that covers multiple aspects of your organization. By implementing the right framework, including the people, processes, and safeguards, your organization can protect PHI and reduce the risk of breaches.
Components of a HIPAA compliant framework
People
The first step in HIPAA compliance is assigning responsibility. Your organization must appoint a designated security official or data steward. This person is responsible for overseeing the implementation of policies, monitoring compliance efforts, and ensuring that all processes related to PHI are secure.
Having a point person for HIPAA compliance also helps establish accountability. This security officer should be well-versed in HIPAA regulations and act as a liaison between the organization's leadership and the staff handling PHI.
Processes
Your organization needs to adopt clear, detailed procedures for handling PHI that cover:
- Risk management: Identifying, assessing, and mitigating potential risks to PHI.
- Incident response: Outline how your organization will respond to potential breaches.
- Audit controls: Regularly reviewing and monitoring how PHI is accessed and used.
Your privacy practices must be integrated into your health information technology (HIT) systems, so compliance becomes a natural part of your workflow. This will enable your organization to manage potential security issues before they escalate proactively.
Information access management
One of the most effective ways to prevent HIPAA violations is through role-based access control (RBAC). This principle ensures that employees only have access to the data necessary for their job functions. “RBAC has been around for decades and still is the single best approach to providing controllable, versatile, compliant access to users,” says Cybersecurity Specialist Larry Justice on a LinkedIn comment.
Limiting access minimizes the chances of PHI being accessed by unauthorized personnel and reduces the risk of internal breaches.
Training and oversight
Every member of your team who interacts with PHI must receive regular HIPAA compliance training. Training ensures that employees understand their responsibilities and the potential risks involved with mishandling sensitive data. In addition, your organization must monitor compliance across departments, ensuring that no one deviates from HIPAA protocols.
Oversight ensures that employees should be aware that their actions are being monitored, and corrective measures must be in place to address violations. This could range from additional training to disciplinary action, depending on the severity of the breach.
See also: How to train healthcare staff on HIPAA compliance
Risk management
Your organization must periodically conduct risk analyses to identify potential vulnerabilities in your HIPAA processes. A risk analysis assesses how PHI is stored, accessed, and transmitted, and highlights areas where improvements can be made.
Once risks are identified, you’ll need a risk management plan to address these vulnerabilities and ensure they’re mitigated promptly. This ongoing evaluation ensures your organization remains compliant and keeps PHI secure.
Physical safeguards
Physical safeguards prevent unauthorized access to facilities or devices where PHI is stored. Examples include:
- Locked doors and restricted areas where PHI is stored.
- Swipe cards or security passes for access control.
- Secure remote working protocols that require employees to follow strict security measures for laptops and mobile devices.
When PHI is physically secure, the chances of theft or unauthorized access diminish significantly.
Learn more: What physical safeguards are required by HIPAA?
Technical safeguards
Technology can significantly reduce non-compliance risk by automating key HIPAA processes, such as access controls, encryption, and audit trails, thereby minimizing human error and unauthorized access to PHI. Technical safeguards ensure that PHI is accessible only to authorized personnel and can help automate compliance processes.
Some of the technical safeguards include:
- Encryption: Encrypt PHI to protect it during transmission and storage.
- Access controls: Automate RBAC to ensure that only authorized individuals have access to PHI.
- Audit trails: Implement systems that log access and changes to PHI, making it easier to identify unauthorized access or alterations.
Transmission security
When PHI is being transmitted over your network or through the cloud, it must be secured. HIPAA requires encryption of data in transit to protect it from interception. Whether your team communicates over email, shares files, or uses a cloud-based system, ensure that all channels are HIPAA compliant.
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FAQs
What is HIPAA?
The Health Insurance Portability and Accountability Act (HIPAA) is a U.S. federal law enacted in 1996 to protect the privacy and security of individuals' medical information, known as Protected Health Information (PHI). HIPAA establishes national standards for healthcare providers, health plans, and their business associates to safeguard sensitive health data.
What are examples of PHI under HIPAA?
PHI includes any information that can identify an individual and relates to their health condition, treatment, or payment for healthcare. Examples include medical records, health insurance information, and demographic details like name, address, or Social Security number.
See also: What are the 18 PHI identifiers?
Tshedimoso Makhene
