What is a HIPAA compliance gap?

A HIPAA compliance gap is a discrepancy or shortcoming between an organization's current practices and the requirements set forth by the Health Insurance Portability and Accountability Act (HIPAA).

Understanding HIPAA compliance gaps

A HIPAA compliance gap occurs when an organization's current practices fail to meet the standards outlined in HIPAA regulations. These gaps can compromise the security and privacy of protected health information (PHI) and expose organizations to compliance risks.

Common areas of HIPAA compliance gaps

Privacy gaps 

Privacy gaps arise when an organization fails to protect patient information or obtain proper authorization for use. Examples include:

• Sharing PHI without the patient’s consent.
• Inadequate safeguards for verbal or written communication involving PHI.

Security gaps

HIPAA mandates administrative, technical, and physical safeguards to protect electronic PHI (ePHI). Common security gaps include:

• Lack of encryption for sensitive data.
• Weak passwords or lack of multi-factor authentication.
• Outdated software and security protocols.

Breach notification gaps 

According to the Department of Health and Human Services (HHS), “a covered entity must notify the Secretary if it discovers a breach of unsecured protected health information.” Failure to follow breach notification protocols constitutes a breach notification gap.

Go deeper: What are the HIPAA breach notification requirements

Training gaps 

Employee training ensures HIPAA compliance. Gaps in training occur when:

• Employees are not adequately informed about HIPAA regulations.
• Regular training sessions are not conducted to address evolving compliance requirements.

Policy and procedure gaps 

HIPAA compliance relies on well-documented policies and procedures. Gaps can arise when:

• Policies are outdated or incomplete.
• Procedures are not consistently followed or enforced.

How to identify HIPAA compliance gaps

• Conduct a risk assessment: Regularly evaluate your organization’s practices against HIPAA requirements. Risk assessments should identify vulnerabilities in how PHI is handled, stored, and shared.
• Review policies and procedures: Ensure that all compliance-related documents are up to date and reflect current regulatory requirements.
• Monitor employee practices: Observe how employees handle PHI and ensure their actions align with training and organizational policies.
• Audit technology systems: Evaluate the security measures protecting ePHI, such as encryption, firewalls, and access controls.

Steps to address HIPAA compliance gaps

Now that the organization has identified the gap, it must be addressed. Addressing HIPAA compliance gaps requires a proactive and systematic approach to ensure your organization meets regulatory standards and protects patient information. By tackling these gaps head-on, you can reduce the risk of breaches, improve operational efficiency, and foster a culture of compliance. 

Below are key steps to help your organization bridge these gaps and strengthen its commitment to safeguarding PHI.

• Develop a remediation plan: Once gaps are identified, create a plan to address them. Assign responsibilities, set deadlines, and prioritize critical issues.
• Enhance employee training: Provide comprehensive training to employees on HIPAA rules and their roles in compliance. Use real-world examples to illustrate best practices.
• Update policies and procedures: Regularly review and revise policies to align with new regulations and organizational changes.
• Invest in technology: Strengthen your IT infrastructure with updated software, encryption, and secure access measures.
• Monitor and improve: Continuously assess compliance efforts and refine strategies to address new risks and gaps.

See also: HIPAA Compliant Email: The Definitive Guide

Consequences of ignoring HIPAA compliance gaps

Failing to address compliance gaps can have severe repercussions, including:

• Data breaches: Unauthorized access to PHI can erode patient trust.
• Legal penalties: HIPAA violations can result in fines ranging from $147 to $71,162 per violation, depending on severity.
• Reputation damage: Non-compliance can tarnish your organization’s credibility.

FAQs

What is the most common cause of HIPAA compliance gaps?

The most common cause is a lack of awareness or training among employees regarding HIPAA requirements. Other frequent factors include outdated policies, insufficient technological safeguards, and failure to conduct regular risk assessments.

How often should organizations review our HIPAA compliance efforts?

HIPAA compliance efforts should be reviewed annually at a minimum. However, more frequent reviews are recommended, especially after significant organizational changes, such as adopting new technology or policies.