The Health Insurance Portability and Accountability Act (HIPAA) is an interlocking series of regulatory standards designed to ensure the legitimate use of sensitive information stored in the form of electronic Protected Health Information (ePHI) and Protected Health Information (PHI). The act was passed in 1996 to improve how healthcare systems use and store patient data. With the modernization and digitization of healthcare services, more and more information was collected, stored, and updated digitally. This helped streamline administrative tasks of healthcare workers and made treatment easier due to the ease of data accessibility. Having digitally active healthcare services has its own benefits and limitations. The online availability of health records and other sensitive information of the patients are at a higher risk of getting unauthorized access, theft, hacked, or leaked.
Congress recognized the need to regulate the disclosure of healthcare records containing patients details and health information. HIPAA was established, passed, and applied, along with stringent security and privacy rules, to Protected Health Information (PHI). HIPAA was introduced to ensure privacy and integrity of healthcare records are guarded at its best in this digital age. IT departments must clearly understand HIPAA to know how to comply with the law and to prevent getting into accidental violations and huge fines.
Who Needs to Be HIPAA Compliant?
According to HIPAA regulations, two types of organizations must be HIPAA compliant: covered entities and business associates. In addition, any organization handling Protected Health Information (PHI) needs to be HIPAA compliant.
Covered entities include the organizations that collect, create, and transmit PHI electronically. For instance, healthcare providers (surgeons, doctors, lab technicians, hospitals, pharmacists, and clinics), U.S. health plans (HMOs, company health plans, Medicare, and Medicaid), and healthcare clearinghouses (community health management information system and billing services).
Business associates includes organizations that deal with PHI. Several businesses handle, process, or transmit PHI, such as data processing firms, data transmission providers, consultants hired for audits or coding reviews, medical transcription services, data storage or document shredding companies, electronic health information exchanges, medical equipment companies, and external auditors or accountants.
Organizations failing to understand or implement HIPAA standards are penalized. Organizations are fined based on the level of their offense. For instance, $50,000 is charged per offense for a Tier 1 violation, which indicates an organization that violated the HIPAA compliance unknowingly and is exercising due diligence. Tiers are categorized based on the severity of the offense, and the organizations can be penalized.
What Are HIPAA Rules?
HIPAA rules are generally divided into several major standards, such as privacy rules, unique identifiers rules, breach notification rules, transactions and code sets (TCS) rules, omnibus final rules, the HITECH Act, and security rules.
What Is the HITECH Act?
The Health Information Technology for Economic and Clinical Health (HITECH) Act is a part of the American Recovery and Reinvestment Act of 2009. It provides Medicaid or Medicare incentives and grants to hospitals and path labs, so they can invest in technologies to improve the efficiency of patient healthcare—equipment required in labs, ventilators, electronic health records (EHRs), health information exchange (HIE), and more. The HITECH Act expands the penalties for HIPAA violations and the scope of HIPAA privacy and security rules.
The HIPAA privacy rule mandates the security and privacy of patient’s rights to PHI. It defines when individual-specific health information can be used and disclosed. This rule only applies to covered entities and includes notices of privacy practices, patients’ rights to access PHI, rights to deny access to PHI, health care providers’ use and disclosure forms, and more. Every organization under a covered entity must follow HIPAA compliance, its policies, and procedures. In addition, employees and the entire staff must be trained to understand the policies.
Unique Identifiers Rule
The HIPAA unique identifier rule is part of HIPAA administrative simplification regulation and defines how unique identifiers work for covered entities while making HIPAA transactions. The purpose of these unique identifiers is to promote consistency, efficiency, and standardization.
HIPAA compliance establishes unique identifiers for:
- Providers—National provider identifier (NPI), a unique 10-digit number to identify health care providers
- Employers—Employer identification number (EIN), issued by the Internal Revenue Service to identify employers conducting electronic transactions
- Health plans
NPIs and EINs are mandatory for all HIPAA transactions.
Breach Notification Rule
The HIPAA breach notification rule is a part of the HITECH Act, which states organizations under covered entities and business associates are given up to sixty days to inform patients, HHS, and the PHI media about the data breaches. However, the rule levies penalties based on two types of breach activity known as minor and meaningful breaches. According to the rule, organizations must report about every kind of breach regardless of its size.
Transactions and Code Sets (TCS) Rule
The HIPAA transaction and code set rule addresses the 5010 and ICD-10 standards and describes the predefined transaction standards and code sets used in the healthcare industry for transactions and communications.
Omnibus Final Rule
The HIPAA final omnibus rule is an addendum and a part of the HITECH Act. It was enacted to establish HIPAA compliance on organizations that come under business associates. It sets the standards and outlines the rules of Business Associate Agreements (BAAs), mandatory contracts between two business associates or between a covered entity and a business associate to share or transfer PHI or ePHI.
The HIPAA security rule sets the national standards and procedures for both business associates and covered entities. The Security Rule states that organizations must securely maintain, handle, and transmit sensitive healthcare information or electronic personal health information (ePHI). The rule was established under HIPAA to maintain the safety and security of ePHI. The regulation must be properly documented in an organization’s HIPAA policies and procedures. Moreover, staff and employees must be trained for compliance with documented attestations. The rule includes physical, administrative, and technical safeguards standards healthcare organizations need to comply with to secure ePHI.
How to Become a HIPAA-Compliant Organization
Organizations need to implement various HIPAA policies and procedures, including the rules mentioned above, to become HIPAA compliant. However, to meet HIPAA compliance at each level, organizations must comply with the security rule and its three critical safeguards outlined below.
The major role of administrative safeguards is to prepare organizations to fight against potential data breaches. Administrative safeguards set a cyberthreat intelligence framework to secure sensitive healthcare data. Administrative safeguards include:
Security Management Process: Organizations that come under HIPAA are required to have a proper assessment plan in place to measure the potential risks and the vulnerabilities to the integrity, confidentiality, and availability of ePHI. Once these organizations identify threat areas where the probability of ePHI breach is higher, they are required to implement security measures to mitigate the risks.
Workforce Security: Organizations need to implement certain protocols for proper provisioning of access rights of the workforce and ensuring all employees are well-trained to meet compliance and have necessary permissions to perform their roles and responsibilities.
Assigned Security Responsibility: Organizations need to designate a member or an employee as a security official responsible for developing and implementing privacy and security measures in the workplace.
Security Awareness and Training: Organizations need to train their employees on the importance of HIPAA compliance. This training can include sessions on updating the security of sensitive organizational information, protection against malicious software breaches, log reporting, monitor logins, and safeguarding passwords.
Information Access Management: Information access management allows only certain rights to be given to employees, depending on their job roles and responsibilities. In other words, it works on the principle of least privilege in which permissions access rights are restricted to secure ePHI and only necessary permissions are granted.
Security Incident Procedures: The security incident standard states organizations must address security threats in two ways. First, immediately respond and take measures to mitigate the potential risks and prevent harmful effects. Second, document and report such issues.
Evaluation: Organizations must take authoritative measures to regularly conduct technical and nontechnical evaluations of compliance, keeping in mind security policies and procedures.
Contingency Plan: Organizations must have a contingency plan and be prepared for possible disasters, such as a natural event or a failure of the ePHI system. Organizations can have a back-up plan, which may include multiple copies of ePHI, disaster recovery plans to restore the lost data, and an emergency operation plan, so necessary business processes (safeguard ePHI) continue to work.
Along with administrative safeguards, it’s important to protect the physical hardware containing ePHI in HIPAA-compliant organizations. Organizations must cultivate a safe environment to uphold security standards, where the machines and the physical hardware cannot be tampered with. Physical safeguards include measures such as:
Facility Access Controls: Along with administrative safeguards, organizations must also limit access to the physical locations where ePHI is stored and should provide access to only personnel responsible for maintaining and securing those records. Organizations can use cloud-based technologies to store data while seeking preventive measures for cloud security.
Device and Media Controls: Security of devices containing ePHI must be a top priority. Such devices or electronic media containing ePHI must be carefully disposed of. Make sure the media is transferred securely before redistributing the device. It’s crucial to maintain records of device circulation, so organizations know the exact movement of the critical data.
Workstation Use: Each workstation used to access ePHI information must be properly governed and secured to protect data.
Workstation Security: Workstation security is mandatory and must be taken care of by physical safeguards or personnel who prevent workstation and ePHI access from unauthorized users. Badge scanners, trained security personnel, or locked doors can be considered physical safeguards.
Technical safeguarding standards predict how securely an organization is transmitting and storing ePHI. The rule addresses how organizations need to control permission access and know about data in rest and data in motion. Organizations must implement technical policies and procedures to maintain PHI data and permit access to only certain individuals.
Audit Controls: Audits are an integral part of HIPAA compliance because they help detect possible breaches. Every covered entity and business associates must conduct annual audits of their organization to assess technical, physical, and administrative gaps to check whether an organization meets security and privacy standards. Audit trails are used to build documentation and institutional records to investigate file accessibility and alterations.
Access Control: Access controls mean the permissions to access the ePHI is given to only specific individuals who need them to perform their job roles and responsibilities. Everyone is assigned a unique ID and granted rights such as Active Directory access. Individuals must understand the importance of automatic log off and encryption measures to ensure data is secure.
Individual or Entity Authentication: Everyone trying to access ePHI data through a workstation must have a unique identity to perform the job roles and responsibilities. Entity authentication is a must, and every organization and individual must abide by the rules.
Integrity: Integrity controls ensure only authorized individuals can access ePHI records and information is secured against improper alteration and destruction. Unauthorized individuals cannot access, leak, sabotage, or modify confidential data. Organizations must take strict measures to follow procedures and use event log software to ensure optimum data security.
Transmission Security: Transmission security standards ensure data security while it’s in transit. Organizations must secure their network by implementing technical security measures to encrypt the data.
What Are HIPAA-Compliant Software Solutions?
Organizations that come under covered entities, business associates, or any business that conducts healthcare operations need to meet HIPAA compliance. As the regulations, policies, and procedures are complex and extensive, IT administrators must incorporate necessary software, hardware, and introduce unique policies and procedures to help the organization to uphold security and privacy standards. Adding a few software solutions helps meet the unique compliance requirements and perform functions like generating audit trail reports. Outlined below are the best HIPAA-compliant software solutions.
Access Rights Manager
Organizations need to manage permission access and track user actions to meet compliance. However, both tasks cannot be achieved manually. Incorporating a HIPAA-compliant software solution can automate these tasks and provide tools for reporting on those activities. Similar to Active Directory handling permissions and group policies, SolarWinds® Access Rights Manager (ARM) is an advanced solution designed to help IT administrators to track permission access rights and changes across files and folders and generate real-time reports. With server maps and access rights visualization features, administrators can view the company’s access rights structure and file sharing process, thereby maintaining confidentiality, integrity, and security of the electronic PHI in accordance with HIPAA. Features of ARM include:
- Role-specific templates to help IT teams create safe user accounts
- Customized Active Directory (AD) and Azure AD reports
- Customized reports with detailed user activities you can send directly to auditors
- Streamlined user onboarding processes
- Most critical aspects of user access management highlighted
- High-risk user accounts identified
- Real-time change tracking and issue detection
Security Event Manager (SEM)
It’s important to scan networks for security breaches, malicious user activity, and cyberattacks regularly. To get a comprehensive protection plan, monitor log activity, and flag suspicious incidents, I recommend SolarWinds Security Event Manager(SEM).
SEM is a powerful tool designed to secure electronic Protected Health Information (ePHI) and meets HIPAA compliance mandates. The tool possesses advanced and robust features for IT administrators to collate information from servers, network devices, applications to determine potential issues, breaches, and detect security threats in real-time. SEM provides an automatic scanning feature for teams to identify threats such as phishing, botnet, ransomware, and malware. Using SolarWinds SEM, admins get quick alerts, so they can start mitigating risks. The tool includes advanced features to meet specific compliance requirements, such as:
- Alert to activity
- Event log correlation
- Infrastructure visibility
- USB protection
- Compliance reports
- Log forwarding
- Automated responses
The Final Word
Every organization considered a business associate or covered entity must take HIPAA regulations seriously and follow them with mandated policies and procedures. Employees, IT administrator teams, staff, and every individual employed in such firms or organizations need to understand the importance of confidentiality of ePHI and their role to uphold the compliance. They should be given proper training of HIPAA compliance along with assessments and document attestations.
Organizations must use software solutions to help them meet regulatory compliance needs and simplify tasks like tracking devices and detecting security threats and breaches through automation. Investing in SolarWinds SEM and ARM is a smart choice as organizations get solutions designed to comply with the rules in a cost-effective plan.