HIPAA Risk Assessment and Compliance
A HIPAA security risk assessment is an examination of an organization's physical and technological security measures to evaluate vulnerabilities and to highlight opportunities for improvement. It should be performed annually but may be performed more often, if there is a trend that warrants change. This analysis aims to help organizations identify and prioritize security improvements that will reduce the impact of a data breach on the organization's business continuity and reputation. Organizations are urged to examine their current security configurations and to plan for future improvements and upgrades.
What Is the Scope of a Security Risk Analysis?
The scope of a HIPAA security risk assessment will vary depending on a client's current security status and its approach to data protection. The objective of a HIPAA risk assessment, however, is to identify potential risks and vulnerabilities to the confidentiality, availability and integrity of all PHI that an organization creates, receives, maintains, or transmits. A HIPAA risk assessment is not a one-time exercise. Assessments should be reviewed periodically and as new work practices are implemented or new technology is introduced.
What Are the Steps in Risk Assessment?
There are five steps in risk management, as discussed below.
Identifying the Hazards
The first step in risk management is to identify the hazards that may cause harm or loss to the organization. There are natural hazards, like floods and earthquakes or human-caused, like theft and arson. Any potential hazard that could compromise patient safety or otherwise create financial liability for the organization must be addressed. The goal is to help identify all potential sources of a data breach, that is, all places where an individual/bad actor might have access to sensitive information and subsequently use or transfer it inappropriately.
Identifying Who Is at Risk
The second step in risk management is identifying who might be harmed by a data breach. The affected parties include employees, patients, and clients. In addition, the degree of harm may vary from inconvenience to identity theft or financial loss. The degree of harm depends on how the information is used and the extent to which it can be used against the affected party.
Evaluate the Vulnerabilities
The third step in risk management is to evaluate the vulnerabilities that could allow data to be leaked. The vulnerabilities are evaluated from the viewpoint of both the employee and the outsider, be it a disgruntled employee, a contractor, a vendor with access to sensitive data, or an outside hacker. The evaluation determines what kind of vulnerabilities exist and what risks they represent for disclosing confidential patient information.
Record the Findings
The fourth step in risk management is to document the findings. The documentation should include a description of the types of hazards and vulnerabilities identified, as well as the controls that will be used to prevent or minimize the loss of data. The documentation should include:
- A description of the types of hazards and vulnerabilities identified
- The controls that will be used to prevent or minimize the loss of data
- A corrective action plan with timelines, in order to mitigate risk
Reviewing the Risk
The fifth step in risk management is assessing the risk level for each hazard and vulnerability. The risk level is measured from low to high with high representing the most significant potential loss.
Is a HIPAA Risk Analysis Necessary?
A HIPAA security risk assessment can be the first step toward improving an organization's security measures and identifying gaps that need to be closed. It can also help an organization identify areas that are already secure and highlight the corresponding opportunity to reduce overall risk by reducing the number of vulnerabilities.
Failure to conduct a risk analysis can cost organizations tens of thousands of dollars and cause large-scale damage. The financial cost is due to lost revenue and reputation, which has a ripple effect on the organization's relationships with its patients, vendors, and employees. The reputation cost is due to allegations that the organization cannot be trusted to protect confidential information.
What Are the Four Factors of a HIPAA Breach Risk Assessment?
There are four factors that must be considered in the HIPAA security risk analysis. These factors are:
What PHI Was Used, Accessed, or Breached?
The first factor is determining which Protected Health Information (PHI) was involved. This includes PHI created or received by a patient, a patient's family members, health care providers, health plans, employers, or other HIPAA-covered entities and business associates.
Who Did What With the PHI?
The second factor involves determining who accessed the information and how. This can include access by a family member, a health care provider, a member of the public, or even a hacker. Patient access can also be involved in cases where the patient has given consent to others to access their information.
How Was the PHI Compromised?
The third factor concerns how PHI was compromised. This includes issues such as malicious software, human error, physical or electronic loss of a device or media containing PHI, or that of a third party not authorized to have access.
How Have You Mitigated the Risk?
The last factor is how the potential risk was mitigated. This may include changes to the organization's policies and procedures, changes in technology such as encryption, or divestiture of specific equipment that are no longer secure.
How to Develop a Risk Management Plan and Implement New Procedures
The Risk Management Plan (RMP) is designed to provide the process for an organization to manage the identification, assessment, and overall risk of PHI. It ensures that business decisions are made consistently and are documented through a process-oriented framework. The RMP should include the following components:
- Determine probable hazards, threats, and vulnerabilities – This involves exploring past and present events, internal and external threats, events, and the potential consequences of these events. It also looks at the interdependencies of PHI to determine the potential damage that may be caused if PHI is lost or stolen.
- Assess and evaluate possible hazards – Ensure that the potential hazards are mapped systematically to assess their severity based on the impact on the organization.
- Identify, prioritize and assess safeguards – This is where business processes, technology, and people can be used to reduce dangers and increase the risks of unauthorized disclosure.
- Assign responsibility for each possible risk – By assigning a risk owner, the organization ensures that the risk assessment is carried out.
- Make proactive reactions – This involves implementing measures that prevent and mitigate loss and restoring lost data.
- Constantly monitor threats – This involves reassessing the risk baseline at regular intervals. Each year, for example, the organization can repeat the risk analysis to ensure that controls remain effective as risks change.
How Often Does a HIPAA Risk Assessment Need to be Performed?
The HIPAA security risk assessment should be performed annually. The frequency will vary depending on the organization's circumstances, including its size and patient population.
The Office for Civil Rights (OCR) is in charge of delivering periodic guidance on the HIPAA security rule requirements. OCR has determined that healthcare organizations have a better chance of maintaining the security of their PHI if they conduct periodic risk assessments on the HIPAA security rule requirements at least annually.
What Is the Difference Between a Risk Assessment and a Risk Analysis?
A risk assessment assesses all possible threats to your company's capacity to conduct business. These threats may include project, enterprise, control, and inherent risks. On the other hand, a risk analysis is a stage in which you assess each identified risk and assign a score using one of two grading systems, quantitative or qualitative. These scores assist you in prioritizing your risks so that you know which ones to handle first and how to manage them effectively. A risk analysis is a part of healthcare risk management that involves calculating and prioritizing the potential risks associated with a process, service, or technology.
Are there Different Types of Risk Assessment for Covered Entities and Business Associates?
Covered entities and business associates must do "A-to-Z" risk assessments for every Protected Health Information generated, utilized, or stored. While business associates may have less PHI than covered entities, the risk assessment must be just as complete and adequately documented. It covers the same areas as a covered entity.
What Are the Most Important Risks to Look Out for in a HIPAA Risk Assessment?
The most important risks to look out for in a HIPAA risk assessment are:
Confidentiality of the PHI
This is the first and most significant risk for covered entities. Organizations may face severe fines and public humiliation if a breach of PHI occurs. It is also the first risk that must be assessed because it directly impacts all other risks.
Integrity of the PHI
Integrity refers to the accuracy and completeness of the PHI. If the information is not accurate and complete, there is a risk that an individual may receive improper treatment or that an individual's identity may be stolen.
Availability of the PHI
Failure to access the PHI in the required time puts patients and providers at risk. The inability to access information may lead some patients to seek care from another provider. Others may delay seeking care until their conditions become more severe with the potential for serious consequences.
Other top issues that may be investigated may include:
- Prohibited uses and disclosures – This includes situations in which the PHI may be used or transmitted to other individuals or other entities that are not permitted by HIPAA (such as the media), wireless devices, and public computers.
- Access constraints – You will need to ensure that access to the PHI is restricted to only those persons or entities who need such access. This includes limiting the number of people who should have access to the PHI and the situations in which they can view it, share it, or print out a hard copy.
- Failure to execute the HIPAA security rule's administrative protections – This includes items like lack of data protection, failure to encrypt PHI being transmitted over the internet, and no clear pathways for handling health data.
- PHI disclosures above the bare minimum – You will need to ensure that any disclosure of PHI is restricted to the bare minimum necessary amount needed to accomplish a purpose.
What Are "Technical And Nontechnical Vulnerabilities"?
A technical vulnerability is a capability, system, or process that can be targeted for remote access. A nontechnical vulnerability does not require specialized knowledge to exploit. Nontechnical vulnerabilities are poor configuration, missing patches, and programming errors that may cause a program to misinterpret data. These defects can be as common as a user entering the wrong login name and password or a hacker emailing unsolicited messages.
What Is a "Reasonably Anticipated Threat"?
Any foreseeable hazards to HIPAA compliance are considered reasonably expected threats. These include not just bad external actors but also risks caused by human mistakes or a lack of understanding owing to a lack of training. This is why identifying reasonably expected dangers requires a "large picture" perspective of organizational operations.
Risk management is a continuous and dynamic process that cannot be left to chance. The most effective security measures are consistent with and support your business objectives. The best way to achieve this is to work with a third-party risk management services provider. They understand the nuances of HIPAA compliance and the needs of businesses that deal with PHI on a daily basis.
Contact The Honest Approach today to see if your business needs a risk assessment!