The Health Insurance Portability and Accountability Act (HIPAA) is a state law that ensures that patient health information (PHI) is not compromised. The law ensures that no sensitive information is disclosed to anyone without the consent of the patient or their legally assigned caregiver.
If you are an organization that provides healthcare support or is needed to handle patient data, risk analysis is a must according to HIPAA security rules. But what even is risk analysis and how can you ensure that your system complies with existing rules? Let’s discuss.
What Is HIPAA Risk Analysis
As an organization that handles healthcare information, the first step of risk analysis is knowing what kind of PHI you have access to. This way, you can determine if there’s any security loophole that needs to be addressed. The analysis doesn’t necessarily have a profound set of rules that suits every organization, but there’s a downloadable guideline by HHS that can help.
More than being one of the HIPAA compliance requirements, risk analysis has its benefits and consequences if not done correctly. There are four tiers of HIPAA violations, having no knowledge of the violation being tier one and willful neglect being tier four. Tier 1 or having no knowledge violation costs around $100 for the first violation. While there were instances where a provider was charged $5.5M for a single violation of tier 4.
What Happens if You Fail to Conduct Risk Analysis
The level of negligence and the number of patients affected by the breach are usually the defining factors of the imposed fines on organizations. As organizations are mandated to know and impose HIPAA regulations, only a few are fined for having no knowledge on this matter.
From the second round of HIPAA audits, the potential PHI breaches have also been fined. If your organization fails to address vulnerabilities or fails to execute the analysis process altogether, the fines can go beyond $1.5M.
You’d better understand the situation with an example. In 2015, Texas Health and Human Services Commission was fined $1.3M due to non-compliance with the HIPAA. They failed to launch an analysis program in time and a review team was sent. The review team found out the following
- An internal software – which handled patient information – was moved to a public server, which potentially exposed patient data;
- No access control was implemented on their applications; and
- The assessment was only done for IT systems, and not organization-wide.
These kinds of incidents call for the need of a detailed and accurate risk analysis. This way, organizations can avoid compromising the PHI.
Who Are in the Firing Line
The majority of hefty fines are imposed on large organizations for HIPAA violations. But, it’s been recorded that among thousands of HIPAA violations every year, only 1% of those consist of breaches that affected more than 500 patients.
If a small organization is found to be breaching HIPAA compliance, the fines can potentially close down the business altogether. Most of the insurance coverage that these small firms have is not enough to pay the fines, hire an IT team, and reinstate public confidence.
Risk analysis plays a critical role for these small and medium organizations. As the assessment cost is a fraction of the fines, staying ahead of that and ensuring security almost always is the most prudent move for them.
Not being a healthcare provider doesn’t help either. If your organization handles PHI in any way, you need to assess HIPAA security risks to run your business. Business associates, vendors, and subcontractors are also required to go through accurate security management.
In 2021, it was revealed that 93 of the breaches among 714 were due to negligence of business associates.
HIPAA Risk Analysis to Follow
If you’re convinced that you need to risk analyzing your organization for HIPAA compliance, let’s discuss the steps you need to take.
Step 1: Determining the ePHI Access
You need to understand what ePHI your organization will have access to. Determine how you store your patient data and understand how the data is transmitted to other departments. This step is not very complicated to follow as you can get this information by following the workflow of the current projects you are operating.
Step 2: Analyze Your Security Measures
Following the deduction of your ePHI storage and access, you need to analyze if your already existing system is secure or not. The best way to assess system vulnerabilities is by trying to breach the system itself. This can be done by hiring IT professionals.
Step 3: Categorize the Risks
After you’ve analyzed and found vulnerabilities in your system, it’s now time to move forward and categorize them by their risk levels. Discuss with your IT team to determine which threats are high-priority and should be fixed right now before you can proceed further with the assessment.
Step 4: Documentation
The objective of these security assessments is to keep patient information secure and not to impose fines on you. Fines are a consequence of potentially neglecting patient information safety standards. Keep your assessment workflow well documented and mention the mitigation steps that you took to fix the vulnerabilities.
Step 5: Do it Regularly
While there’s no written rule for the periodicity of risk analysis, you should maintain an annual cycle to ensure that you stay ahead of the latest vulnerabilities. As the technology of both hackers and security experts grows, your responsibility is to keep your systems updated with the latest IT updates to keep PHI safe.
How to Develop a Risk Management Plan
After you’ve assessed and mitigated the risks, it’s now time to ensure that you don’t fall behind. Erect risk management plans for your organization to keep your systems updated and compliant.
Stay Updated
Keep your systems updated with the latest guidelines announced by HIPAA. If your ePHI handling systems aren’t updated for the last three years, it’s now time to do so. Change your applications if need be, but don’t risk paying fines.
Breach Protocol
In case of a breach, train your employees on how to read, analyze, and solve the problem without exposing too much patient data.
Employee Training
Train your employees to handle patient data efficiently. HIPAA requires your employees to be sound about their duty towards PHI and patients themselves.
Business Associate Agreement
Sign a contract with your business associates that handle patient data on your behalf. Ensure that the organization that you are working with is also HIPAA compliant. The contract should clearly mention the permissible and impermissible uses of PHI.
The Bottom Line
If you don’t want to pay fines and gamble public confidence for risking patient data according to HIPAA rules, it’s best to follow these 5 risk analysis steps to ensure that your organization is ready for HIPAA reviews. After a successful review, develop a risk management plan that covers employee training and breach protocol.
