HIPAA (Health Insurance Portability and Accountability Act) provides guidance and regulations on handling PHI (protected health information) and applies to any healthcare organization or its business associates. The aim of HIPAA is to ensure that PHI stays secure and confidential. However, breaches in the healthcare realm happen every day. To mitigate this risk, you’ll need to conduct a HIPAA security risk analysis.
Whether your organization is well-versed in these exercises or is just learning about them, you’ll find the information in this article helpful and valuable. We’ll explain what a risk analysis is, what it should cover, best practices, and how to find the best partner to perform one.
What Is a HIPAA Security Risk Analysis?
The HIPAA Security Rule requires that covered entities and their business partners conduct risk analysis regarding the usage and protection of ePHI (electronic PHI). It’s a critical component of maintaining HIPAA compliance with the goal of identifying weaknesses and addressing them to prevent data breaches.
Per HIPAA rules, any healthcare entity or company that creates, accesses, or uses ePHI must conduct these annually. The second requirement for a HIPAA security risk analysis appears in the Breach Notification Rule. You must perform an analysis if there has been an impermissible use or disclosure to determine if the event requires notification to the HHS (Health and Human Services) and impacted individuals.
You may also launch a HIPAA security risk analysis if major changes happen, like adopting new software, changing network configurations, or any other major event.
The OCR (Office for Civil Rights), which is responsible for enforcing HIPAA, provides guidance on the requirements for such a risk analysis. Here are the critical requirements outlined:
- Assess any potential risks and vulnerabilities regarding the confidentiality, integrity, and availability of electronic PHI.
- Review compliance with HIPAA standards.
- Identify how ePHI is created, received, maintained, and transmitted.
- Determine how vendors or third parties with which you engage create, receive, maintain, and transmit ePHI.
- Define all the threats to the security of the data, including human (internal and external), natural (flooding, earthquakes, etc.), and environmental (physical and cyber).
After an analysis, your organization will need to take action to reduce risks. The OCR guidance recommends doing these things if applicable:
- Designing personnel screening processes.
- Determining what data to back up and how.
- Employing encryption for data at rest and in transit.
- Addressing data authentication needs.
The document also offers best practices for what should be in the scope of the HIPAA Security Risk Analysis.
What Should the Scope of Your HIPAA Security Risk Analysis Include?
There are many methods for these assessments. How you conduct yours will depend on your business model, the volume of data, and many other factors. The following are what we consider the gold standard of a HIPAA Security Risk Analysis.
The big picture of “scope” is that the evaluation should include risks and vulnerabilities that could impact the confidentiality, integrity, and availability of ePHI that an organization creates, receives, maintains, or transmits. Thus, it’s all forms of electronic media containing ePHI. “Electronic media” is broadly defined and pertains to just about anything from a single hard drive to your entire cloud network.
In addition to electronic media, you also need to include physical ones. Hard copies of documents with patient information apply as well.
The scope is large, but the analysis itself can follow six specific elements to streamline it and ensure the most thorough analysis.
The Six Elements of a Security Risk Analysis
There are six steps in a HIPAA Security Risk Analysis. Let’s look at each one and what it requires.
- Data collection: You’ll classify the location of all ePHI within your organization. There are a few ways to facilitate this, including reviewing past or existing projects, performing interviews, or going over documentation. Whatever process you use, you must also document it.
- Potential threat and vulnerability identification and documentation: Next, you must determine threats to ePHI that you reasonably anticipate. You’ll need to do the same with vulnerabilities, which, if exploited, could increase the risk of a breach.
- Evaluating current security measures: In step three, you’ll note the current state of security for your organization. This should include what you do to safeguard ePHI, what provisions within the Security Rule are in place, and determining if the protocols in place are configured and used correctly.
- Discerning the likelihood of a threat occurrence: After evaluating the current state, you’ll move to gauge the possibility of risk to ePHI. The results of this and the threats previously identified will disclose what threats you should consider as “reasonably anticipated.”
- Assessing the potential impact of a threat occurrence: In this step, you’re focusing on what happens if a security incident takes place and what the effects would be. You can create a list and document the threats on a scale from most severe to least.
- Concluding the level of risk: At the end of the process, you’ll define your level of risk based on threat likelihoods and impacts. Risk is highest when a threat is likely to occur and would significantly affect an organization. Conversely, if there’s a low risk of either of these things, the level is minor.
What Should You Expect After a HIPAA Security Risk Analysis?
Remember that assessments are a continuous process, and you’ll have previous ones to measure performance. After each, you’ll want to compare findings and move forward with a plan.
An assessment conducted by an experienced and technically adept team delivers a lot of valuable information. You have good reason to take action once you know your blind spots. First, you want to remain HIPAA compliant and not face fines, which will be steeper if you’re not conducting these HIPAA security risk analysis.
Second, you want to prevent breaches which cause reputational harm and distrust. It’s hard to remove the tarnish that such an event creates for your brand.
Third, in addition to fines, you could face lawsuits from victims of the breach or provide them with support like free credit monitoring.
These annual assessments provide you with a framework of where all the possible weaknesses are in your network. You can use them in conjunction with penetration testing to get a complete picture.
A security partner can carry out both an analysis and penetration testing. An outside firm will be able to pinpoint this conclusively and don’t have any bias that exists from internal auditors.
Together, you should work on retooling your risk management plan to include the following:
- Implement new policies that fortify your data safeguard processes and any change management procedures.
- Look at all high vulnerabilities and create a plan to reduce the risk associated with these by upgrading technology or increasing monitoring.
- Develop advanced training programs for all employees that handle ePHI above and beyond what HIPAA requires.
- Make decisions about decommissioning legacy applications and migrating to limit the inherent risk of using systems that are no longer maintained.
- List out any configurations that are improper and remediate those.
Your risk management plan may also include other areas of security that need evaluation, such as medical devices, payment compliance, and audits of third parties. These are critical elements of your security framework but don’t necessarily include ePHI. They can, however, be areas of vulnerability.
How to Find a Security Partner to Conduct Your HIPAA Analysis
Small and large organizations choose to hire security firms to conduct HIPAA assessments. After all, these groups have extensive knowledge and expertise. They will uncover anything that could be a threat and will be comprehensive in their review.
When seeking a partner, consider these things:
- What’s their level of experience?
- Are they HIPAA fluent?
- Do they offer a portfolio of services regarding healthcare security?
- How long will it take them to complete the analysis?
- Can they help you with your risk management plan?
- Do they customize assessments for each of their clients?
- What tools do they use to assess risk?
- What does the assessment process look like?
- How will they communicate with you and keep you updated?
There are many options for HIPAA security specialists. Most offer a lot of the same services. However, you want to find a firm you can trust above all else. Starting with a foundation of trust and competency ensures that the partnership will be collaborative and mutually beneficial. Something else to consider is the reports and documents they’ll provide you. You need them to be easy to understand and implement versus hundreds of pages that are nothing but technical jargon.
Talk to the HIPAA Experts at Blue Goat Cyber
HIPAA Security Risk Analysis don’t have to be inconvenient and time-consuming. When you work with our team of experts, we do all the heavy lifting to keep your organization compliant and data secure. Our people, processes, and services make us a unique group in the cybersecurity industry, as we focus on security holistically and deliver insights and reports that you can use.