HIPAA Security: 7 Steps for Compliance with the Security Rule
What Are the HIPAA Security and Privacy Rules?
The HIPAA Security and Privacy Rules are essential components of the Health Insurance Portability and Accountability Act (HIPAA), a federal law enacted in the United States in 1996. These regulations establish the standards for protecting the privacy and security of certain health information, specifically, individually identifiable health information.
The Privacy Rule protects the privacy of personal health information, also known as Protected Health Information (PHI). The rule applies to all forms of PHI, whether electronic, written, or oral. It requires health care providers, health plans, and other entities covered by HIPAA to implement safeguards to protect the privacy of PHI and sets limits and conditions on the uses and disclosures of such information without patient authorization.
The Security Rule is a subset of the Privacy Rule and relates specifically to Electronic Protected Health Information (ePHI). It establishes national standards to protect individuals’ electronic personal health information that is created, received, used, or maintained by a covered entity. The Security Rule requires entities to ensure the confidentiality, integrity, and security of ePHI.
This is part of a series of articles about HIPAA compliance.
Who is Covered by the HIPAA Security Rule?
The HIPAA Security Rule applies to what the legislation defines as ‘covered entities’. These include health care providers, such as hospitals, clinics, nursing homes, pharmacies, and doctors who transmit health information electronically in connection with certain transactions. Health insurance companies, HMOs, company health plans, and government programs that pay for healthcare, like Medicare and Medicaid, are also covered entities. Additionally, health care clearinghouses, such as billing services, community health management information systems, and re-pricing companies, are covered by these regulations.
Business associates (BAs) of these covered entities are also required to comply with the HIPAA Security Rule. These business associates are third-party service providers who perform functions or activities on behalf of, or provide services to, a covered entity that involves the use or disclosure of PHI. This includes contractors, consultants, vendors, and subcontractors. The rule mandates that covered entities must have contracts or other arrangements with business associates to ensure that they only use and disclose PHI appropriately and safeguard it.
What Are the Three Standards of the HIPAA Security Rule?
The HIPAA Security Rule identifies three types of security safeguards required for compliance: administrative, physical, and technical. Each of these standards has specific implementation specifications that covered entities and business associates must adhere to, in order to ensure the confidentiality, integrity, and availability of ePHI.
Administrative Safeguards
Administrative safeguards are administrative actions, policies, and procedures to manage the selection, development, implementation, and maintenance of security measures to protect ePHI and manage the conduct of the covered entity’s workforce in relation to the protection of that information.
They include risk analysis and management, training of employees, establishment of a security official, access management, workforce security, and evaluation of security policies and procedures. The goal is to create a formal security management process, assign security responsibility to a dedicated individual, institute workforce security awareness and training, and develop contingency plans, among other actions.
Physical Safeguards
Physical safeguards refer to physical measures, policies, and procedures to protect a covered entity’s electronic information systems, related buildings, and equipment from natural and environmental hazards, and unauthorized intrusion.
These include facility access controls, workstation use and security, and device and media controls. Covered entities and business associates should implement policies to limit physical access to electronic information systems and the facilities they are housed in while ensuring that authorized access is allowed. This can involve procedures for the proper use of and access to workstations and electronic media, as well as policies regarding the transfer, removal, disposal, and re-use of electronic media.
Technical Safeguards
Technical safeguards are the technology and the policy and procedures for its use that protect ePHI and control access to it. They provide the technology requirements and policies for protecting ePHI, particularly focusing on encryption and decryption, access controls, audit controls, and integrity controls.
Access controls ensure only authorized individuals can access ePHI. Audit controls are hardware, software, and procedural mechanisms that record and examine access and other activity in information systems. Integrity controls ensure ePHI is not altered or destroyed in an unauthorized manner, while transmission security measures protect against unauthorized access to ePHI that is being transmitted over an electronic network.
7 Critical Steps for Compliance with HIPAA Privacy and Security Rules
Fully complying with the HIPAA Privacy and Security rules is complex and cannot be fully addressed in this article. However, below we review seven essential steps that will typically be part of an organization’s HIPAA compliance efforts.
1. Conduct a Risk Analysis
A risk analysis involves identifying and assessing the risks to the confidentiality, integrity, and availability of ePHI within your organization. The risk analysis should be comprehensive, covering all systems, applications, and processes that create, receive, maintain or transmit ePHI.
The risk analysis should identify potential vulnerabilities, such as outdated software, lack of encryption, inadequate access controls, or lack of employee training. It should also assess the potential impacts of these vulnerabilities, considering factors such as the volume of ePHI, the type of ePHI, and the potential harm to individuals if the ePHI were compromised.
After identifying and assessing the risks, the next step is to prioritize them based on their likelihood and potential impact, and develop a risk management plan. This plan should outline the measures that will be implemented to reduce the risks to an acceptable level, and the timeline for their implementation.
2. Assigned Security Responsibility
One of the requirements of the HIPAA Security Rule is the assignment of a security official who is responsible for the development and implementation of the policies and procedures required by the rule. This individual, often referred to as the HIPAA Security Officer, plays a crucial role in maintaining HIPAA Security compliance.
The HIPAA Security Officer should have a thorough understanding of the HIPAA Security Rule, and be capable of performing a risk analysis, developing and implementing security policies and procedures, and overseeing security awareness and training programs. They should also be responsible for managing security incidents and breaches, and for ensuring that the organization is prepared for a HIPAA audit or investigation.
3. Workstation and Device Security
Workstations and devices that store or process ePHI pose significant risks to HIPAA Security compliance. Therefore, it’s crucial to implement policies and procedures that govern the use of these workstations and devices, and to ensure that they are adequately protected.
Workstations should be located in secure areas, and screen savers or automatic logoff features should be used to prevent unauthorized access. Devices that store ePHI, such as laptops or mobile devices, should be encrypted and password-protected. They should also be stored in secure locations when not in use, and should be securely wiped or destroyed when they are no longer needed.
4. Install Mechanisms to Restrict Access to ePHI
Access to ePHI should be strictly controlled, with access granted only to those persons or software programs that have been authorized based on their role or function. This involves implementing technical measures such as access controls, authentication, and encryption, as well as administrative measures such as access policies and procedures.
Access controls should ensure that only authorized individuals can access ePHI, and that they can only access the minimum necessary information to perform their job functions. Authentication mechanisms should be used to verify the identity of those seeking access to ePHI, and encryption should be used to protect ePHI during transmission and storage.
Access policies and procedures should outline the process for granting, modifying, and revoking access, and should define the roles and responsibilities of users, supervisors, and the HIPAA Security Officer. They should also define the actions to be taken in the event of a violation of the access policies and procedures.
5. Establish Internal Communication Plans for Cybersecurity Events
Effective internal communication is vital for managing cybersecurity events, especially those involving ePHI. Establishing an internal communication plan ensures that all relevant personnel are informed and know their roles in the event of a security incident. This plan should specify how information about potential or actual breaches is communicated within the organization, including the channels of communication, the flow of information, and the roles and responsibilities of each team member.
The plan should detail the procedures for reporting suspected or confirmed breaches of ePHI. This includes identifying to whom such incidents should be reported, how quickly they should be reported after discovery, and the specific information to be included in the initial report.
The communication plan should also outline the process for ongoing communication during the incident management process, ensuring that key stakeholders, including the HIPAA Security Officer and IT staff, are kept informed of developments and response efforts. Additionally, the plan should include provisions for debriefing and post-incident analysis, allowing the organization to learn and improve its security posture from each incident.
6. Establish a Breach Notification Protocol
Despite your best efforts to protect ePHI, breaches can and do occur. Therefore, it’s crucial to have a breach notification protocol in place. This protocol should outline the steps to be taken in the event of a breach, including the identification and containment of the breach, the assessment of the risks associated with the breach, and the notification of the affected individuals and the Department of Health and Human Services (HHS).
The breach notification protocol should also outline the steps to be taken to prevent future breaches, such as the implementation of additional security measures, the revision of policies and procedures, or the provision of additional training to employees.
7. Keep Extensive Records to Demonstrate Compliance in Case of Audit
One of the key aspects of HIPAA Security compliance is the ability to demonstrate compliance in case of an audit or investigation. This involves keeping records of all security policies and procedures, risk assessments, and training materials, and making them available to the HHS upon request.
These records should provide evidence of the implementation of the required safeguards, and should demonstrate that the organization has conducted a comprehensive risk analysis, implemented a risk management plan, assigned a HIPAA Security Officer, and provided training to all employees.
Related content: Learn more about HIPAA compliance checklist.
HIPAA Compliance with Exabeam
Noncompliance with HIPAA can result in heavy fines from OCR and other consequences. When patch management, access controls, and monitoring are not fully implemented with the right solution stack, it leaves the organization vulnerable to ransomware and other attack vectors that can impact patient care.
Exabeam Security Operations Platform telemetry combines logs with context, security intelligence feeds, and AI analysis to identify anomalous behaviors that indicate potential attacks. Pre-built Dashboards make HIPAA Compliance reporting easier. Whether you are using a framework like NIST or MITRE ATT&CKⓇ Exabeam offers a clear path to track your compliance and governance request needs — while all establishing what normal looks like in your environment and for every entity logged in.
The Outcomes Navigator offers continuous visualization and insight into your detection coverage and improvements made, which provides suggestions for improvements in log parsing as well as showing which sources and detections are most effective against which parts of the ATT&CK framework and use cases are most indicative of network penetration, persistence, and lateral movement.
For more info, visit the Exabeam Compliance page