Understanding HIPAA Compliance for Healthcare IT Systems

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For many, working in healthcare is a dream.

You pursue the career because you believe in it.

It provides rewarding experiences and promise as a long-term occupational pursuit.

But, even dream jobs come with baggage, and in healthcare, most of that baggage is tied to rules and regulations.

While these rules are certainly important, keeping up with everything can prove a challenge.

In some cases, the greatest challenges come from regulations that really extend outside your expertise as a healthcare professional.

We’re talking about HIPAA and the long list of requirements surrounding your technology.

It’s a lot to learn, but you’re also directly responsible for compliance.

With that in mind, this comprehensive guide will get you well on your way to HIPAA-compliant operations.


What Is HIPAA?

The Health Insurance Portability and Accountability Act (HIPAA) was first published in the 90s.

It has since seen plenty of updates, but the gist of the act remains intact: create national standards for health documentation.

Those standards cover a lot of ground, much of which aims to ensure the accuracy and integrity of medical records.

Other parts of HIPAA focus on privacy protection for patients.

Among the latter rules is a specific section that looks at electronic documents and communication.

That section is known as the Security Rule, and it more or less tells healthcare providers and medical professionals how to secure their records.

The Security Rule is the primary focus of today’s discussion.

As we go through it, you will learn the essentials of what HIPAA compliance entails, why it matters, and how you can successfully live up to the regulations.


Why Is HIPAA Important?

Remember that HIPAA was developed to set standards for records integrity.

HIPAA protects patients. If records are not maintained accurately and reliably, medical mistakes happen. Patients may directly receive harm as a result.

Considering that medical malpractice is a leading cause of death in the United States, record integrity holds paramount importance in healthcare.

Beyond that, protecting patient information and securing privacy also merit national standards and the stark attention of individuals in the medical field.

Health information has been and can be used for harmful discriminatory practices.

Also, it’s one of the most personal bits of information that exist.

Following HIPAA ensures that you are up to national standards and taking reasonable measures to protect such personal information.

This builds patient trust and confidence.

Last, but often most compelling, HIPAA violations come with steep penalties.

You can incur up to $50,000 per violation and time in prison.

This is not something to take lightly.


HIPAA Compliance Requirements

HIPAA and the Security Rule cover a lot of ground, but you can break all of the rules into four general rules:

• Ensure the confidentiality, integrity, and availability of all electronic health documents

• Identify and defend from threats reasonably anticipated

• Protect against improper disclosures

• Ensure that all employees comply.

In greater detail, these ideas fall into two categories: protecting information and creating and maintaining secure systems.


Protected Health Information

Protecting health information boils down to access and control, and that begins at a physical level.

Random strangers should be physically impeded from touching devices that have direct access to medical records.

This is why such devices are behind counters, closed doors, or other barriers that keep them out of common touch.

More than that, workstations and sensitive devices need proper security in the ways they are stored.

They should be under supervision or behind a lock when not in use.

Once physical security is in place, digital security still matters.

Access control is an entire branch of cybersecurity that limits who can access what information within a network. Health providers need to maintain such systems so that unauthorized persons cannot access records.

Additionally, authorized persons should not be able to access health information beyond the scope of their roles.


Privacy and Security Rules

Secure systems are built by their rules. In a workplace, you can institute practices that improve security.

People should not use personal devices to retrieve sensitive information.

Records should only be transmitted over secure communication channels.

Employees should not verbally convey sensitive information in unsecured settings.

There are also digital rules that govern device behaviors.

Devices can automatically encrypt records.

Communication can default to a secure socket layer or comparably safe communication methods.

Digital policies can ensure record integrity and automate access control to prevent unauthorized changes to documents.

HIPAA does not expressly outline how you need to secure devices and records.

Instead, you are responsible for understanding common risks and protecting against them.


Risk Management for HIPAA Compliance

Knowing your expectations certainly represents the first step in compliance, but you have a ways to go from there.

The next step is creating a plan of action.

For that, you need to conduct risk assessments and then implement security measures accordingly.


Conducting Risk Assessments

HIPAA directly requires risk assessments.

Through these, you determine the likelihood and impact of risks to your digital documents and communication methods.

Each risk determined to pose a reasonable likelihood of occurring must be countered.

In order to counter reasonable risks, HIPAA requires that you choose security measures and document your plans of action.

As an example, if you implement an encryption method for digital document storage, the method and type of encryption need to be documented and kept accessible in the case of a HIPAA audit (more on those later).

The good news is that HIPAA risk assessments look like any other risk assessment in the cybersecurity space.

The bad news is that the average healthcare provider lacks the IT expertise to carry this out independently.

In short, you need IT support to properly assess risk.


Implementing Security Measures

Once your assessments conclude and you document your plans of action, they have to be carried out.

This path is typically straightforward.

You already drafted security measures.

It’s a matter of living up to them.

From the HIPAA compliance perspective, you are intended to maintain “continuous security” from the conclusion of your assessments.

You are also supposed to provide a rationale for each of your security measures (which you hopefully answered when documenting your plans of action).


Training and Awareness Programs for Healthcare Offices


Automated practices offer a lot in terms of security and compliance, but there’s another element to consider.

You have people in your organization, and they must act in compliance with HIPAA as well.

All of the security features in the world amount to nothing if your staff creates vulnerabilities.


Importance of Staff Training

Anyone who accesses or handles health documents is responsible for living up to HIPAA standards.

This does not mean that every assistant on staff has to deeply understand the technical protocols in play.

Instead, it means they are responsible for understanding what kinds of documents are protected by HIPAA and the actions they are expected to take to protect those documents.

In general, these actions include protecting screens from prying eyes, avoiding disallowed verbal disclosures, and following implemented security practices (like using a strong password for their accounts).

Clearly, staff personnel need training.

How can you expect them to know the rules and expectations without it?

That’s obvious, but there’s another aspect many in the medical field overlook.

User practices actually pose the top security threat for any organization.

It turns out that 88 percent of data breaches are caused by internal employees doing something wrong.

That’s true in medical facilities too.

Teach your staff how to protect data.

It’s the only way to stay in compliance.


Developing Effective Training Programs

That leads to the inevitable question: how do you train staff?

There are many resources in place, but ultimately, you have to commit to an investment plan.

It will take time and money out of your budget to teach everyone HIPAA compliance.

You have to decide how much is reasonable.

In most cases, outsourcing proves cost-effective.

Seasoned experts can walk you through training best practices and even directly provide training to your organization.

Even with outsourced training, one element remains under your control.

Your organization will have to determine how it holds members accountable for receiving and utilizing training.


HIPAA Compliance Audits and Penalties in Healthcare

With a better understanding of how HIPAA compliance works and how you can face it, it’s time to talk about enforcement.

HIPAA regulations are enforced almost entirely through audits and subsequent penalties.


Preparing for Audits

HIPAA is often enforced through audits.

The goal of an audit is to find potential flaws or existing violations to point them out to organizations.

Typically speaking, when problems are identified, organizations are given time to make corrections.

To prepare for an audit, two things are necessary (assuming you went through the proper actions of risk assessment and prevention).

First, remind staff of their responsibilities regarding HIPAA.

Even if they all received training at some point, a few reminders for best practices go a long way.

Second, double-check documentation.

Ensure that your plans of action, justifications, and risk assessments are all up to date and readily accessible.

Additionally, make sure your organization has been on top of self-reporting.

When HIPAA violations are noticed within your organization, you can correct the problem and self-report.

Doing so indicates that your organization follows procedures and works to stay in compliance.

If known violations are not reported, you can expect trouble with your audit.


Understanding Potential Penalties

Any time medical records are shared improperly, you face a violation.

Additionally, if your audit finds vulnerabilities and you fail to correct them, you will likely be penalized.

Penalties range according to the severity of the infraction, the intent behind the action, and your efforts to take corrective action.

The smallest penalties start at a $100 fine, and the most severe penalties can get up to $250,000 per infraction and 10 years or more in jail.

Those extreme penalties only apply when the violator demonstrates criminal intent to sell health data.

In general, if the violations are not deliberate, you get 60 days to take corrective action.

Of course, violations are dealt with on a case-by-case basis, so keep that in mind.


Get Professional Help With HIPAA Compliance

HIPAA compliance is essential in any healthcare setting.

While you can understand most of the rules and regulations, IT-specific regulations can prove harder to follow.

Your best bet is to find a managed IT provider that understands HIPAA and can take care of most of it for you.

MainSpring offers such services with a strong vertical expertise in healthcare and HIPAA compliance.

Contact us to discuss risk assessments, HIPAA audits, staff training, and comprehensive services that protect you and your patients.