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HIPAA Risk Analysis Requirements

Risk Mitigation, identify, assess, reduce risk

Nefarious characters see healthcare organizations as high value yet relatively easy targets. These are referred to as target rich, cyber poor.  Given that healthcare organizations have a combination of personally identifiable information, financial information, health records, and countless medical devices, they are essentially a one-stop shop for a bad actor. Understanding the HIPAA risk analysis requirements can help save your organization from these criminals.

There has been a significant rise in the number and severity of cyber-attacks against hospitals and medical practices in the last few years. These attacks expose vulnerabilities and endanger patient safety. The more they happen, the more expensive, and dangerous they become.

Although the HIPAA Security Rule does not specify how often a risk analysis must be conducted, it is recommended to review your systems at least once a year. Keep in mind if you introduce new equipment, software, or suffer a security incident, you may need to evaluate your risks more often.

If you need a HIPAA Security Risk Analysis, check out our:

The OCR conducted a webinar regarding Risk Analysis Requirements and discussed the areas that are deficient.

The OCR mentioned the following:

  1. The lack of a system wide accurate and thorough analysis. (Step 1 Questionnaire)
  2. Performing only the MIPS risk analysis does not encompass the system wide requirements.
  3. PCI/DSS is more than likely not a complete risk assessment since it does not include ePHI.
  4. Instead of a system wide accurate and thorough risk assessment, a summary or heat map is provided without the backup documentation.
  5. Lack of inventory list to track which devices access, transmit, or store ePHI. (Located in the Profile)
  6. No method to track operating systems that become out of date. (Documented in the inventory list)
  7. Lack of mitigation documentation after the risk analysis was completed. (Step 1 Risk Management Plan)
  8. Lack of sanctions against staff who violate HIPAA. (Step 3 Policies and Procedures)
  9. Lack of security software / equipment updates. (Documented in reports from your IT company and stored in the Profile under Uploads)

Let’s all work together to keep patient data safe and secure. If you need assistance with HIPAA Compliance, check out our HIPAA Keeper™. It’s an online compliance system that has everything you need to get compliant and stay compliant. Best of all you will have a HIPAA security analyst to guide you every step of the way!

“Simplifying HIPAA through Automation, Education, and Support”

About Suze Shaffer

Suze Shaffer is the Owner and President of Aris Medical Solutions, a healthcare compliance company dedicated to simplifying HIPAA compliance. Through its online compliance solution, the HIPAA Keeper™, Aris Medical Solutions provides healthcare providers and business associates with the tools, documentation, training, and expert guidance needed to achieve and maintain HIPAA compliance.

Through the HIPAA Keeper™, Aris has assisted organizations nationwide with conducting risk analyses, developing risk management plans, implementing HIPAA Privacy and Security policies and procedures, and strengthening safeguards for protected health information. Aris Medical Solutions also considers applicable federal and state privacy and security requirements to help clients build a more comprehensive compliance program.

Suze is also a speaker and has presented at numerous conferences and professional events on HIPAA compliance, cybersecurity, risk management, and data breach prevention. Helping organizations understand their responsibilities and identify vulnerabilities before they result in a breach, audit, or investigation. She believes effective compliance begins with education. By helping organizations understand not only what they are required to do, but why those safeguards are important, organizations are better prepared to protect patient information and reduce their compliance risks.

At Aris Medical Solutions, the mission is simple: “Simplifying HIPAA” through education, expert guidance, and the HIPAA Keeper™, Aris Medical Solutions helps organizations turn complicated compliance requirements into a manageable, ongoing process.

The information provided reflects regulatory requirements and guidance available at the time of writing and is intended for educational purposes only. It should not be considered legal advice.

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