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HIPAA Security Rule requirements, Part I

It is hard to believe we are in 2021, but I am sure you are like the rest of us and glad to see 2020 in the rear-view mirror.

As we move into this new year, we need to look ahead and learn from what has happened in the past. Last month we informed you about many HIPAA violations that the Office for Civil Rights (OCR) had investigated. Most of these violations could have been prevented. In fact, I was talking with a colleague that owns an audit log monitoring system and he informed me that during the pandemic they saw a 90% increase in snooping into patient records of the same last name. Fortunately for his clients, this was immediately stopped, and the employee(s) were sanctioned. This made me want to remind you of a few requirements under HIPAA.

 

  • 164.308(a)(1)(ii)(c) Sanction Policy – is a “required” standard under the HIPAA Security Rule. Employers are required by law to apply sanctions against employees who violate HIPAA, otherwise the employer could be fined.

 

  • 164.308(a)(1)(ii)(d) Information System Activity Review – is another required standard. Which requires procedures to regularly review records of information system activity, such as audit logs, access reports, and security incident tracking reports. A security incident can be best described as the attempted or successful unauthorized access, use, disclosure, modification, or destruction of information or interference with system operations in an information system.

 

  • 164.312(b) Audit Controls – is yet another required standard that states you must implement hardware, software, and/or procedural mechanisms that record and examine activity in information systems that contain or use electronic protected health information (ePHI). This standard goes hand in hand with Information System Activity Review.

 

What does this mean to you?

First, you must understand what is considered “normal” usage within your software/hardware that contains ePHI. Then you must monitor your systems for abnormal behavior. This is a HUGE time-consuming task and unless you are monitoring every employee, 24/7 you may miss something. We highly recommend utilizing a third party to do this for you. The company we work with has interfaces with over 60 EHRs and is fully automated. If they do not have an interface, they will create one, or show you how to upload the logs in a matter of minutes instead of hours. No more looking over lengthy audit log reports. You simply receive an alert when there is abnormal activity. Best of all, this protects your patient data and your practice from fines and penalties. If you would like to learn more about this service, use the contact us page.

 

If you need assistance with HIPAA Risk Management or guidance with your HIPAA Compliance, contact us at 877.659.2467 or complete the contact us form.

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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