HIPAA Risk Analysis Requirements

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”

Workstation Security

HIPAA Compliance is more than just about a patient’s right to access their information. Although the HIPAA Privacy Rule is how most of this began, it is so much more now! The HIPAA Security Rule outlines administrative safeguards, physical, and technical security. Most organizations are so busy trying to figure out how to protect themselves from the unknown (technical concerns) that they forget about the actual physical security. We are not just talking about building security systems, but how you secure the individual devices that are utilized within your facility and those who travel with portable devices.

Here are some helpful ideas to review with your particular situation:

  1. Although utilizing a security system that has motion sensors is better than nothing, using security cameras usually discourages theft.
  2. Conduct a walk through of your facility and create an inventory list of all devices that access or store ePHI. Knowing what you have, where it is located, and if it contains ePHI is essential in securing your data. This includes portable devices and small electronic media. Remember, printers, copiers, and scanners can store data as well.
  3. Review the location of all devices that access or store ePHI. Ensure they are not located in an area that could be easily accessed by an unauthorized person or utilize cable locks. If screens are viewable and cannot be relocated, the use of privacy screens are highly recommended. Encryption is recommended on any device that contains ePHI. If the devices are transported they should be encrypted even if they do not contain ePHI. If they are ever lost or stolen and the encryption is engaged, it would not be a reportable breach.
  4. If your USB drives are not used, locks should be installed. This is an inexpensive method to protect the network. If your workstations utilize CD/DVD drives, these should be disabled as well. Another option would be to configure this through a Microsoft Group Policy.
  5. Make sure paper PHI is not left in areas that could be accessed by another as well. This includes where you store your excess paper charts. These areas should be locked when not in use. It is also recommended to utilize signage instructing “Employees Only”.
  6. Employees can be your biggest asset or your largest liability. Training your employees on computer security is an ongoing process. Annual HIPAA training should include the HIPAA privacy rule and HIPAA security rule. Also, add monthly security reminders to keep HIPAA fresh in their minds. Continuing education is the key to safety.
  7. HIPAA Policies and procedures are the backbone of an organization. Properly trained employees know and understand what is required and needed. The data that a health care provider has in its possession is priceless. This data must be secure physically and technically. All of this is necessary to avoid a data breach.

If an organization fails to secure patient information the Office for Civil Rights (OCR) will open an investigation and the organization can end up with massive fines. These fines have ranged from $250K to $3.5M. Although the fines are based on the organization’s ability to pay, the days of receiving just a $50K fine seems to be over. Best practices would be to review your HIPAA risk analysis and make sure it is thorough. Some online risk assessments unfortunately do not uncover all of your vulnerabilities. The OCR could consider this as willful neglect even though you didn’t know. Make sure you update your risk management plan and mitigate those vulnerabilities. Small oversights could cost you a fortune.

For more information on how Aris Medical Solutions can help your organization with HIPAA Compliance and Protecting your Data call 877.659.2467.

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Healthcare Cyber Attacks went up almost 90% in 2017

By Aris Medical Solutions

There were 132 reported breaches under investigation from Health and Human Services’ (HHS) Office for Civil Rights (OCR) in 2017 related to Hacking/IT Incident. As you review the report you can see how many were related to email and desktop computers.

Click here to see a list of current data breaches: OCR breach portal

So how does this happen? More than likely it has been caused by an unsuspecting employee. Healthcare is typically targeted with ransomware through social engineering. Practices need to be vigilant in educating their staff to be extremely careful when it comes to clicking on emails or surfing the web with their work computers. That is why we always recommend work computers be used exclusively for work. Plus, personal email addresses should never be utilized to communicate with patients or vendors for a number of reasons, this being just one!

There were many server attacks as well. This can happen in the same manner, especially when someone is logged in with administrative rights when they should be logged in as a user instead.

When it comes to cloud storage or cloud based EHRs, these too can be hacked although it is not as common. Most of the time this is caused by a misconfiguration in the network.

What can you do to prevent this from happening to you?

First of all, conduct a full HIPAA Security Risk Analysis, you need to know where your data is in order to create a Risk Management Plan to protect your organization.
Secondly, continual education on new threats to inform your employees how to be diligent.
Most of all, make sure your IT professional is a network security specialist. Doing your own network security is not longer an option, you must utilize a professional to ensure your network is secure. This includes your websites and cloud services.

For more information on how Aris Medical Solutions can help your organization with HIPAA Compliance and Protecting your Data call 877.659.2467 or click here to contact us.

“Protecting Organizations through Automation, Education, and Support”

MIPS, MACRA, and Risk Assessments


By Aris Medical Solutions


MIPS (Merit-based Incentive Payment System) and MACRA (Medicare Access and CHIP Reauthorization Act) is designed to create better patient outcomes and reward those providers that accurately document the progress of their patients. This all sounds great but it takes additional time until this new workflow is established. This is very frustrating to providers who just want to take care of their patients. It is a “learned” function and can be dealt with accordingly if you keep your patience. I know what you are thinking…. and it is easier said than done.

So many practices think since “meaningful use” went away they no longer need to conduct a risk analysis. This is incorrect information. Part of the requirements are that you must still conduct a risk analysis or update the one you already have. When “updating” your risk analysis, be very careful. You are attesting that you have reviewed your vulnerabilities and mitigated those risks.

Conducting a thorough risk analysis is more than just checking a box. It is meant to assist the organization in identifying possible vulnerabilities so you have the opportunity to mitigate them to prevent data breaches. If you merely change the date on your risk analysis and later suffer a breach; that could come back to harm you. If you skip over this or do not take this seriously, you are literally putting your practice at risk.

The best way to tackle this elephant in the room is… one step at a time!

  1. Review your technology devices. Determine if anything has been or needs to be replaced and/or updated.
  2. Understand where and how data is created, accessed, and stored. This includes reviewing the workflow of everyone involved with PHI and ePHI.
  3. Conduct your risk analysis and update the risk management plan. If you choose to “update or review” your existing risk analysis, make sure you do not overlook anything.
  4. If you have not not done so already, create a Incident Response Team (IRT). Utilizing the Security Incident Report will help in determining whether the security incident should be treated as a data breach or not.
  5. When it comes to the actually MIPS documentation, there are organizations that will assist you at no cost to the practice. Don’t chance missing this opportunity to ensure your documentation is accurate.

For more information on how Aris Medical Solutions can help your organization with HIPAA Compliance and Protecting your Data call 877.659.2467 or click here to contact us.

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Why should I try to secure my data?


By Aris Medical Solutions

HIPAA Data security

With all of the large data breaches making the news many smaller organizations think why bother. If the large companies can’t keep their data save, there is no way I can. Keep in mind, large organizations are a huge target and their data is sought after on a grander scale. Smaller companies are targets too, because their data is easier to capture. Smaller organizations typically do not have a qualified IT person or company that oversees their network. Unsuspecting employees are usually how the data is compromised because they have not been properly trained.

Here are some helpful hints how you can protect your data:

  1. Conduct a thorough risk analysis. Know where your data is and how it is accessed.
  2. Create a risk management plan to demonstrate your efforts in compliance.
  3. Conduct a network security audit to ensure your computers/network do not have any open vulnerabilities. This is more than just a scan of your network.
  4. Create a full set of privacy and security policies and procedures so employees understand patient’s rights and how to protect their data.
  5. Employee education. This is more than just once a year HIPAA training. This should be included in your monthly/quarterly meetings. Monthly emails can be sent to the staff as reminders of how important their vigilance is needed.

Patient data is valuable on the dark web and it is up to us to protect the data. One breach can destroy your organization unless you have a lot of money for reputation management. So when you are thinking about how much all of this “prevention” is going to cost, it will cost so much more if you ignore this need.

For the current breaches under investigation click below:

You can also view archived investigations that have been resolved or that are older than 24 months on the same website.
For more information on how Aris Medical Solutions can help your organization with HIPAA Compliance and Protecting your Data call 877.659.2467 or click here to contact us.

“Protecting Organizations through Partnership, Education, and Support”

Office for Civil Rights (OCR) Self Reporting – Should you do it?


By Aris Medical Solutions


If you have a minor breach (under 500 records) you are required to self report this breach within 60 days after the end of the calendar year in which the disclosure occurred. If you report it, you run the risk of being investigated. So many times I hear organizations say… why would I “report” myself, that would be insane! If you do not report it and it is discovered at a later date, the fines will be increased and they will investigate heavily to determine if you have concealed any other breaches. So, the answer is YES; you should self report.

Understand that the different agencies like the Office for Civil RIghts (OCR) who enforces HIPAA, Federal Trade Commission (FTC), Department of Justice (DOJ), and Centers for Medicare and Medicaid (CMS) more than likely communicate with each other. If you are audited or investigated by one agency, they are looking at your organization as a whole and may report their findings to other agencies. In one scenario that we recently were made aware of the organization was expecting an investigation from the Office for Civil Rights and the Department of Justice showed up! These agencies can decide how and what to investigate based on the information they have received.

The best way to protect your organization is to make sure you have a complete and thorough risk analysis. This will uncover potential vulnerabilities and give you the opportunity to mitigate them BEFORE something happens. Next, make sure you have a risk management plan that dates/documents what you have implemented/corrected based on your risk analysis. Policies, procedures, and documentation are the foundation of all organizations. Your employees need clear and concise procedures so they understand what they need to do. This always insulates you from misunderstanding. Above all, it demonstrates your compliance efforts!

For more information on how Aris Medical Solutions can help your organization with HIPAA Compliance and Protecting your Data call 877.659.2467 or click here to contact us.

“Protecting Organizations through Partnership, Education, and Support”

Is it time review your Policies and Procedures?


By Aris Medical Solutions


As you know you HIPAA Compliance is not a once and done process. It continually changes and evolves as your organization grows and your technology changes. This is a reminder to review what you have in place to ensure it still adequately safeguards your data.

Here are some quick helpful tips:

  1. Review your Notice of Privacy Practices. Have you implemented any new technology or added any new services that needs to posted? If you have a website make sure you update your NPP there as well.
  2. If you have a “Contact us” or an “Appointment Scheduler” form on your website and your website is not HTTPS, we recommend placing a disclaimer advising patients not to send personal information via the form. If you do have an HTTPS site, make sure your hosting vendor understands HIPAA and review where the data is sent and stored.
  3. Review your Technology Equipment. Have you added any new software or hardware? Do you regularly check your firewall settings? Are you reviewing your website security to ensure it is up to date? Are you documenting your IT efforts or reviewing your monthly IT vendor reports?
  4. Have you reviewed your list of Business Associates to ensure you have BA agreement in place with ALL of your Associates?
  5. Review your Inventory list. Have you added any new equipment or have you disposed of any?
  6. Have you conducted your annual HIPAA training for everyone? Is it documented?
  7. Have you tested your Contingency Plan?

Of course we could go on and on, but hopefully this will jumpstart your thinking process! Remember, your Risk Management Plan is a living document that needs to be updated on a continual basis. As you review your compliance efforts be sure to document this in your Plan.

For more information on how Aris Medical Solutions can help your organization with HIPAA Compliance and Protecting your Data call 877.659.2467 or click here to contact us.

“Protecting Organizations through Partnership, Education, and Support”

Patient Data is a Hot Commodity


By Aris Medical Solutions


Health care organizations are now a primary target since they are the custodians of patient data and a plethora of information. The reason patient information is sought after so much is because it can be sold on the black market for a decent price. Social Security Numbers also have a longer shelf life unlike credit card numbers. Therefore it is imperative that any company or person that is involved with healthcare data do what they can to protect their computers and/or network.

Criminals are diligent in trying to gain access to these valuable databases. They can get into your network through social engineering, malware, and mobile devices to name a few. Sadly, most attacks go undetected for months, sometimes even a year unless it is ransomware when you are “notified” immediately!

Under the Security Rule, all entities that work with Protected Health Information are required to conduct a Risk Analysis to uncover any potential vulnerabilities. Then they must create a Risk Management plan to correct those deficiencies. Although most of the “technical” standards are addressable and not required, this does not mean optional. All covered entities and business associates must have reasonable and appropriate safeguards in place to protect their data. Aside from your normal IT services, we believe it will only be a matter of time before network security audits will become mandatory. Keep in mind your Policies and Procedures are still the backbone of HIPAA Compliance.

So what can you do to protect your data and your organization?

  1. Conduct a security risk analysis
  2. Mitigate the vulnerabilities that are discovered
  3. Request a third party network security audit
  4. Request documentation that your business associates are HIPAA Compliant
  5. Continual EDUCATION!

These are just some of the basics that you should implement. For more information on how Aris Medical Solutions can help your organization with HIPAA Compliance and Protecting your Data call 877.659.2467 or click here to contact us.

“Protecting Organizations through Partnership, Education, and Support”

Storing Patient Records


By Aris Medical Solutions


Since most medical practices are going electronic, it may be time to free up some of that precious space in your office. Make sure when, how, and where you decided to store your data is secure.

Some practices move excess patient charts to a self storage unit. It’s cheap and if you have an patient chart inventory list you should be safe… right?
What happens if the facility burns down?
What if someone breaks in and it is not discovered for months?
What if you don’t have an inventory list of which records are in there?

  • Did you know that PHI is considered PHI until after a person has been deceased for 50 years! That means even if the person isn’t alive, it is still a reportable breach!
  • Did you know that if you can’t determine if ANY records or WHICH records were stolen, you would have to report all of them.

Self storage units may sound like a good deal. That good deal could cost you more in the end. If the unit burns or if it is vandalized, you could be charged for wilful neglect for NOT securing the records. Not to mention, you may be required to report this as a data breach and cost you nearly $350.00 per record! Are you willing to accept that risk? After all, the OCR doesn’t specifically state what is or is not HIPAA compliant. If you suffer a data breach, THEN they will determine if you had reasonable and appropriate safeguards in place.

Now I will ask you.. Wouldn’t it make sense to spend about the same amount of money and have a professional company store your records? That’s right; for about $50.00 per month you can store approximately 100 boxes of records! Of course pricing will depends on your location and how many you need to store. When organizing the records, we suggest by year and alphabetize them. This makes it much easier when the time comes to destroy them!

If you need assistance with a Risk Analysis, Risk Management Plan, or implementing a full set of HIPAA Policies and Procedures, call Aris at 877.659.2467 or click here to schedule a demo. We offer a full range of services from a Do-It-Yourself HIPAA program to a Full HIPAA Implementation package.

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