To safeguard sensitive and private health-related information, HIPAA compliance was introduced in 1996. HIPAA stands for Health Insurance Portability and Accountability Act. It is essentially a series of standards that regulate the use of protected health information (PHI).
For a more detailed, in-depth look into HIPAA compliance and certification. In this article, we’ll cover the following:
Table of Contents
What is HIPAA Compliance?
HIPAA compliance is known as the process that enables business associates and covered entities to follow to secure Protected Health Information (PHI) as per the regulations given in the Health Insurance Portability and Accountability Act.
Essentially, it’s aimed at ensuring that people’s healthcare data remains private and protected. To help you understand the process better, here’s what the different terms mean:
- Protected Health Information (PHI) refers to the primary information HIPAA compliance is responsible for protecting and keeping private. The Safe Harbor Rule determines the data type that must be removed to declassify PHI.
- Covered Entities: Individuals who work in the healthcare industry use and have access to PHI. These individuals include doctors, nurses, and insurance companies.
- Business Associates: All those individuals and services who work with a covered entity but in a non-healthcare capacity. They are further responsible for maintaining HIPAA compliance, just like covered entities. Therefore, business associates are professionals in the healthcare industry, such as accountants, IT personnel, lawyers, etc., and have access to PHI.
So if you were curious about who needs HIPAA compliance, the answer would be – covered entities and business associates.
Important HIPAA Rules
Several HIPAA rules have come and gone since its inception in 1996. But for starters, these are the primary rules you should be aware of:
HIPAA Privacy Rule
It establishes the national standards that need to be in place for a patient’s right to PHI. It also includes covered entities but not business associates. All the guidelines must be present in the organization’s HIPAA Policies and Procedures, and each employee should be trained.
HIPAA Security Rule
It’s responsible for setting national standards that protect the maintenance, transmission, and handling of ePHI (basically Protected Health Information that’s used in the electronic form). This rule documents all the physical, administrative, and technical safeguards that need to be included.
HIPAA Breach Notification Rule
These are the standards that both covered entities and business associates must follow if any data breach of PHI or ePHI occurs. Depending on the scope and size of the breach, different requirements are stated under this rule.
HIPAA Omnibus Rule
An appendix is implemented to apply HIPAA to business associates and not just covered entities. It clearly states that all business associates must be HIPAA compliant and even have rules around Business Associate Agreements (BAAs). These contracts must be implemented only between two business associates or between a covered entity and a business associate before transferring any PHI or ePHI.
Process of Becoming HIPAA Compliant
To become HIPAA compliant, you’ll need to ensure that you meet all the given requirements using the perfect combination of correct technology usage, internal processes, and aiming for the right external partnerships.
You’ll need to cover these bases to attain HIPAA compliance:
Execute safeguards
To become HIPAA compliant and maintain it, you’ll need to have concrete PHI safeguards, physical as well as digital. For safety purposes, it’s better only to let authorized personnel access places where physical PHI is stored. Good passwords and logins must be set up.
Build policies: Developing and implementing robust cybersecurity standards, policies, and procedures should be among your priority goals. Further, you’ll need to ensure that every administrative system and process is HIPAA compliant and that the staff is well-trained. Don’t forget to properly document and disseminate the policy across the organization.
Assess risks: All covered entities should be asked to undergo HIPAA risk assessment annually. In case you haven’t started one yet, make sure that you do so at the earliest. These risk audits should include all the additional administrative, physical security, and technical security measures employed by the organization to attain HIPAA compliance.
Inspect violations: Since we don’t live in an ideal world, your whole organization will probably not be HIPAA compliant every day of the year. So to stay on the safer side, you need to keep on top of things and be prepared for lapses. It would be best if you had processes that can be carried out to do root cause analysis and then remediate the issue so that it doesn’t crop up again.
These four features will help you complete the HIPAA certification and maintain it most efficiently.
Ultimate HIPAA Compliance Checklist
As you get ready to get your HIPAA certification, make sure to keep this HIPAA compliance checklist in mind:
- Have a thorough understanding of all the HIPAA privacy and security rules.
- Figure out if the privacy rule applies to your business, practice, or healthcare organization or not.
- Safeguard the right kind of patient data (such as names, birthdates, contact information, medical records, account numbers, and so on).
- Ensure that you steer clear of any HIPAA violations.
- Always stay aware of the latest changes or updates on HIPAA.
- Have an explicit knowledge of COVID’s impact on HIPAA.
- Extensively document everything, from who’s viewing the PHI to what they’re accessing.
- In case of any breaches, report them as soon as possible.
Security Tips for HIPAA Compliance
Since the primary goal of HIPAA compliance is to secure information, you need to take all the measures necessary to improve the security of your PHI. Some actions you can take are:
- Strong passwords should be set up, and only a few authorized personnel should be given access. Further, it is advised to change passwords frequently.
- Detailed logs of who has access to the PHI, who is viewing it, and for how long must be maintained. This helps in complying with HIPAA guidelines and security purposes and keeping track of any breaches.
- You should choose a multi-layered security system since just simple user IDs and logins won’t do any good in case of a breach. You’ll need to analyze and take measures to secure different layers, such as networks, systems, software, etc.
Getting HIPAA certification helps you become a part of a living culture that enables healthcare organizations to gain credibility, establish trust, and, most importantly, protect patients’ privacy. And if you’re unsure about the process of achieving HIPAA compliance or anything else related to it, just reach out!
About IS Auditr
IS Auditr is a team of experienced ISO auditors. They offer several end-to-end services, provide certifications to businesses and help them enhance their day-to-day operations. If you want to know more about our services, contact us.