The Health Information Technology for Economic and Clinical Health Act or HITRUST legislation is responsible for implementing the Health Insurance Portability and Accountability Act (HIPAA) to a broader selection of organizations. Expanding the reach of HIPAA to a wider enterprise base allowed the Health Information Technology for Economic and Clinical Health Act (HITECH) to transform HIPAA compliance into a virtually ubiquitous legislation. As such, you require an in-depth understanding on ways of managing your HIPAA compliance regardless of whether you are a Software-as-a-Service platform or doctor’s office.
HIPAA Compliance Management
What is HIPAA?
HIPAA was enacted back in 1996 by Congress as a way of safeguarding information, specifically when people changed their jobs. Aside from passing the Privacy Rule back in 2013, the US Department of Health and Human Services defined Protected Health Information of PHI as any piece of information that is held by a covered entity that touches on the payment for healthcare that can be connected to a person, provision of health care or health status.
In 2005, the HIPAA Security Rule made updates to the regulation, concentrating on PHI that has been electronically stored (ePHI). The revised legislation integrated three extra compliance areas whereby two of them affect IT departments. Physical safeguards encompass controlling access to data storage sections whereas administrative safeguards entail procedures and policies that display compliance. On the other hand, technical safeguards include communications relaying PHI electronically across open networks.
Who requires to HIPAA Compliant?
If you transfer, handle, or even look at PHI or ePHI, you ought to be HIPAA compliant. Covered entities like health care clearinghouses and health plans as well as healthcare providers such as nurses and doctors, all should be compliant. They fall under a healthcare-based IT regulation, as they work in medical areas.
Nevertheless, HITECH is known for casting a broader net through instituting the “business associates” idea. Business associates entail any entity or person that is involved in the disclosure of or use of safeguarded health details as part of their provided service.
Alternatively, if you are an audit company conducting compliance for somebody who requires being HIPAA compliant, you should also be HIPAA compliant. Also, if you are a SaaS software provider who assists in facilitating payment processing, you have to be compliant. What’s more, human resource department platforms must be compliant, as they aid the HR in managing a company’s healthcare program.
What are the Implications of Breaching HIPAA?
The Office for Civil Rights (OCR), a unit of the Department of Health and Human Services (HSS), is tasked with the role of enforcing the Privacy and Security Rules. Even though HHS revised the Enforcement Rule in between 1996 and 2009, HITECH not only reinforced HIPAA but also merged the rules, specifically under the Omnibus Act.
Who you require Continuous Monitoring
Based on the Administrative Safeguards necessities in the Security Rule, the Health Insurance Portability and Accountability Act (HIPAA) calls for the need to conduct a risk assessment and retain a continuous risk evaluation process. The provisions of the Administrative Safeguards as stipulated in the Security Rule require all covered entities to carry out risk analysis, as a portion of their security management procedures.
In this case, the Security Rule’s risk management and analysis provisions are looked into separately. The reason is that, by assisting to identify which security policies are ideal and reasonable for a given covered entity, risk analysis impacts the execution of all the protections in the Security Rule.
How Maintaining a Continuous Compliance Program Facilitates Risk Management
Presently, risk management goes beyond answering questionnaires. In fact, controls can become obsolete almost instantly. Furthermore, new threats crop up constantly. Although regular monitoring enables you to look into the risks that pose a threat to your data, it serves as just the initial step.
As far as continuous compliance is concerned, you are required to deal with new risks as soon as they arise. The US Department of Health and Human Services (HHS) stipulates that the compliance prerequisite is different from monitoring.
Integrity controls. Covered entities have to put in place procedures and policies that make sure e-PHI is not inappropriately destroyed or altered. As such, electronic policies have to be implemented in a bid to confirm that e-PHI has not been wrongfully altered or even destroyed.
How to Incorporate Continuous Audit into your HIPAA Risk Management Program
In case you assume a security-first approach, specifically towards cybersecurity compliance, then bear in mind that you are monitoring risks and mitigating them. This technique enables you to uphold data confidentiality, accessibility, and integrity. However, if you want to retain your HIPAA compliance, you ought to prove your actions.
Your continuous auditing program is essential for proving your compliance. Your external and internal auditors require documentation that authenticates your compliance and monitoring. In addition, ensuring successful audit results calls for documents that show you identifying risks and mitigating them as fast as possible.