The HIPAA Security Rule mandates that healthcare organizations must have the appropriate technical, administrative, and physical safeguards in place to protect the integrity, security, and confidentiality of electronically stored health data against a data breach or cyber attack.
To remain compliant with HIPAA regulations, healthcare organizations must conduct an annual risk analysis. However, each year numerous medical facilities fail to perform the proper assessment, resulting in penalties, fees, and potentially compromised patient data.
What to Know About HIPAA Risk Analysis
Healthcare security leaders know that a consistent HIPAA Risk Analysis is essential to maintaining network security and help prevent a possible data breach within your facility or across your organization. However, the lack of awareness, implementation consistency, and extended education regarding HIPAA Risk Analysis can result in uncertainty regarding what to expect when beginning the process.
The HHS Security Standards Guide outlines several required components for healthcare and healthcare-related organizations to include in their documentation in order to properly manage electronic protected health information (EPHI), including:
Scope of the Analysis
The analysis scope outlines any potential vulnerabilities, threats, or risks to both the access and integrity of EPHI. It’s important to consider cybersecurity between multiple locations as well as any third-party HIPAA hosting terms within the assessment scope.
Data Collection Methods
Healthcare IT departments must clearly outline where their internal data is being stored and transmitted throughout the organization to ensure every phase of data storage meets the stringent requirements mandated through HIPAA.
Determine Potential Compromises And Threats
Systematically working through your existing internal network security process to identify and log possible data threats is a vital component in the risk analysis process. Pinpointing any anticipated threats to stored sensitive data or possible EPHI leaks can create a focus for your organization as you work to counteract possible compromises.
Evaluate Existing Security Measures
How do you and your IT team currently protect data and maintain secure email at your healthcare organization? Outlining various technology safeguards such as two-factor authentication, encryption, and other security tactics can provide necessary insight on HIPAA compliance with current data storage and management.
Calculate The Likelihood Of A Cyber Attack
Assessing the probability of EPHI risks in conjunction with already identified possible threats and compromises can help you estimate the likelihood of a data breach.
Identify Possible Impact Of Data Breach
In addition to outlining the probability of a cyber attack, your organization’s HIPAA Risk Analysis should also estimate the maximum impact a data breach would have on your organization. This particular section of the assessment should include factors such as the total number of people that could be impacted, as well as the full extent of sensitive data that could be exposed in the event of a cyber attack.
Gauge Level Of Risk
Taking account of the likelihood of a cyber attack in light of the overall impact levels of the breach helps healthcare organizations determine the appropriate risk level. Not only should healthcare organizations approximate their level of risk, but they should also provide a list of corrective actions that can mitigate threats and compromises.
Once you’ve carefully aggregated the necessary data, you can create a finalized documentation for submission and develop a schedule for periodic review and updates to your completed HIPAA Risk Analysis for long-term, sustainable network security and compliance.
