If you are involved with the healthcare industry, you’ve probably heard of HIPAA, the Health Insurance Portability and Accountability Act. Regulations and best practices surrounding HIPAA can be confusing, but it’s critical that anyone connected to the healthcare industry understand at least the basics.
So we’re here to break things down for you.
First, and perhaps most important, is to answer one of the most commonly asked questions:
What is HIPAA compliance?
HIPPA Compliance Definition
Through ongoing regulations, HIPAA compliance is a living entity that health care organizations must implement into their business in order to protect the privacy, security, and integrity of protected health information. HIPAA compliance requirements are discussed near the end of this post.
Before we continue, three more acronyms need to be highlighted which figure prominently in the definition:
- PHI = Protected Health Information
- HHS = Department of Health and Human Services
- OCR = Office for Civil Rights
HIPAA’s regulatory standards were created to establish the legal use and disclosure of protected health information (PHI). The Department of Health and Human Services (HHS) regulates compliance, and the Office for Civil Rights (OCR) enforces compliance.
The OCR also provides ongoing guidance on developments affecting health care and is responsible for investigating HIPAA violations.
Need a HIPAA compliance checklist? Absolute’s got you covered!
While HHS and OCR are self-explanatory, PHI requires further explanation.
Protected Health Information (PHI) is the combination of one’s identifying information — such as your name or address) — and any health-related data collected from a healthcare practitioner or facility, such as your medical record, any conversations with providers, or billing/insurance information.
PHI is anything that contains both your Personally Identifiable Information (PII) and your health information.
For example, if we know that Sheldon Cooper is diagnosed with obsessive-compulsive disorder, that’s PHI. Why? Because it contains PII — Sheldon Cooper, and also health information — obsessive-compulsive disorder. Sheldon’s PHI would, therefore, be protected by HIPAA.
One more definition: ePHI, electronic protected health information, is when PHI is transmitted, stored, or accessed electronically. ePHI falls under the HIPAA Security Rule, a HIPAA regulation addendum which came into effect to address the rapid changes in medical technology and how health records are stored.
Why HIPAA is Important
There are countless reasons why HIPAA is important, but the key takeaways are these: it aims to ensure privacy and confidentiality; it allows patients access to their healthcare data; and also reduces fraudulent activity and improves data systems. It all boils down to data security.
For healthcare organizations, HIPAA provides a framework that safeguards who has access to and who can view specific health data while restricting to whom that information can be shared with. Any organization dealing with PHI must also have physical, network, and process security measures in place to be compliant.
Even subcontractors and any other related business associates must be compliant.
HIPAA is there to protect individuals and to ensure everyone has full access to a copy of their personal medical records. It is ultimately a civil rights issue. It mandates data protection for anyone who creates, stores, transmits or uses individually identifiable health information.
All healthcare entities and companies which handle, store, maintain, or transmit patient health information are expected to be in complete compliance with the regulations of the HIPAA law.
David Harlow, an attorney, and consultant specializing in healthcare data and digital health matters, states that HIPAA should be seen as the minimum standard regarding privacy and security standards and protections. “Simply complying with HIPAA is not enough,” he said. “There are more stringent state laws (which vary, state to state) and some industry best practices which are more protective of patient data.”
What are HIPAA Guidelines
With HIPAA, there’s a lot of information to digest when it comes to the guidelines providers must follow to be compliant. What’s most important — and what we will be focusing on — is to clarify what HIPAA violations are, as well as to define what it means to be HIPAA compliant.
A HIPAA violation occurs when there is a breach of an organization’s compliance program in which the integrity of PHI or ePHI is compromised.
It’s important to note that data breaches are not the same as HIPAA violations. A data breach can also be a HIPAA violation, but only when that breach is caused by a breakdown in the HIPAA compliance program or by a specific violation of an organization’s HIPAA policies.
For example, a data breach would be if a laptop belonging to an organizations’ doctor is stolen and that laptop contains unencrypted access to medical records. If that organization did not have a policy which stated laptops couldn’t be taken offsite then it would also be a HIPAA violation.
According to Harlow, publisher of HealthBlawg, enforcement of violations is likely more limited to cases in which there has been a data breach. In his definition, a data breach is when PHI is released to or obtained by a third party without the patient’s authorization, other than for purposes of treatment, payment or healthcare operations.
“We can learn from cases where the OCR has entered into settlement agreements with Covered Entities (practitioners) or Business Associates (third parties) that have experienced data breaches,” he said. “The settlement agreements are made public, together with case summaries. From my perspective, it is critical that the regulated community understand and appreciate that the weakest link is the often the human link.”
One data breach we can all learn from is the Anthem Insurance Company hack, which relied on an unsuspecting employee clicking on a link in a phishing email.
“Staff must be trained and tested, and systems and failsafes must be put into place,” said Harlow. “Hundreds of millions of dollars of remediation costs, class action settlement payments and fines were paid out by Anthem as a result of that click.”
He advises that the government does not discriminate when enforcing the rules, as they will fine the small entities along with the large companies. Perhaps not in millions of dollars, but significant sums nonetheless.
To further break down the takeaways from healthcare security breaches, you’ll find some great lessons here from Josh Mayfield, Absolute’s Director of Security Strategy.
Finally, it’s critical to point out that if you’ve been breached, you need to report the breach in a timely manner. In 2017, OCR brought about its first HIPAA settlement for a violation of the Breach Notification Rule levying a $475,000 fine against Presence Health for failure to properly follow the rule.
Common HIPAA violations include:
- Stolen smartphones, laptops or USB devices
- Cyber hack or attack, including malware incidents and ransomware attacks
- Business associate breach
- Electronic health record (EHR) breach
- Office break-in
- Sending PHI to the wrong patient/contact
- Discussing PHI outside of the office
- Social media posts
HIPAA Compliance Requirements
This compliance list represents a baseline for processes that businesses should be following:
- Remediation Plans
- Policies, Procedures, Employee Training
- Business Associate Management
- Incident Management
While all of these are important, Harlow recommends focusing on the need to address the privacy and security of PHI holistically, through continuous review and improvement of systems, policies and procedures, training and implementation.
“This is not a ‘set it and forget it’ sort of compliance exercise,” he said. “I would also emphasize that the HIPAA rules are written as flexible standards that are to be implemented based on the size and nature of the covered entity or business associate.” For instance, Amazon’s compliance program for its HIPAA-compliant cloud services will not be the same as the compliance program implemented by a multi-specialty physician practice.
At the end of the day, complying with HIPAA regulations may seem tedious, but in today’s threat landscape we all need to practice proper security hygiene anyway to protect ourselves.
The ramifications of not doing so are too severe to ignore.
We’ve covered plenty of ground, but to learn even more about achieving HIPAA compliance and how Absolute can help your business, download our white paper here.