Key Takeaways
- HIPAA compliance shields your private health information from access, use, and disclosure.
- Covered entities and business associates are required to comply with relevant HIPAA rules.
- The three HIPAA safeguards are Administrative, Physical, and Technical.
- A solid compliance program comprises risk assessments, employee training, access controls, policies, and incident response.
If you do need to be compliant, learning what the HIPAA compliance requirements are to stick to is essential.
Simply put, the term HIPAA compliant refers to an entity that has implemented the necessary federal regulations to safeguard sensitive health information – while still enabling providers to provide care to be carried out. Let's find out how to achieve HIPAA compliance with this guide.
What Is HIPAA Compliance?
HIPAA compliance refers to making sure that your organization is adhering to all of the standards required by the HIPAA law. These standards include guidelines on the use, sharing, storage, and protection of protected health information. HIPAA Compliance deals with standards that include the privacy rule, breach notification rule, and security rule.
The common, day-to-day HIPAA compliance entails is not an end point; it's part of your business as usual and a natural aspect of your way of working. Having, and being able to maintain, safeguards, policies and procedures documented and staff trained, a risk analysis and management process, and an incident response plan.
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Who Needs to Be HIPAA Compliant?
The notion of being HIPAA compliant generally applies to covered entities and business associates. A covered entity is any healthcare provider, health plan, or healthcare clearinghouse; a business associate is any organization that performs a service for a covered entity.
Here are a few examples of a business associate: A billing company, an IT vendor or service provider, a consultant, or another general vendor who works with a covered entity and has access to PHI. The first step to establishing a HIPAA compliance program is to understand which HIPAA regulations apply to a business or organization.
What Are The HIPAA Compliance Requirements?
The requirements will depend on what the organization does and whether it is a business associate or covered entity; however, every organization needs to implement certain measures to safeguard PHI and ensure compliance with HIPAA regulations. These measures include risk assessment, implementing safeguards, training, access control, vendor management, and documentation.
How can organizations get their arms around the PHI that's generated, received, stored, or transmitted?
Starting with a risk analysis will highlight where PHI is being generated, received, stored, or transmitted. Once the vulnerabilities are determined, it will be easier to identify and implement the necessary protections. HIPAA compliance standards aren't about buying a specific collection of technologies.
What Are The Three HIPAA Safeguards?
According to the Security Rule, administrative, physical, and technical safeguards are the three core areas that provide protection for electronic protected health information.
- Administrative Safeguards: These consist of risk management, workforce security, security policies and procedures, training, and contingency planning.
- Physical Safeguards: These apply to locations, equipment, electronic media, and workstations to safeguard against physical threats.
- Technical Safeguards: These are the technology and the related policies and procedures that work to make sure the safety, integrity, and security of ePHI.
This is one of the key components of effective HIPAA compliance automation. Instead of simply implementing technology, an organization should evaluate how it can leverage all three in conjunction.
How to Become HIPAA Compliant
Not sure how to become HIPAA compliant? Begin with what PHI your organization captures and who has access to it. Conducting a risk analysis will identify areas of exposure and prioritize measures to mitigate them. Organizations can then implement safeguards and document and monitor their compliance progress.
HIPAA policies and procedures define the expectations for how your staff members will treat sensitive data. Your policies can address procedures related to: access control, privacy, security events, workforce training, and acceptable use of systems. All employees should be trained on the policies so they are familiar with them in their daily work.
HIPAA Compliance Checklist For Organizations
A useful HIPAA compliance checklist will help to make the expansive HIPAA requirements manageable. What the exact HIPAA compliance checklist covers will vary by organization, but there are several areas to which you should pay close attention.
- Conduct and document a risk analysis.
- Address identified security risks.
- Create and review HIPAA policies and procedures.
- Train employees on privacy and security responsibilities.
- Restrict PHI access according to job responsibilities.
- Protect devices, systems, and physical work areas.
- Review business associate relationships and agreements.
- Develop processes for incident and breach response.
- Maintain appropriate compliance documentation.
Review your HIPAA compliance checklist regularly. Never complete your review and then forget it. A new employee, new technology, a new vendor, a new system, a new way of doing things - all these things bring new risks to the table. Take the time to ensure your policies and procedures are still up to date.
How to Attain HIPAA Compliance Over Time
Achieving Compliance isn't enough. Ongoing vigilance is necessary to ensure that HIPAA compliance is sustained due to the ever-evolving nature of technology, practices, and security threats. Companies must regularly review access to information and systems, perform regular risk assessments, train employees, and evaluate policies, vendors, and technical controls.
HIPAA compliance should include a plan for incident response, which should support long-term HIPAA compliance. A business needs procedures in place for how to recognize, investigate, report, and respond to potential incidents and breaches. Depending on the incident, the HIPAA Breach Notification Rule requires notifications to individuals, HHS, and even the media.
Conclusion
Compliance with the HIPAA Rules is an ongoing process, and knowing what HIPAA compliance and HIPAA requirements are, how to satisfy the three safeguards, and having good HIPAA policies and procedures in place can assist organizations with safeguarding sensitive health data. AttestPath simplifies the compliance workflow by automating evidence collection, policy generation and continuos monitoring.
A monthly HIPAA compliance checklist can help organizations identify gaps and resolve issues in their security program.
Frequent Questions Asked
Do Independent Healthcare Providers fall under the Protection of HIPAA?
As a healthcare provider who conducts a covered transaction (certain electronic billings and other transactions), independent healthcare professionals may be covered entities. The requirements that apply to them will depend on their practice and their use of PHI.
Does HIPAA apply to paper medical records?
Yes, some HIPAA Privacy Rule provisions may also govern electronic protected health information. The Security Rule, for example, applies only to protected health information stored electronically. Businesses should assess which HIPAA rules govern their application of each type of information.
Do employees get personally held accountable for HIPAA compliance?
While the onus is on companies to create adequate compliance programs, staff have many important roles to play. This includes adhering to relevant HIPAA policies, taking required training, safeguarding credentials, restricting PHI access, and alerting the designated authority to any privacy or security concerns.
Would HIPAA Compliance Avoid Every Data Breach?
No security program can prevent all breaches. Managing risks is the goal of HIPAA compliance. Effective access controls, employee awareness and education, audit controls, and response to incidents can help prevent the number and severity of security incidents.
Will HIPAA regulations evolve?
HIPAA rules and guidance will evolve as rules, technology, and facilities evolve. As rules and technology evolve, organizations will have to be vigilant and monitor the rules and guidelines relating to these and periodically evaluate their procedures, risk analysis, safeguards, and training of employees.
