What Is a HIPAA Security Risk Analysis?

HIPAA Knowledge Hub

Conducting a HIPAA security risk analysis could ensure that your company is regulation-ready

If you’re like most compliance managers in healthcare, your HIPAA compliance strategy relies on paperwork. Checking controls. Checking findings. Checking boxes. However, HIPAA compliance can produce robust protection when you fully understand how it applies to you and your business.

One of the most often overlooked activities is a HIPAA security risk analysis. This tool helps assure that your data is secure and protected.

And since protecting HIPAA-covered data from risk is a mission-critical task, you must take steps now to mitigate risks.

Keep reading to learn more about HIPAA security risk analysis — or skip ahead to the section of your choice.

The Purpose of HIPAA Guidelines

Let’s make sure we have the basics down first. HIPAA guidelines are standards that safeguard the privacy of a patient’s information. This information is called protected health information (PHI).

The guidelines include rules for patient authorization. They also cover the use and disclosure of PHI. Learn more about navigating the world of HIPAA with the rest of our HIPAA Knowledge Hub series of articles:

HIPAA Knowledge Hub 

  • Learn how you can safeguard private data with our HIPAA compliance best practices.

    9.5 min read|Categories: Blog, HIPAA, Internal Audit|
  • Rather than being a “set it and forget it” situation, staying HIPAA compliant is an ongoing, concerted effort for healthcare facilities.

    8.5 min read|Categories: Blog, Compliance Management, HIPAA|
  • Check out our guide for HIPAA-compliant best practices to see how your program stacks up.

    8.2 min read|Categories: Blog, Compliance Management, HIPAA|
  • Compliance software can streamline your HIPAA efforts, but what if you still need the help of a hands-on audit company?

    8.7 min read|Categories: Blog, Compliance Management, HIPAA|

With HIPAA guidelines, you can also learn how to create a notice of privacy practices, how to use PHI for marketing appropriately, and how to deal with breaches.

Here, we’ll explore HIPAA guidelines in more detail so that you learn how to meet HIPAA guidelines for privacy, assess potential risks—and take steps now to mitigate them.

Who must comply with HIPAA guidelines?

Several kinds of organizations must comply with HIPAA guidelines. These organizations are considered “covered entities.”

Finally, third-party organizations that use or disclose individually identifiable health information, referred to as “Business Associates” under HIPAA, must also follow the guidelines. These organizations typically perform or provide functions for covered entities and could be considered third parties.

If your organization falls into one of these groups, you must comply with HIPAA guidelines. As a result, you’ll want to conduct a HIPAA security risk analysis. With a comprehensive analysis, you can identify your risks and work to resolve them.

Understanding HIPAA security risk analysis

If you are a covered entity, you are required to implement security safeguards. It’s your responsibility to know the rules and show that you’re following them. Your organization’s safeguards must protect the availability, confidentiality and integrity of patient information. And this information includes any patient type of data that you create, store, transmit or receive in digital form.

It’s a big responsibility. The first step in identifying safeguards is a HIPAA security risk analysis. It consists of conducting a complete and accurate assessment of potential risks and vulnerabilities.

Hidden vulnerabilities could threaten to compromise the availability, integrity or confidentiality of patient health records—the precise things you are essentially promised to protect as a covered entity. A risk analysis can help you identify those vulnerabilities and implement the necessary safeguards.

HIPAA guidelines clearly outline the type of patient information that you must protect, which includes any data that you:

  • Create

  • Receive

  • Maintain

  • Transmit

This also includes all forms of digital patient information. For example, your organization might store patient data on hard drives or smart cards. Or sensitive patient information may reside on employees’ personal digital assistants or portable digital storage devices.

Unfortunately, HIPPA guidelines define electronic media broadly, which can cause some confusion. You should know that digital or electronic media can mean something as small as a single employee workstation or as large as a complex, multilocation patient information network. And everything in between.

An overview of the process

The HIPAA guidelines are composed of a series of codependent regulations. Collectively, these regulations are called HIPAA rules. The HIPAA rules encompass the:

All the HIPAA rule sets are approved national standards for covered entities. Take a deeper dive into each rule in our related Do You Have an Effective HIPAA Compliance Program? article.

While the HIPAA privacy and security guidelines may seem like distant, bureaucratic instructions, they have very real, local impacts to your business. Many organizations run into trouble with HIPAA regulations.

The most common mistake is failing to document policies and procedures. Often, this kind of oversight will become apparent after a breach.

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In an era when companies are digitally reliant and interdependent on one another for day-to-day business, it’s more important than ever that your suppliers, vendors and third parties comply with HIPAA guidelines, too. You might find that you’re held liable for damages if you know your vendor is violating HIPAA security and privacy rules. If a lawsuit arises, the court can also grant an injunction to prohibit future HIPAA violations.

No one wants to get caught on the wrong side of violating HIPAA rules. This outcome could severely impact your organization’s operations, reputation or financial health in ways you never anticipated.

With this in mind, there are three security standards that HIPAA guidelines suggest you manage:

As the name suggests, physical safeguards relate to the physical security of your office spaces. These areas include places where you store both hardcopy and digital patient information, like storage rooms, file cabinets and EMR devices.

Physical safeguards can include alarm and security systems. They can also include locking devices for the storage of sensitive patient information.

A physical safeguard can also include ensuring that there are no security gaps on the premises, which could allow unauthorized people to enter.

You should also limit access control to employees with a need. Even then, someone must monitor access to sensitive files with security clearance above this level of access.

Today, there’s no shortage of cybersecurity horror stories. Seems like a new breach makes headlines every day. Don’t be the next headline.

The technical safeguards portion of HIPAA security risk analysis is one of the most important guidelines to follow because a cyber threat can come from anywhere at any time. New, emerging threats are constantly surfacing.

Technical safeguards relate to cybersecurity. These safeguards might include the use of a firewall, ensuring encryption and backing up information in the event of data loss.

Employees are your first line of defense.

Administrative safeguards involve proper employee training. Your staff must know how to execute the security measures that your company implements.

Typically, the company will communicate an organized collection of policies and procedures to thoroughly protect information. The effort includes continued staff training to make sure everyone stays up-to-date and that the organization stays in compliance with said policies.

If, for example, a security breach occurs, you want to know that anyone on the team knows how to act quickly in order to save data from getting exposed or lost.

In addition to establishing these, your organization should also maintain records to document these administrative practices.

Moving toward compliance

No matter your role—or roles—in compliance, you’re likely mired in reporting. Too many reports loaded with too much data.

Or you might have the opposite problem. You might have a desperate need for data to fill a report.

Or maybe building the report is the problem. You might spend so much time building laborious reports that you have no time to extract meaningful insights from the data.

None of these scenarios are ideal.

We know audits can help this situation and are certainly necessary, but we also know they are time-consuming and expensive. What’s more, using up your people power for a compliance initiative isn’t always seen as the best use of company resources.

The solution? Automate HIPAA security risk analysis with a software platform, like Onspring. With automation, the process is remarkably cheaper, faster and easier.

Even with a skeleton team on a tight timeline with an even tighter budget, you can complete all of your assessments & audits with accuracy, which leads your team to compliance faster.

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