What Counts as a HIPAA Violation? – Wheelhouse IT

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HIPAA Violation: What You Need to Know

Health information is not always as private as you might believe. HIPAA violations can occur without your knowledge, putting your health at risk. These serious violations can result in fines, suspension of hospital privileges, including health plans, and criminal charges. We’ll go over HIPAA, what constitutes a HIPAA violation, and how to keep your health information safe. Read on to find out how to avoid this from happening to you.

What Is HIPAA

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) ensured individuals’ health information privacy and security. The act establishes national standards for protecting electronic healthcare information and prevents healthcare fraud. It also requires covered entities, such as hospitals and doctors, to take steps to protect the confidentiality of protected health information.

HIPAA violations can happen without your knowledge. Only health care providers, their business associates, and the government can access protected health information. Individuals who knowingly obtain or disclose PHI in any manner not permitted by HIPAA may be subject to penalties for violations to criminal fines, and imprisonment for many years.

10 Most Common HIPAA Violations

There are several ways in which individuals can violate HIPAA. Some of the most common violation examples include:

  1. Unlawful disclosures of sensitive health information (PHI): This is when someone knowingly obtains or discloses protected health information in any manner not permitted by HIPAA. For example, sharing PHI with friends or family members, posting it on social media, or selling it to third-party companies.
  2. Unauthorized access to protected health information: This refers to accessing protected health information on another computer without proper authorization. For instance, accessing medical records of someone you do not know or shareseveralseveral your PHI with unauthorized individuals.
  3. Failure to record and log compliance efforts: This is when PHI is disposed of in a way that does not protect the individual’s privacy. For example, throwing protected health information into the trash can where others can easily access it.
  4. Failure to complete a risk assessment: By law, individuals must assess the safeguards needed to protect PHI. It includes what type of information needs to be protected and what steps need to be taken to remain private.
  5. Failure to manage threats to PHI’s confidentiality, integrity, and availability: This includes implementing safeguards to protect PHI from unauthorized access, alteration, or destruction.
  6. Failure to conduct risk analyses when appropriate to maintain PHI’s confidentiality, integrity, and accessibility: This often leads to HIPAA violations. It includes failure to properly password protect electronic PHI, including digital files, using unencrypted email to transmit PHI and unprotected health information on computers or networks.
  7. Inability to keep and monitor PHI access logs: This is a requirement of HIPAA. Access logs must be kept for six years and include the individual’s name, who accessed PHI, what information was accessed, and when it was accessed.
  8. Failure to enter into a HIPAA-compliant business associate agreement with vendors before providing PHI access: Under HIPAA, all covered entities who handle PHI must have a business associate agreement in place. This document spells out the terms and conditions of how protected health information will be shared between the parties involved.
  9. Failure to give copies of PHI to patients upon request Failure to set access controls to limit who can view PHI: This allows individuals only to view the specific information they are authorized to see.
  10. Failure to terminate PHI access rights when they are no longer needed: This includes former employees, students, volunteers, and other individuals who have had access to protected health information.

What You Can Do to Protect Your Health Information

There are a number of things you can do to protect your health information and avoid HIPAA violations. Some of the most important include:

Keep Your Personal Health Information (PHI) Confidential 

Avoid disclosure of PHI to anyone who is not authorized to receive it. Do not, for example, share your private health information with friends or family members who are not involved in your healthcare.

Make Sure Your Healthcare Providers Are HIPAA Compliant

Only give PHI to individuals who need it for their work. Ask what they plan to do with the information and if you agree, then share the data. For instance, if you have surgery, your doctor will need to know about all of your allergies.

Always Read Any Agreements Before Allowing Third Party Access to Your Health Records

Ensure you have read and understood the business associate agreement before granting third-party access to patient records. This document specifies the terms and conditions under which PHI may be used and the privacy safeguards that will be in place. Before any of a patient’s PHI can be disclosed to a third party for a purpose other than those expressly permitted by the HIPAA Privacy Rule, the patient must sign an authorization form.

Use a Secure Email System

When emailing PHI, use a secure email system to protect the information from unauthorized individuals. For example, the PHI should be encrypted and protected by a password.

Report Any Data Breaches 

If you become aware of security breaches, report them to the Department of Health and Human Services (HHS) immediately. For instance, if your health information is stolen from your doctor’s office, you should report the incident to HHS.

Review Your Notice of Privacy Practices

You should review and understand what PHI is included in the notice of privacy practice to know that you cannot share information without authorization. For example, a doctor’s office may consist of your Social Security number in the notice of privacy practices.

By taking these steps, you can help protect the privacy of patients’ health information and avoid HIPAA violations. HIPAA violations can happen without your knowledge, but you can take steps to protect yourself. 

 

By keeping personal health information confidential and sharing only what is needed, individuals can keep their health information safe and avoid HIPAA violations. This can be avoided through proper employee training and enforcement by a compliance officer or other staff member.

The Consequences of Violating HIPAA

Potential violations of HIPAA can face a number of consequences, including violation fines and imprisonment. Fines for violating HIPAA are with a minimum of $50,000 per violation, with a maximum of $250,000 per year for violations of the same provision.

Healthcare Employees who have access to health information who violate HIPAA may also be subject to civil penalties and imprisonment. For instance, a person who knowingly obtains or discloses protected health information without proper authorization or consent form could face imprisonment of up to one year.

In addition, all HIPAA violations have civil consequences as well. Individuals can be sued by the U.S Department of Health and Human Services (HHS) for breaching health information or disclosing it in violation of HIPAA. In addition, they can be sued by the person whose protected health information has been disclosed or breached.

The consequences of HIPAA violations are serious and should not be taken lightly.

Why Do We Need to Know About HIPAA Violations?

HIPAA violations occur every year and can have serious consequences. For example, what you do with your health information could affect the rest of your life if it is exposed in a data breach or shared without authorization. Also, what we share about our healthcare may impact others’ lives when they need to find a doctor who can treat them. By taking steps to protect your health information, you can avoid what may be a costly mistake that could follow you for the rest of your life.

Individuals need to be aware of HIPAA violations to protect their health information. By understanding the different ways to violate HIPAA, individuals can take steps to ensure their PHI remains confidential. Knowing what to do if a data breach occurs will help limit the damage if unauthorized access to PHI occurs. You should only share PHI with those who need to know, and all individuals need to understand what constitutes HIPAA violations.

 

Wheelhouse IT Managed Service Provider Offers HIPAA Compliant Solutions

Healthcare IT is a complex and ever-changing field. The regulations and compliance requirements can be overwhelming for even the most seasoned health care professional. 

Wheelhouse IT Managed Service Provider offers HIPAA compliant cloud hosting, disaster recovery, managed backup solutions to help your organization comply with HIPAA guidelines while saving you time and money. We also offer HIPAA compliance training and internal audits to businesses like yours. We know how confusing it can be to find out what’s required of you by law, so we have created this website as an easy reference guide to all things HIPAA-related. 

Our services are designed specifically for the Healthcare Industry, which means our team has worked directly with clients in your position before. Hence, we understand exactly what additional layer of support you need when it comes to security compliance issues like these. We offer a variety of different packages that will fit any budget or needs ranging from complete end-to-end management, including hardware installation/configuration, software installation/configuration, network setup/troubleshooting & monitoring, to remote 24/7 support and access to our secure HIPAA compliant cloud hosting platform.

If you are looking for a hassle-free, worry-free way to keep your healthcare data safe and compliant, please do not hesitate to contact us today. We would be more than happy to discuss our HIPAA-compliant hosting solutions with you in more detail and answer any questions you may have.

Please feel free to browse our website or contact us directly today at (877) 771-2384 to find out how we can help your medical practice, hospital, clinic, laboratory, dentist office, or other healthcare facility meet HIPAA requirements quickly and easily at a price that fits your budget.

 

We look forward to working with you to make your medical practice or organization HIPAA compliant, and you can be sure that because we are committed to helping healthcare and other medical facilities like yours meet their compliance requirements, we will do everything in our power to keep your data safe.

Phishing Attacks Are Still Getting More Sophisticated

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Phishing attacks are nothing new in the business world, and they will almost certainly become more prevalent as time passes. Unfortunately, phishing attacks have adapted their practices to get around advancements in security technology, so businesses must work extra hard to spread awareness of phishing to their employees and train them appropriately.

Let’s discuss some of the ways your business might become the target of a phishing attack. There might even be some avenues on this list you may not have considered!

Traditional Email Phishing

Email phishing is the primary method of phishing used by hackers because of how easy it is to send mass emails to countless recipients. These phishing emails often ask users to click on links, download attachments, or confirm sensitive information. A spam filter is often enough to block most phishing emails, but spear-phishing attacks that are focused on one individual user can often make their way through.

Phone Scams

Sometimes hackers will call or text users and ask them to confirm sensitive information, like their date of birth, credit card number, etc. Especially around the holiday season, you may see texts with links to what is supposedly shipping information on a product you have ordered, but in reality, it is a link to download malware or a trap to collect your sensitive information.

Fake Websites

These are particularly crafty, as they can often mirror actual websites with slight variations of their domain name. Common targets for fake website creation are banks, well-known retailers like Amazon, and government agencies. Always assess whether you are on the correct page, and look for encryption in the URL, before entering sensitive information into any websites you encounter.

Social Media Phishing

A recent trend in the cyberthreat space is social media phishing, where hackers use social media as an intermediary for spreading threats. They might use social media messaging apps to contact people directly, or they may make posts that are seemingly quite legitimate but are in fact designed to spread malware or harvest credentials. You must be very careful on social media to avoid phishing attacks.

Ultimately, the best way to safeguard your business from potential phishing attacks is to increase awareness throughout your business. This means having a training protocol implemented for your employees, both new and existing, and constantly reinforcing cybersecurity best practices.

WheelHouse IT can not only help you implement security solutions for enhanced protection, but we can also train your employees and reinforce appropriate cybersecurity practices through periodic testing. To learn more, reach out to us at (877) 771-2384 ext. 2.

3 Reasons Why Open-Source Software Can Be Problematic

programmer working lady using computer laptop working on unlock lock with coding symbol.

Every business uses some form of software, whether it’s for word processing or detecting malware. When you add up the costs for programs to open and edit PDFs, perform basic accounting, and create images, it’s tempting to see what’s available through open-source channels.

Although finding open-source software will inevitably cut down on your business’s costs, it is intrinsically problematic, and we’ll show you three reasons why you should avoid it when you can.

What is Open-Source Software?

Open-source software (OSS) is a type of software that is provided to the general public along with its source code. That means programmers can take that code and alter it to suit their needs or fix it up over time. This software also comes with rules about how to control its distribution. Needless to say, most big-name software companies would never do this.

How Does Open-Source Software Work?

Open-source software works by being stored in a public place, often on websites, where the product can be viewed and distributed. Anyone can download the software and use the code or offer suggested changes to it.

Furthermore, OSS comes with a license agreement that details how people can use, alter, and distribute the software. When the OSS code is changed, the alterations and methods used to make those changes have to be detailed in the documentation, and some changes in functionality may not be available to all users free of charge. They’ll become a premium service.

Problems with Open-Source Software

Although it may be tempting to completely outfit a business with OSS, that might not be a wise decision. Take a look at three problems inherent in using open-source software.

Licensing Issues

The legal uncertainty surrounding open-source licenses poses a real threat to small businesses. When using OSS, there is no way for most people to know if the software has code that was copied from another company. If your business was ever caught using legally protected code without permission, the legal consequences could be dire, to say the least. It would certainly cost more than a yearly license renewal.

Vulnerabilities Are Made Public

The year 2021 might go down in history as being one of the worst for ransomware and hacking. More people are figuring out how to exploit vulnerabilities in systems and get away with it.

You may have already figured out the problem with OSS and security: the code is available to everyone, including hackers. These vulnerabilities are made public all the time, and it only takes a savvy person to figure out how to exploit the system and become a threat.

Not Knowing Your Sources

How do you know whether to trust an OSS? The truth is that trust for an OSS comes from a majority opinion of users and developers, and it is built over time. Yet, new open-source programs are being released all the time.

Imagine that you need an accounting program, and you choose to download the first OSS version you find, but it doesn’t have a positive consensus from users and reviewers.  You’ve just put yourself and your business at risk because you do not know the source of the code.

It could be stolen code, a malware trap, or trouble of another sort.

Not all OSS is bad, but there are some bad ones out there, and you need the confidence to say you can tell the difference.

Open-source software is highly customizable but often not as well polished as software from major companies. To avoid the risks associated with OSS, it’s often better to pay for a licensing fee and get the ongoing security and trust that comes from working with an established company.

WheelHouse IT is a gold-level Microsoft partner who can help you get the most out of your software.
Learn more at our Microsoft page or contact us so we can help evaluate your needs and point you in the right direction.

How To Send HIPAA Compliant Email

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How To Send HIPAA Compliant Email

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) set the standard for healthcare providers in protecting sensitive patient data. Any organization that handles protected health information (PHI) must adhere to all applicable physical, network, and process security measures. HIPAA-compliant email solutions and all aspects of email security fall under this category. But HIPAA compliance for email communications (email accounts and email services) is often viewed as a baffling subject matter.

Organizations subject to HIPAA include covered entities (any company that provides treatment, medical practices, payment, or healthcare operations) and business associates (any company with access to PHI that provides support for covered entities). Even subcontractors (i.e. business associates of business associates) must comply with HIPAA secure communications rule. These organizations and entities have to overcome all compliance challenges that may come their way, in order not to breach HIPAA rules.

What is HIPAA compliant email?

In 2000 the HIPAA Privacy Rule created for the first time a set of national standards for safeguarding certain health information. It allows covered entities to disclose PHI to a business associate if it receives assurances that the business associate will use the information only within the scope in which it was engaged by the covered entity.

The HIPAA Security Rule was added in 2003 to set out what safeguards must be in place to protect electronic PHI (ePHI), which is health information that is held or transferred in electronic form.

In regards to email, covered entities are required to take reasonable steps to protect ePHI as it’s transmitted electronically to the recipient’s inbox.

Once the email reaches the recipient, the obligation of the sender ends, and it becomes the recipient’s job to secure any PHI they have in their inbox.

If you are using a third party to transmit or host ePHI, the company is required by law to sign a business associate agreement (BAA) with you. A BAA establishes that certain administrative, physical, and technical safeguards are in place to protect patient data.

While no certification makes an email provider HIPAA compliant, meeting the requirements set by the HIPAA Privacy & Security Rules is the best place to start, along with ensuring strong technical security measures to make sure ePHI is protected inbox to inbox.

 Does HIPAA require email encryption?

The terms “required” and “addressable” are used to describe HIPAA encryption requirements. Encryption protocols labeled as mandatory must be implemented if you want to remain in compliance with HIPAA. If a risk assessment determines that encryption is necessary to protect ePHI, addressable encryption protocols must be implemented.

This decision should be documented and an equivalent solution implemented to protect ePHI if your organization decides encryption is not necessary. Because there is no suitable alternative to encryption for protecting ePHI in an email, it is effectively necessary. Your patients’ information and your organization could be at risk if you don’t encrypt your emails.

 

There are a few things to keep in mind to ensure that your email is HIPAA-compliant:

Ensure you have email encryption (end-to-end encryption) for email

Email is a quick and easy way to communicate electronically for healthcare organizations, but it does not necessarily ensure security nor usually have extra security and compliant technology solutions. Even services that encrypt messages in transit may not have the required level of security to make them HIPAA compliant. To make your email is HIPAA compliant and ensure cloud-based email security, you should ensure you have end-to-end encryption, which encrypts both messages in transit and stored messages. Access controls are used to ensure only the intended recipient and the sender can access the messages.

Some email service providers require individual emails to be encrypted by clicking a button or using a portal. Since it is easy to forget to turn on encryption and accidentally send an unencrypted email, it is a better choice to encrypt all emails, not only those that contain ePHI. This will reduce the potential for human error.

The type of encryption used is also important. While previously Data Encryption Standard (DES) was considered secure, that is no longer the case. You should consult NIST for advice on suitable encryption standards. Currently, AES 128, 192, or AES 256-bit encryption is recommended.

For many HIPAA-covered entities, especially smaller healthcare providers that do not have in-house IT staff to ensure their email is HIPAA-compliant, the use of a third-party HIPAA-compliant email service provider is strongly recommended.

Research potential HIPAA-compliant email service providers to ensure that they provide a service that is suitable for your requirements. A search on Google will produce several potential service providers.

Enter into a HIPAA-compliant business associate agreement with your email provider

In your compliance effort, before using a third-party email service to send ePHI, you should obtain a business associate agreement. As outlined in the business associate agreement, the service provider is responsible for ensuring ePHI’s confidentiality, integrity, and availability through the use of administrative, physical, and technical safeguards.

You should look for an alternative option if an email service provider or compliant email vendor refuses to sign a business associate agreement as one of the business requirements. To work with HIPAA-covered entities and their business associates, an email service provider should be willing to sign a BAA.

Ensure your email is configured correctly

It is possible to violate HIPAA rules even if a BAA is obtained because of the risks of email. It is not enough to use a BAA-protected email service to ensure that your email is HIPAA compliant, you must ensure that your email is configured correctly and take appropriate compliance security measures.

Develop policies on the use of email and train your staff

Training your staff on the proper use of email concerning ePHI and compliance with regulations is essential after you have implemented your HIPAA-compliant email service. Health care workers, in the busy healthcare environment, have been responsible for several data breaches, including the unintentional transmission of ePHI via email without encryption and the transmission of ePHI to individuals who were not authorized to see the data. Employees must be aware of their HIPAA obligations and trained on how to use the email service to comply with the law.

Ensure all emails are retained

Because email retention is not specifically mentioned in HIPAA legislation, HIPAA’s rules on email retention are a little unclear. Covered entities should maintain an email archive, or at least ensure that emails are backed up and stored because individuals can request information on disclosures of protected health information and email communications may be required when legal action is taken against a healthcare organization. Emails may also be required to be kept for a set period of time under state law. Because of this, you should check the laws governing email in the states where you do business. Consult a lawyer if you’re unsure about anything.

HIPAA requires covered entities to keep documentation related to their compliance efforts for six years, and the retention period for security-related emails and emails relating to privacy policy changes should be six years.

Storage space is required even for small and medium-sized healthcare organizations to store 6 years of emails, including attachments. When it comes time to back up your emails, consider using a secure, encrypted email archive instead. Additionally, since an email archive is indexed, searching for emails in an archive is a quick and easy process. Emails can be quickly and easily retrieved if they are needed for legal discovery or a compliance audit.

To be classified as a business associate under HIPAA, any email archiving service provider will be subject to the same regulations as email service providers. It would be necessary to sign a BAA with that service provider and obtain reasonable assurances that they will abide by HIPAA rules.

Obtain consent from patients before communicating with them via email

HIPAA-covered entities need to remember that even if a HIPAA-compliant email provider is used, the patient’s written consent must be obtained before any ePHI is sent via email, no matter how convenient it may be. Patients should be made aware of the potential dangers of sending confidential information via email. Emails containing electronic health information (ePHI) can be sent if the sender is willing to accept the risks.

Partner with Wheelhouse IT 

You may believe that you can meet the requirements of the Health Insurance Portability and Accountability Act (HIPAA) on your own, and you may be right. A HIPAA-verified Managed Service Provider (MSP) makes it much easier to achieve HIPAA compliance than if you were to do it on your own.

To keep your organization and in-house IT department HIPAA compliant, you can rely on Wheelhouse IT. Some of the benefits of working with us include:

  • Conducting HIPAA security risk assessments
  • Encrypting all PHI and stored data
  • Implementing backup and disaster recovery plans to keep data secure
  • Identifying system vulnerabilities and providing high-quality solutions
  • Providing the necessary technology to ensure data security
  • Providing services such as Remote Monitoring Management (RMM), cloud-to-cloud backup, and authentication and access management 

If you are looking for the assistance of an MSP for your HIPAA compliance needs, call the team at Wheelhouse IT today!

What Are The Three Rules of HIPAA?

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What Are The Three Rules of HIPAA?

The Health Insurance Portability and Accountability Act (HIPAA) lays out three rules for protecting patient health information, namely:

  • The Privacy Rule 
  • The Security Rule
  • The Breach Notification Rule

A national standard is established when these three rules are followed, and health information that could be used to identify a person is addressed by these standards and privacy procedures.

Failure to adhere to the three HIPAA rules, compliance obligations, and security policy–or any security breach of electronic information systems through unauthorized access to electronic health records, confidential health, and medical history, or electronically protected health information–can result in civil money penalties (and even criminal penalties), a loss of reputation for healthcare professionals due to intentional violations, and even the loss of employment for an employee.

Businesses can face fines of up to $1.5 million for failing to comply with the law and addressable implementation specifications. As a result, if you are one of the covered entities under HIPAA, you must follow the three HIPAA rules and security management processes, taking appropriate corrective action when necessary.

Why are the three rules necessary?

For Private Healthcare Information (PHI): there wasn’t much of a consensus on what the best practices for PHI should be. But things began to change after the introduction of HIPAA.

In the beginning, there were privacy and security rules. Protected health information (PHI) was the focus of HIPAA’s new standards, which applied to the entire healthcare industry.

In addition to this, HIPAA’s primary goal was to improve the patient experience. Covered entities were given a variety of policies and procedures to ensure that their clients’ information was protected without a lot of hassle. Reduced paperwork, in addition to improving workflow, is a benefit to the covered entity.

To meet HIPAA’s requirements, code sets must be used in conjunction with patient identifiers. Health insurance portability is aided as a result of this ease of information transfer. With the Portability and Accountability Act in mind, healthcare providers are attempting to make the patient’s experience more pleasant.

HIPA’s rules also serve some much more minor purposes. Life insurance loans may be exempt from tax deductions, depending on the circumstances. It also improves the efficiency of healthcare services and makes it easier for patients to interact with them.

Who needs to have HIPAA compliance?

Private hospitals, health insurance companies, medical discount providers, and other business associates are all included in the scope of HIPAA’s application.

This type of business is known as  “covered entities,” and must abide by the HIPAA regulations and security standards. Exceptions to the HIPAA rules for covered entities are extremely rare.

A company or organization that provides third-party health and human services to a covered entity must adhere to the HIPAA regulations. As “business associates,” these companies are subject to the same regulations as the covered entities, even though they do not provide direct services.

The business associate agreement must be signed by both business associates and covered entities. Before undergoing any procedures, the confidentiality and integrity of PHI must be preserved, and the business associate agreement does that.

The three main rules of HIPAA

As mentioned earlier in this article, HIPAA legislation is made up of a few rules that outline what you must do to comply with the law. We’ll now discuss them in detail below:

1. The HIPAA privacy rule

HIPAA defines the circumstances under which a person may disclose or use PHI. Everyone has a right to privacy, but as we all know, there are some situations in which the rule might be applied. Those who are covered by this policy must adhere to a set of rules.

The standards set by the privacy rule address subjects such as: 

  • Which organizations must follow the HIPAA standards
  • What is protected health information (PHI)
  • How organizations can share and use PHI
  • Permitted usage and disclosure of PHI
  • Patient’s rights over their health information

In 2003, the HIPAA Privacy Rule was first put into place. That includes healthcare providers, as well as clearinghouses, and other health insurance entities. Healthcare-related business partners joined the list in 2013.

For the most part, the rule on patient privacy restricts the extent to which medical records can be shared without explicit consent. Allows patients and their next of kin (representatives) to access their medical records under the HIPAA privacy rule These requests for access and disclosure must be responded to within 30 days of receipt by the Covered Entities. 

Healthcare entities covered by HIPAA include:

  • Health plans 
  • Health care clearinghouses 
  • Health care providers 

The privacy rule restricts the usage of health information, which could identify a person (PHI). Covered entities cannot use or disclose PHI unless:

  • It’s permitted under the privacy rule, or
  • The individual has authorized it in writing.

The privacy rule does not restrict de-identified health information. 

2. The HIPAA security rule

The HIPAA Security Rule sets out the minimum standards for protecting electronic health information (ePHI). To access that information in electronic format, even those who are technically capable of doing so would have to meet those standards.

The HIPAA security rule covers the following aspects:

  • The organizations that may need to follow the security rule and be deemed covered entities.
  • Safeguards, policies, and procedures that can be put in place to meet HIPAA compliance
  • Health care information that is under the protection of the security rule

To put it simply, anyone who is part of the BA or CE and can access, alter, create or transfer recorded ePHI will be required to follow these standards. These technical safeguards will involve NIST-standard encryption in case the information goes outside the firewall of the company. 

In addition to technical safeguards, the security rule will include several physical safeguards. If you’re in a public area, you won’t be able to see the screen because of a workstation layout. Only a specific area within the company’s network allows you to do this.

Administrative safeguards are also checked, and they are combined with the security rule and the privacy rule. A privacy officer and a security officer are required to conduct regular (an ongoing process) audits and risk analyses as part of these safeguards.

These evaluations are critical to the safety of the system. When considering possible threats to the PHI, they don’t care if it’s just a theory. Consequently, they plan to implement a risk management plan based on it to avoid any potential risks that could occur in the future. 

A covered entity must take the following steps to ensure the security of all ePHI they create, send, or receive:

  • Ensure the confidentiality integrity and availability of the PHI
  • Protect against improper uses and disclosures of data
  • Protect the ePHI against potential threats, safeguarding their medical records
  • Train employees so that they are aware of the compliance factors of the security rule
  • Adapt the policies and procedures to meet the updated security rule

Confidentiality, integrity, and availability rules in health care must be met by the covered entity.

3. The HIPAA breach notification rule

Occasionally, there may be a breach. The breach notification rule comes into play here. The Department of Health and Human Services must be informed as soon as possible if there has been a data breach. Regardless of the nature of the breach, this must be done within 60 days of its discovery, this is where a good risk management plan comes in handy.

If a breach during administrative actions involves a person‘s personal information, that person must be notified within 60 days of the discovery of the breach.

In the event of a large-scale breach that affects more than 500 patients in a specific jurisdiction, the media should be informed as well.

An immediate announcement of a privacy violation is required by the HIPAA rule for breach notification. The Office for Civil Rights may impose fines if you don’t comply.

Alternatively, the Covered Entity may decide not to send a breach notification if it can show that the critical element of the PHI has not been compromised. A violation of privacy and security rules would be warranted if they are found to have been compromised.

Reportable Breaches and Exceptions

A breach of PHI occurs when an organization uses or improperly discloses PHI. However, they are only required to send alerts for PHI that is not encrypted. In addition to this, there are three additional circumstances in which the breach notification rule is more lenient, during such compliance violations and PHI breaches.

  1. If it was unintentional or done in good faith, and was within the scope of the authority.
  2. If it was done unintentionally between two people permitted to access the PHI.
  3. If the organization has a good faith belief that the person to whom the disclosure was made would not be able to retain the PHI.

Under such a case, the organization should ensure that such incidents don’t reoccur and take corrective action plans. Breach alerts are required only for unsecured PHI. If you secured it as specified by this guidance, then you don’t need to send the alerts. 

Partner with Wheelhouse IT 

You may believe that you can meet the requirements of the Health Insurance Portability and Accountability Act (HIPAA) on your own, and you may be right. A HIPAA-verified Managed Service Provider (MSP) makes it much easier to achieve HIPAA compliance than if you were to do it on your own.

To keep your organization and in-house IT department HIPAA compliant, you can rely on Wheelhouse IT. Some of the benefits of working with us include:

  • Conducting HIPAA security risk assessments
  • Encrypting all PHI and stored data
  • Implementing backup and disaster recovery plans to keep data secure
  • Identifying system vulnerabilities and providing high-quality solutions
  • Providing the necessary technology to ensure data security
  • Providing services such as Remote Monitoring Management (RMM), cloud-to-cloud backup, and authentication and access control

If you are looking for the assistance of an MSP for your HIPAA compliance needs, call us at Wheelhouse IT today!