If your healthcare organization collects and stores personal information as part of your operations, it’s vital that you and your staff are familiar with and adhering to the Health Insurance Portability and Accountability Act (HIPAA). HIPAA includes three rules for protecting patient health information, namely:
- The Privacy Rule
- The Security Rule
- The Breach Notification Rule
HIPAA was established by the federal government in 1996 with the intent to protect sensitive patient information from disclosure. As a healthcare organization, it’s paramount that you’re shielding your patients’ information from inadvertent or intentional exposure and potential risks. Any identifiable health information needs to be protected as mandated by national standards. There are serious consequences for failure to adhere to the three HIPAA rules, including financial penalties. 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, and even the loss of employment for an employee.
Businesses can face fines of up to $1.5 million per year in monetary penalties 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.
How HIPAA Helps Private Health Care Organizations
Prior to the introduction of HIPAA, Private Healthcare Information (PHI) wasn’t securely protected as there were no directive mandates or processes in place to secure personal health information.
In the early origin of HIPAA, there were privacy and security rules outlined to help protect patient records. Protected Health Information (PHI) was the focus of HIPAA’s new standards, which applied to the entire healthcare industry.
In addition to providing important protections, ultimately HIPAA’s primary goal was to improve the patient experience. Covered entities were given a variety of policies and procedures to ensure that their client’s information was protected without a lot of hassle. As healthcare providers implemented these policies, their patients and employees benefitted from the resulting reduced paperwork and improved workflow.
One way to meet HIPAA’s requirements is to use code sets in conjunction with patient identifiers. These codes shielding identifiable health information improved health insurance portability as it increased the ease of information transfer. With the Portability and Accountability Act in mind, healthcare providers attempt to make the patient’s experience more pleasant.
HIPAA’s federal standards 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.
These types of businesses are 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 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.
Before engaging in any shared healthcare operations, a business associate agreement must be signed by both business associates and covered entities. Before undergoing any procedures, the confidentiality and integrity of protected health information must be preserved, and the business associate agreement does that.
What Are the Three Main Rules of HIPAA
As mentioned earlier in this article, HIPAA legislation comprises 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 protected health information. Everyone has a right to privacy and this rule helps ensure that appropriate safeguards are in place to protect personal health information. Those who are covered by this policy must adhere to a special 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
- A patient’s rights over their health information
In 2003, the HIPAA Privacy Rule was first put into place. At that point, the affected entities included healthcare providers as well as healthcare 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. It does also provide some rights to patients including their right to obtain and examine their own health information. For example, it allows patients and their next of kin (representatives) to access their medical records under the HIPAA privacy rule. As outlined in the Privacy Rule, any requests for access and disclosure must be responded to within 30 days of receipt by the Covered Entities. Upon receipt, if a patient determines an error, the Privacy Rule enables them to request a correction.
The Privacy Rule also restricts the usage of health information which could identify a person (protected health information or 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 healthcare organizations to protect electronic protected 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. At its core, the HIPAA Security Rule requires healthcare providers to have the necessary administrative, physical, and technical safeguards implemented to ensure the ePHI’s integrity, security, and confidentiality is maintained.
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 business associates (BA) or covered entities (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. These physical safeguards may entail positioning workspaces in certain ways. For example, if your administrative staff are in a public area, others shouldn’t be able to see a computer screen because of a workstation layout.
Administrative safeguards are also checked and they include the Security Rule and the Privacy Rule. A privacy officer and a security officer are required to conduct regular audits and have a risk analysis process as part of these safeguards on an ongoing basis.
These evaluations are critical to the safety of the system. When considering possible threats to protected health information, your privacy officer and security officer don’t care if it’s just a theory. Consequently, they plan to implement a risk management plan in response to their audits and hypotheses to help 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 ePHI
- 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 include any updates to the Security Rule
Confidentiality, integrity, and availability rules in health care must be met by the covered entity. Access to health data needs to be secure and protected from any potential breaches.
3. The HIPAA Breach Notification Rule
Occasionally, there may be a breach that leaves your patients’ protected health information vulnerable. A breach can be any impermissible disclosure under the Privacy Rule that may compromise the security or privacy of protected health information. This is where the Breach Notification Rule would be enacted. 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 or scale of the breach, this must be done within 60 days of its discovery. This is where a good risk management plan is valuable.
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, even if it’s an accidental disclosure. However, organizations are only required to send alerts for identifiable health information 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. This may include:
- If it was unintentional or done in good faith, and was within the scope of the authority.
- If it was done unintentionally between two people permitted to access the PHI.
- 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.
How Wheelhouse IT Can Help You Adhere to HIPAA Guidelines
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
WheelHouse IT is ready to help your business navigate HIPAA compliance.
If you are looking for the assistance of an MSP for your HIPAA compliance needs, book time on our calendar below.