The 2012 audits conducted by the Office for Civil Rights (OCR), the governing body that enforces HIPAA regulations, revealed an egregious lack of compliance across the healthcare industry.
With the next round of audits scheduled to begin soon, it’s hard to say how forgiving the OCR will be.
One thing is for sure: The OCR expects healthcare organisations to monitor themselves. Even so, many companies have yet to initiate a thorough internal audit of their data security risks. Besides taking a gamble with compliance, these firms are at risk of exposing entire business operations to possible breach.
Whatever the motivation, starting or refining an internal audit for compliance will undoubtedly take a considerable amount of effort. Can’t afford the disruption? Think again. An unanticipated random audit by the OCR will cost you more in the long run if you have not taken some basic precautions. To be minimally prepared, here are seven items you must not overlook:
Conduct a risk assessment. This is going to be your vital first step. You will want to do a thorough evaluation of potential threats to the confidentiality and integrity of all electronic protected health information (ePHI) throughout your organisation. Because of the disparity in the size, scope and resources of covered entities, the OCR does not dictate what levels of risk you assign to each area under consideration. That will be up to you.
Identify where patient data resides. This constitutes one of the most vulnerable areas for many companies and should be a foundational step in your risk assessment. Find out where all of your data lives—data can be stored on the server, multi-function copier/printers, spreadsheets, mobile devices, external media and with third parties. The OCR is quite strict about this and has been known to levy steep fines for data breaches where an organisation has failed to consider all locations of unprotected data.
Document all decisions. Should your organisation be chosen for an audit by the OCR, written justification of all decisions will be taken into consideration. Begin a log to document how—and why—each decision is made with regards to compliance. Flexibility is built in to the HIPAA regulations to accommodate smaller organisations with more limited resources, but you still need to justify why each decision was made.
Identify ALL business associates. Regulations require that all third parties with whom a firm shares ePHI have up-to-date contracts in place. If a business associate experiences a breach, any of the firms they share data with could be included in the investigation.
Assess physical aspects of data handling and storage. Check for secure access to the server room, location of workstations, visibility of screens, document shredding, disposal of old equipment etc. A general rule of thumb: Give everyone minimum access to each area of the system so they can perform their jobs adequately.
Schedule security training. Auditors pay close attention to how employees handle sensitive data. Staff should be trained in such areas as how to store portable workstations, process printouts and adhere to guidelines for mobile device use. The IT department should also be instructed on how to proactively check network device logs, maintain secure access to the system and be on the lookout for anomalies.
Deploy encryption. While there is a cost attached to this, encrypted data can turn all of your problems into non-issues should an employee lose a laptop or a smart phone that contains ePHI.
Take an h
onest look at your data security controls in each of these seven areas. If you are able to do this with an open mind—and address what needs fixing—you will most likely pass an OCR audit with flying colours should you be selected for one. And of course, it goes without saying that you should make sure you have addressed all of the standards and implementation specifications in the HIPAA security rule, including developing and deploying a comprehensive set of security policies.
Aside from compliance, conducting an internal assessment will illuminate security gaps that are exposing one of your company’s most valuable assets—data—to hackers and malware. Findings will justify decisions such as allocating a higher budget for network security tools or engaging a data security management service.
If you hire a third party to conduct the audit, expect this: Cyber security professionals are thorough, pinpoint issues faster and develop data security solutions that accommodate cross-functional requirements and limitations. While being audited by an outside firm can make employees feel as though they are under investigation, a good cyber security firm is partnering with you to help you meet compliance, protect your data and save you money.
Taking a methodical approach to risk analysis will reveal how you are performing now—and where you need to be. Don’t panic if you find that you are below compliance and your data was at greater risk than you had thought. Knowledge is power. Conducting an internal audit and putting better data security controls in place is taking the expected level of responsibility for the ePHI that has been entrusted to your care.
Jason is Practice Leader at LBMC Managed Security Services.
