Are you confused at how to be full HIPAA compliant amidst all this broad complexity in compliance? To ease the confusion out, we have here broken down the HIPAA Compliance into its most basic steps.
HIPAA compliance – The Healthcare Insurance Portability and Accountability Act was signed into law in 1996 with the original intention of helping more Americans gain health insurance coverage and ensuring that employees would not lose their health insurance if they changed jobs.
The act sets standards for the safeguarding of identifiable health information which was later defined and expanded via the passage of the Privacy Rule, Security Rule, HITECH Act, and other expansions of the original HIPAA law.
Understanding HIPAA Compliance
HIPAA compliance consists of complex regulations which can be confusing to understand because the standards to achieve compliance are not clearly stated. There are different standards for different organizations under HIPAA compliance, available to secure and safeguard the protected health information.
HIPAA act sets standards for all the companies that deal with patient protected health information. According to the act, to be considered compliance with the HIPAA, the companies must have physical, technical, and administrative security measures in place and follow those procedures. It is obligatory for everyone with access to the patient information – including the healthcare personnel, business associates, vendors, and service providers to meet HIPAA compliance.
The process of achieving HIPAA compliance into several manageable basic steps have been broken down below:
- Understanding what patient privacy entails
- Knowing HIPAA’s required mandates
- Understanding the roles security and privacy play in the use of Electronic Health Records (EHR)
- Completing Security Risk Analysis and Management
- Disaster preparedness
- Ongoing HIPAA training
- Understanding business associate agreements and other collaborations
Understanding Patient Privacy
A major chunk of the HIPAA act requirement is to understand patient privacy, which means understanding the provisions under the Act. The Privacy Rule, under Title II of HIPAA, puts in place federal protections for Protected Health Information (PHI) that is individually identifiable.
Under the Privacy Rule, the patients are provided with certain rights regarding their health information along with extending it to all covered entities and business associates. The Rule also allows the patient to make decisions about how their information will be used, but the Privacy Rule has another component as well.
The Rule has provisions that permit the disclosure of assured information under circumstances where a person’s health is at risk only.
Knowing The Required Mandates of HIPAA
If you are not aware of all the required mandates of the HIPAA compliance, it is not possible to be fully compliant. However, the list of security safeguards that must be in place for compliance is quite long.
Here is a list of the required mandates that you should be aware of:
- The Unique Identifiers Rule gives practices a specific numerical code to additionally improve efficiency. This is also known as the National Provider Identifier (NPI).
- The Privacy Rule pertains to PHI and taking all necessary measures to keep this information protected, as well as describing instances in which sharing this information might be acceptable. Individuals must be notified of how their PHI is being used.
- The Omnibus Rule updates HIPAA to include the directive that all “business associates” must be compliant as well.
- Transaction and Code Set Rules layout the standardized guidelines for how electronic transactions should take place.
- The Enforcement Rule lays out the aforementioned civil and criminal penalties for non-compliance.
- The remaining three titles (III, IV, V) lay out the guidelines and enforcements for tax-related health provisions, for group health insurance plans, for employer health insurance plans, and information relating to ex-patriates.
Understanding Security And Privacy On Electronic Health Records
Incentivized meaningful use of EHRs was introduced under the American Recovery Reinvestment Act (ARRA) of 2009. The Act is meant to ensure security and privacy with the use of EHRs. The HITECH act establishes strict laws regarding the significant use of EHRs, while the Omnibus Rule expands on penalties put in place by the HITECH act.
According to the rule, it is required to set up the physical, administrative, and technical safeguards to protect electronic PHI. Some safety measures in place that can ease your concerns about EHRs are:
- Setting appropriate access controls to limit who in an organization can view ePHI
- Passwords and PINs with limited access
- Encryption of your stored information.
- Training your employees on what is considering PHI and how to protect it
- An audit “paper trail” that reveals who accessed and/or corrected your information and when.
Security Risk Analysis and Management
The Security Management Process standard, contained by the administrative safeguards section of the HIPAA Security Rule, dictates that covered entities will, “implement policies and procedures to prevent, detect, contain, and correct security violations.”
There are four mandatory specifications under the Security Management Process standard till now but the most pertinent is Risk Assessment and Risk Management. Both of these play a critical role in an organization’s compliance with the Security Rule. These components are essential as they tend to create the foundation on which other security measures are built.
Under the Act, Risk Analysis requires entities to “conduct an accurate and thorough assessment of the potential risks and vulnerabilities to the confidentiality, integrity, and availability of electronically protected health information held by the covered entity.”
There is no single specified way to conduct Risk Analysis and Management, and approaches will vary largely from entity to entity. To make these compliance standards more accessible, the OCR provides a complete guide to understanding HIPAA’s security series, including possible frameworks, and other pertinent advice.
HIPAA has been updated multiple times from time to time to date and expects them to pour in more in the future.
As you can see, HIPAA can seem large and confusing, which is why a process and framework was made to help guide organizations to achieve and maintain HIPAA compliance. Take it out for a spin: the trial is free.
From AI to multiple frameworks, HIPAA compliance allows organizations to fall under scrutiny and abide by all the necessary measurements which will prove out to be beneficial for them in the long run.