The 411 on HITECH and HIPAA IT Compliance

By Judi Grassi

2020 Alliance sponsor feature article courtesy of Carolinas IT: A Logically Company

Most group practices and clinics have adopted the Electronic Health Record (EHR). If you’re one of these organizations, you know how imperative it is to keep your Electronic Protected Health Information (EPHI) safe. Both HIPAA and the HITECH Act lay out very specific requirements about data protection and regardless of your size, you are required to keep your Protected Health Information (PHI) data secure. This is especially imperative if your organization electronically transmits health information for financial or administrative reasons, such as claims processing, benefit eligibility, referral authorization requests, and other transactions defined under the HIPAA Transactions Rule.

Three Areas of HIPAA IT Compliance

HIPAA IT compliance is the responsibility of every administrative and clinical staff member in your organization. To make compliance requirements easier to digest, HHS established three areas of HIPAA IT compliance.

1. 1. Administrative — These measures ensure the integrity of patient data and accessibility only to authorized parties. It requires HCOs to:
      • Implement a security management process that identifies potential risks to EPHI and appropriate security measures to reduce risks and vulnerabilities.
      • Designate a security official who is responsible for ensuring HIPAA and HITECH compliance.
      • Identify who has authorized access to EPHI.
      • Provide appropriate security training to employees and follow through with appropriate sanctions against any employee who violates security policies.
      • Perform a periodic assessment to assess the effectiveness of your security policies.
   2. Physical — These measures ensure the security of facilities and devices that contain EPHI. It provides HCOs to:
      • Limit physical access to their facilities to authorized personnel only and protect against physical intrusion.
      • Ensure secure access to workstations and electronic media. This includes procedures for the transfer, removal, disposal, and re-use of electronic media to ensure appropriate protection of EPHI.
   3. Technical — These measures ensure that your IT systems and networks are secure from data breaches and unauthorized access. It requires HCOs to:
      • Protect their IT systems against digital intrusion and ensure that EPHI is transmitted over a secure network.
      • Only allow authorized individuals to access EPHI and ensure IT systems provide an audit trail to track EPHI access.
      • Ensure EPHI is not improperly or erroneously altered or destroyed.

HITECH Compliance

The HITECH Act of 2009 shored up these privacy and security provisions:

• HCOs, business associates, and service providers are all responsible for the security of EPHI.
• HCOs must promptly notify affected individuals whose PHI was compromised.
• HCOs must report any security breach that affects more than 500 individuals to the HHS Secretary.
• HCO business associates must notify the HCO of any breach at or by the business associate.
• Breaches affecting fewer than 500 individuals must be reported to the HHS Secretary on an annual basis.

How to Comply with HIPAA and HITECH Technical Measures
Whether you are a hospital, clinic, medical practice, HCO business associate, or HCO service provider, you will need to address the following in order to comply with HIPAA and HITECH technical measures.

• Develop policies and procedures for data backup and recovery.
• Back up your data on a regular, frequent basis and ensure you can retrieve exact copies of EPHI and restore any lost data. Follow the 3-2-1 backup rule: 3 copies of your data across 2 media with 1 copy stored offsite.
• Establish acceptable but aggressive Recover Time Objectives (RTOs) and Recovery Point Objectives (RPOs) and develop a disaster recovery plan that meets these objectives.
• Periodically test your disaster recovery plan to be sure it works before a real disaster happens.
• Perform an annual risk assessment to determine whether your systems and data are a security risk and how vulnerable you are to attack.
• Develop a data breach response plan to identify who is responsible for what when a breach occurs, how to communicate with individuals whose PHI was compromised, how to handle the media, minimize further data loss, and remediate the breach.
• Encrypt EPHI data in transit and at rest.
• Ensure HCO business associates and service providers meet HIPAA and HITECH security requirements.

Noncompliance Fines
If you are found in noncompliance with HIPAA and HITECH regulations, it can cost you. Fines are based on the violation category or level of perceived negligence and can range from $100 to $50,000 per violation, with a maximum penalty of $1.5 million per year for each violation (see Figure 1).

Figure 1

If you are breached and fined, your organization is listed on the HHS Office for Civil Rights (OCR) Breach Portal and “Wall of Shame” if the breach involves 500 or more individuals. If your organization has a breach of this magnitude, the name of your HCO will be permanently listed.

Final Thoughts

HCOs have two choices when it comes to HIPAA IT compliance requirements: DIY (Do It Yourself) or hire an IT Managed Service Provider (MSP). Whether you are a large or small HCO, you may find that you have limited IT resources and/or skills in-house to ensure your EPHI is private and secure. Therefore, many HCOs look to HIPAA-compliant MSPs to back up their systems, ensure the privacy of EPHI, and provide the best protection from security breaches.

Figure 1: Categories of Violations and Respective Penalty Amounts Available. Source: https://www.federalregister.gov/documents/2013/01/25/2013-01073/modifications-to-the-hipaa-privacy-security-enforcement-and-breach-notification-rules-under-the#h-95

HIPAA Compliance and Information Technology

2018 Alliance sponsor article courtesy of HitsTech

The HIPAA Security Rule, in force since April 21, 2005, established three safeguards:

• Administrative policies and procedures designed to clearly show how the entity will comply with the act.
• Physical measures that control access to data storage areas.
• Technical methods securing “protected health Information” (PHI) that, when transmitted electronically over open networks, is known as ePHI.

The first two safeguards take time and effort but most healthcare providers have staff who can read the manuals, apply the guidelines and develop a compliant infrastructure.

The technical safeguard provision is entirely different!

HIPAA IT skills are not easily mastered. It requires the ability to understand the rules and regulations, envision a network (along with the ePHI flowing through it), and spot vulnerabilities. This must usually be done with a limited budget and with a minimum disruption of provider efficiency.

Deciding how to protect your information is a critical decision. The financial penalties resulting from data breaches along with the colossal costs of issuing breach notifications, providing credit monitoring services, and conducting damage mitigation makes investment in the protection of PHI extraordinarily cost-effective .

If you decide to handle HIPAA technical issues by hiring an in-house IT professional or contract with a Managed Services Provider (MSP) who specializes in healthcare, how do you make the right decision?

Most importantly, your applicant must present a plan that addresses four issues:

1. 1. The protection of the entire volume of PHI and ePHI you process. This includes:
      • Patient names, pictures, biometric data, addresses, contact numbers, insurance information, and any identifying numbers or data.
      • Health insurance plan beneficiary numbers.
      • Vehicle identifiers and serial numbers including license plates.
      • Device identifiers and serial numbers.
      • Web URLs and Internet protocol (IP) addresses.
   2. The ability to defend against known and anticipated threats. Failure to use current generation OS software and protection and tardiness in the implementation of published fixes and patches makes you 40 times more likely to be hacked.
   3. Compliance by other “Covered entities,” “business associates” and third-party service providers who might access your PHI. This includes items sometimes overlooked such as x-rays, physician appointment schedules, dictated notes, conversations, and information placed in patient portals.
   4. Security network components that are affordable and operationally feasible. The following diagrams identifies these components.²

 

²Prevention Data Breaches Diagram used with permission of the HIPAA Journal 2017

There are specific HIPAA standards for servers, hosted environments, cloud utilization VPN architecture, workstations and network components. Your staff or MSP must provide evidence that the components they intend to deploy meet these specifications.

The technical defense you deploy must compensate for common human failings by using:

• Password best practices. Passwords cannot be used by a group, must not be assigned to a position and must be changed every 90 days. Passwords must be sophisticated using letters, symbols, differing case and numbers.
• Screen protectors that limit a third party’s ability to view a protected screen. These are commercially available.
• Automatic controls that close a computer when it is left unattended.
• Auditing techniques that ensure business associate networks are compliant. Remember you remain responsible for ePHI even when it leaves your network for another.
• Restricted use of mobile devices such as flash drives that are not encrypted or are left in unprotected locations.
• Technology that locks misplaced mobile devices.
• Tracking that identifies attempted hacks and determines if data has been compromised.
• An automatic restoration protocol that frequently backs up data so that if you are successfully attacked, it will disable the threat and immediately return your network to its last safe status.
• Disposal procedures that ensure that any device to be disposed of is wiped completely before release from the protected environment.

While I hope this synopsis is helpful, I highly recommend you look at the 2017 edition of the HIPAA Journal’s “HIPAA Compliance Guide”. It provides a detailed analysis of the points made in this paper.

Armed with “Compliance Guide” expertise, explain your goals to your IT staff or MSP and leave the driving to them.

Sandra Loftin
Chief Executive Officer
HitsTech