HIPAA privacy rule was enacted more than a decade ago and health organizations, ever since, are putting consistent efforts to ensure that the health information remains private and secure. The HIPAA (Health Insurance Portability and Accountability Act) regulations are vast and complex at places and healthcare organizations require a thorough understanding and substantial effort to maintain compliance. Consequently, many organizations, especially the smaller hospitals and physician practices, often fail to keep up with the requirements and land into hefty fines for HIPAA violation. In some healthcare organizations, the staff does not understand who exactly is in charge of maintaining the compliance and in others they ignore the gaps in the procedures believing it to be a low-risk area. HIPAA violations can lead to major financial and reputation damage and this calls for identifying and analyzing the HIPAA compliance gaps and working towards closing them.
HIPAA Gap Analysis
The U.S. Department of Health and Human Services (HHS) defines a HIPAA gap analysis as “a narrowed examination of a covered entity or business associate’s enterprise to assess whether certain controls or safeguards required by the Security Rule have been implemented.” Gap analysis is crucial for hospitals, medical groups and other healthcare organizations that are obliged to comply with the privacy rules, to identify the safety gaps and risks. Also, this should be an ongoing process — evaluating the security gaps and taking corrective measures should be a part of the regular operations. The staff must be regularly reminded that each one of them must take up the responsibility of ensuring that the healthcare operations are HIPAA compliant.
The Need for Gap Analysis
As the world is adopting digital technologies at practically every step, there is an ever-increasing need for analyzing and closing the compliance gaps. The use of portable devices is rising and electronic health records and patient information are becoming more vulnerable than ever. The risk of the devices being stolen or the data being hacked is increasing and, adding to it, the hackers are upgrading their methods and technologies continuously. Several cases of data breach also owe to human errors, like an employee sharing security code with non-authorized personnel, a physician forgetting to lock his system, etc. HIPAA breaches often occur through minor mistakes and lead to major non-compliance issues.
Preparing for a HIPAA Gap Analysis
Recruiting your staff to perform the gap analysis is good only if they have a thorough understanding of the regulations and experience of gap assessment. Also, preparing a detailed and accurate report is essential for closing the gaps successfully. Alternately, you can also recruit a third party for the job, like a consulting firm. In short, gap analysis needs to be performed by experts that can notice and evaluate even the hard-to-detect issues. The taskalso requires arranging and organizing the essential materials pertaining to HIPAA regulations in your organization. This include:
- Policies and procedures of your organization that define how the health data is stored and disclosed
- Information on employee training and policies that indicates your staff is informed and updated on HIPAA regulations
- Copies of all the HIPAA and other state regulations for reference
- Detailed information on IT systems, repair logs and other relevant procedures that reveal what measures your organization is taking to protect health data
- Insurance policies that cover breaches under HIPAA compliance
Key Considerations for Gap Analysis and Closure
HIPAA gap analysis requires a thorough examination of all the policies and procedures and must address all the security issues. Preparing a comprehensive report is critical to fix the system for remaining compliant. It needs to highlight all the vulnerable points and recommend steps to reduce risk. The report should also mention the emergency response protocols that the staff must follow in case of data breach. Identifying the key personnel responsible for supervising the compliance activities is also important. The gap analysis must consider that data sharing is not restricted to a single department and examine all the channels of ePHI (Electronic Protected Health Information) access, along with data backup and recovery procedures. Following gap analysis, the organization needs to act on the following areas:
- Taking disciplinary actions against employees that intentionally or unintentionally facilitate data breach
- Implementing procedures and policies to strengthen security and close gaps
- Introducing review methods for evaluating the security systems on a regular basis
Maintaining full compliance with HIPAA might seem like an overwhelming task but a well-defined approach can help you achieve it. Also, the staff’s attitude towards HIPAA plays a major role, for which the organization needs to develop a culture that emphasizes the significance. Allocating resources and implementing strategies aren’t enough to avoid breaches; the organizations must also oversee if the entire system is working effectively towards compliance. Being alert and honest about the risks is an important step for keeping the health information safe. Healthcare organizations need to consider HIPAA gap analysis as an essential part of their operations to ensure that there are no risks gone unnoticed which might lead to breaches and penalties.