Hipaa compliance what does it mean

These physical safeguards include…. Access control includes…. Other technical policies for HIPAA compliance need to cover integrity controls, or measures put in place to confirm that ePHI is not altered or destroyed.

IT disaster recovery and offsite backup are key components that ensure that electronic media errors and failures are quickly remedied so that patient health information is recovered accurately and intact. This safeguard addresses all methods of data transmission, including email, internet, or private networks, such as a private cloud. The HITECH Act was put into place due to the development of health technology and the increased use, storage, and transmission of electronic health information.

The need for data security has grown with the increase in the use and sharing of electronic patient data. Today, high-quality care requires healthcare organizations to meet this accelerated demand for data while complying with HIPAA regulations and protecting PHI.

Having a data protection strategy in place allows healthcare organizations to:. The best data protection solutions recognize and protect patient data in all forms, including structured and unstructured data , emails, documents, and scans, while allowing healthcare providers to share data securely to ensure the best possible patient care. Patients entrust their data to healthcare organizations, and it is the duty of these organizations to take care of their protected health information.

To learn more about best practices for healthcare data protection, read our guide to healthcare cybersecurity. Healthcare is, almost undoubtedly, set to change the most over the next several years. Maintaining privacy compliance is also more difficult. Factors increasing the risk of private health information include:. OCR is exercising its enforcement discretion to not impose penalties for noncompliance with the HIPAA Rules in connection with the good faith provision of telehealth using such non-public facing audio or video communication products during the COVID nationwide public health emergency.

This exercise of discretion applies to telehealth provided for any reason, regardless of whether the telehealth service is related to the diagnosis and treatment of health conditions related to COVID Make sure to follow these updates from those who monitor and enforce HIPAA compliance in order to ensure the safest environment.

There are exceptions. Most health care providers employed by a hospital are not Covered Entities. Employers — despite maintaining health care information about their employees — are not generally Covered Entities unless they provide self-insured health cover or benefits such as an Employee Assistance Program EAP. A Business Associate is a person or business that provides a service to — or performs a certain function or activity for — a Covered Entity when that service, function or activity involves the Business Associate having access to PHI maintained by the Covered Entity.

Examples of Business Associates include lawyers, accountants, IT contractors, billing companies, cloud storage services, email encryption services, etc. Before having access to PHI, the Business Associate must sign a Business Associate Agreement with the Covered Entity stating what PHI they can access, how it is to be used, and that it will be returned or destroyed once the task it is needed for is completed. All risk assessments, HIPAA-related policies and reasons why addressable safeguards have not been implemented must be chronicled in case a breach of PHI occurs and an investigation takes place to establish how the breach happened.

Business unsure of their obligation to comply with the HIPAA requirements should seek professional advice. The rule applies to anybody or any system that has access to confidential patient data. The Technical Safeguards concern the technology that is used to protect ePHI and provide access to the data.

This is so that any breach of confidential patient data renders the data unreadable, undecipherable and unusable. Thereafter organizations are free to select whichever mechanisms are most appropriate to:. They also stipulate how workstations and mobile devices should be secured against unauthorized access:. The Administrative Safeguards are the policies and procedures which bring the Privacy Rule and the Security Rule together. They are the pivotal elements of a HIPAA compliance checklist and require that a Security Officer and a Privacy Officer be assigned to put the measures in place to protect ePHI, while they also govern the conduct of the workforce.

Risk assessments are going to be checked thoroughly in subsequent audit phases; not just to make sure that the organization in question has conducted one, but to ensure to ensure they are comprehensive and ongoing. The decision must be documented in writing and include the factors that were considered, as well as the results of the risk assessment, on which the decision was based.

In force since , the Privacy Rule applies to all healthcare organizations, the providers of health plans including employers , healthcare clearinghouses and — from — the Business Associates of covered entities. The Privacy Rule demands that appropriate safeguards are implemented to protect the privacy of Personal Health Information. It also sets limits and conditions on the use and disclosure of that information without patient authorization.

The Rule also gives patients — or their nominated representatives — rights over their health information; including the right to obtain a copy of their health records — or examine them — and the ability to request corrections if necessary.

Under the Privacy Rule, Covered Entities are required to respond to patient access requests within 30 days. Notices of Privacy Practices NPPs must also be issued to advise patients and plan members of the circumstances under which their data will be used or shared.

Covered Entities should make sure their patient authorization forms have been updated to include the disclosure of immunization records to schools, include the option for patients to restrict disclosure of PHI to a health plan when they have paid for a procedure privately , and also the option of providing an electronic copy of healthcare records to a patient when requested.

The Breach Notification Rule also requires entities to promptly notify the Department of Health and Human Services of such a breach of PHI and issue a notice to the media if the breach affects more than five hundred patients.

There is also a requirement to report smaller breaches — those affecting fewer than individuals — via the OCR web portal. These smaller breach reports should ideally be made once the initial investigation has been conducted. The OCR only requires these reports to be made annually. Breach notifications must be made without unreasonable delay and in no case later than 60 days following the discovery of a breach. When notifying a patient of a breach, the Covered Entity must inform the individual of the steps they should take to protect themselves from potential harm, include a brief description of what the covered entity is doing to investigate the breach, and the actions taken so far to prevent further breaches and security incidents.

It amended definitions, clarified procedures and policies, and expanded the HIPAA compliance checklist to cover Business Associates and their subcontractors. Business Associates are classed as any individual or organization that creates, receives, maintains or transmits Protected Health Information in the course of performing functions on behalf of a Covered Entity.

The term Business Associate also includes contractors, consultants, data storage companies, health information organizations, and any subcontractors engaged by Business Associates.

Definition changes were also made to the term Business Associate, the term Workforce was amended to include employees, volunteers, and trainees, and the nature of Personally Identifiable Information that is classified as PHI was updated. Although not part of a HIPAA compliance checklist, covered entities should be aware of the following penalties:. Fines are imposed per violation category and reflect the number of records exposed in a breach, the risk posed by the exposure of that data, and the level of negligence involved.

It should also be noted that penalties for willful neglect can also lead to criminal charges being filed. Civil lawsuits for damages can also be filed by victims of a breach. The organizations most commonly subject to enforcement action are private medical practices solo doctors or dentists, group practices, and so on , hospitals, outpatient facilities such as pain clinics or rehabilitation centers, insurance groups, and pharmacies. The most common disclosures to the HHS are:.

The HIPAA risk assessment and an analysis of its findings will help organizations to comply with many other areas on our HIPAA compliance checklist, and should be reviewed regularly when changes to the workforce, work practices, or technology occur. Depending on the size, capability, and complexity of a Covered Entity, compiling a fully comprehensive HIPAA risk assessment can be an extremely long-winded task. The vast majority of ePHI breaches result from the loss or theft of mobile devices containing unencrypted data and the transmission of unsecured ePHI across open networks.

Breaches of this nature are easily avoidable if all ePHI is encrypted. Remember that the Privacy rule protects individual PHI by governing the practice of all covered entities, from doctors and nurses to lawyers and insurance providers. HIPAA defines these individuals and organizations as covered entities:.

The third action item in your HIPAA compliance checklist is knowing what types of patient data you need to protect and begin putting the right security and privacy measures in place. This can be in any form of media, from paper and electronic to verbal communications. This typically includes — but is not exclusively limited to — the following kinds of patient data:.

The most common type of violation is actually internal, and not the result of any outsider hack or data breach. Typically, violations stem from negligence or only partial compliance with the Privacy Rule. A workstation left unlocked or paper file misplaced in a public setting — although not malicious — are the types of violations to be most on guard for. Not properly configuring software like Office for HIPAA compliance is another great example of a non-intentional violation.

Which violations that your company is most at risk for depends on the nature of your business and relationship with patients and their data. How and when you need to notify customers depends on the nature of the breach. A minor or smaller breach is one that affects fewer than individuals within a single jurisdiction. Affected individuals must also be notified within 60 days of then when the breach took place. On the other hand, a meaningful breach is one that affects over people within a given jurisdiction.

You should also be ready to notify affected parties upon immediate discovery of the breach. Moreover, meaningful breaches need to be reported to local law enforcement agencies immediately.

You will also need to coordinate with local media agencies and organizations as a part of notifying affected parties. While meaningful breaches are rare, part of your HIPAA compliance journey is making sure you have all the resources in place in case such a breach does occur. But you need to be aware of the penalties that do exist, how they function,K and the potentially negative consequences.