HIPAA Compliance: A Simple Guide

TL;DR

This guide helps you understand and achieve HIPAA compliance. It covers key areas like risk assessment, policies & procedures, training, security measures (technical, physical, administrative), breach notification, and ongoing monitoring.

1. Understand HIPAA Basics

HIPAA stands for the Health Insurance Portability and Accountability Act. It protects sensitive patient health information (PHI). There are three main rules:

• Privacy Rule: Sets limits on how PHI can be used and disclosed.
• Security Rule: Protects electronic PHI (ePHI).
• Breach Notification Rule: Requires notification following a breach of unsecured PHI.

You need to know which parts apply to your organisation.

2. Risk Assessment

1. Identify PHI: What patient data do you handle? (e.g., names, dates of birth, medical records).
2. Threats & Vulnerabilities: What could harm that data? (e.g., hacking, malware, accidental loss).
3. Impact Analysis: How bad would a breach be?
4. Document Everything: Keep a record of your assessment. There are tools available to help with this; searching for ‘HIPAA risk assessment template’ will find several options.

3. Policies & Procedures

Write down how you’ll protect PHI. These should be clear and easy to follow.

• Access Control: Who can see what data?
• Data Backup & Recovery: How will you restore data if something goes wrong?
• Incident Response: What do you do in case of a breach?
• Sanction Policy: Consequences for violating policies.

Example snippet (Access Control):

Policy: Access to patient records is limited to authorised personnel only, based on the principle of least privilege. Requests for access must be submitted in writing and approved by the Privacy Officer.

4. Employee Training

1. Initial Training: All staff handling PHI need training when they start.
2. Regular Updates: HIPAA rules change; update training annually or as needed.
3. Topics: Privacy Rule, Security Rule, Breach Notification Rule, your organisation’s policies.
4. Record Keeping: Document who was trained and when.

5. Technical Safeguards

Protect ePHI with technology.

• Encryption: Protect data at rest and in transit (e.g., using HTTPS for websites).
• Firewalls: Block unauthorised access to your network.
• Antivirus/Malware Protection: Keep systems clean.
• Access Controls: Use strong passwords, multi-factor authentication.
• Audit Logs: Track who accesses ePHI and when.

Example (Firewall rule):

iptables -A INPUT -p tcp --dport 80 -j ACCEPT # Allow HTTP traffic

6. Physical Safeguards

• Facility Access Controls: Limit physical access to areas where PHI is stored.
• Workstation Security: Secure computers and devices.
• Device & Media Controls: Manage hardware securely (e.g., secure disposal of old hard drives).

7. Administrative Safeguards

• Security Officer: Person responsible for cyber security.
• Privacy Officer: Person responsible for privacy compliance.
• Business Associate Agreements (BAAs): If you share PHI with third parties, have a BAA in place.

8. Breach Notification

1. Identify Breaches: Know what constitutes a breach.
2. Risk Assessment: Determine the risk level of the breach.
3. Notification Requirements: Notify affected individuals, HHS (Department of Health and Human Services), and potentially the media depending on the size of the breach.

9. Ongoing Monitoring & Updates

• Regular Audits: Check if you’re following your policies.
• Vulnerability Scanning: Identify weaknesses in your systems.
• Stay Informed: Keep up with changes to HIPAA rules and best practices.