What Guidance and Tools Can Help HIPAA Entities Conduct Its Risk Analysis

The HIPAA Risk analysis is an essential part of HIPAA compliance, however plenty of healthcare companies and business associates fail at it. Hence they are prone to paying for pricey data breaches and big financial fines for HIPAA noncompliance.

HIPAA Risk Analysis – What is it?

As per 45 C.F.R. § 164.308(u)(1)(ii)(A), the HIPAA Security Rule’s administrative controls demand that all HIPAA-covered entities must perform an exact and complete assessment of the potential risks and vulnerabilities to electronic protected health information (ePHI) integrity, confidentiality, and availability.

The risk analysis is a needed element of HIPAA compliance and it should be the initial step when applying safety measures that are in accordance with the standards and prerequisites of the HIPAA Security Rule. The lack of a comprehensive risk analysis would mean that an organization’s risk management team wouldn’t be able to address the risks – § 164.308(u)(1)(ii)(B) to reduce them to an acceptable degree that follow the General Security standards – § 164.306 (a).

A HIPAA risk analysis is also needed to determine whether the use of encryption or alternative safeguards will suffice – See 45 C.F.R. §§ 164.312(a)(2)(iv) and (e)(2)(ii).

A risk analysis acts as a guide that organizations can use to authenticate requirements – 45 C.F.R. § 164.312(c)(2) – and to know the strategies for safeguarding ePHI in transit – 45 C.F.R. § 164.312(c)(2).

Letting risks continue to be gives cyber criminals and malicious actors a way to take advantage of and bring about ePHI impermissible disclosure.

When investigating data breaches, the Department of Health and Human Services’ Office for Civil Rights determines if the entity was unable to abide by the HIPAA Rules thereby causing the breach. One violation frequently identified by OCR is the inability of the entity to conduct a comprehensive risk analysis. It is a primary reason why OCR issues a financial fine.

HIPAA Risk Analysis – What are the Requirements?

A HIPAA risk analysis is mandatory for HIPAA compliance, yet there isn’t any thorough explanation about the requirements or methods to follow in doing a risk analysis. That’s because there is no single method of risk analysis that will suit all entities. No specific best practices will similarly assure conformity to the HIPAA Security Rule.

The prerequisites of a HIPAA risk analysis are specified on the HHS site. HHS issued a guidance on the requirements of the HIPAA Security Rule risk analysis, which is available here.  More details in the NIST Risk Management Guide for Information Technology Systems is likewise accessible here.

A Security Risk Assessment Tool to Help With the HIPAA Risk Analysis

The risk analysis procedure is a challenging task. To make it simpler, the HHS’ Office of the National Coordinator for Health Information Technology (ONC), in synergy with the Office for Civil Rights, has produced a security risk assessment tool to help HIPAA-covered entities carry out a security risk assessment.

The tool has to be downloaded and set up. Then, healthcare companies could enter data to create a report that gives these details: the risks in policies, operations and systems; and information on the techniques to be used for decreasing weak points when the entity is conducting a risk assessment.

The tool was upgraded to version 3.0 on October 15, 2018, making it simpler to use and more appropriate to the risks of the health data’s integrity, confidentiality, and availability. The tool describes HIPAA Security Rule safety steps that would provide improved performance; the records of how the company uses the safety measures to counteract known risks.

The new functions of the upgraded tool contain better user interface, customized assessment logic, a modular workflow, threat and vulnerability scores, a development tracker, in depth reports, monitoring report, business associate, and many enhancements to improve the user experience.)

Making use of the tool is not an assurance that the organization is in compliance with the HIPAA, state, local or federal regulations. Nevertheless, the tool is highly beneficial for leading HIPAA-covered entities and business associates performing a HIPAA-compliant risk analysis. You can pick up the current Security Risk Assessment Tool from the HealthIT.gov website.