This document lists certain HIPAA requirements that are likely to be relevant in a research context. This document is not complete and is intended only to highlight the big picture of HIPAA compliance. This documents is based on the ‘HIPAA Checklist’ at this url: http://www.hipaajournal.com/hipaa-compliance-checklist/
The Technical Safeguards concern the technology that is used to protect electronic Protected Health Information (ePHI) and provide access to the data. The only stipulation is that ePHI – whether at rest or in transit – must be encrypted to NIST standards once it travels beyond an organization´s internal firewalled servers. 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:
- Implement a means of access control (required) – This not only means assigning a centrally-controlled unique username and PIN code for each user, but also establishing procedures to govern the release or disclosure of ePHI during an emergency.
- Implement tools for encryption and decryption (addressable) – This guideline relates to the devices used by authorized users, which must have the functionality to encrypt messages when they are sent beyond an internal firewalled server, and decrypt those messages when they are received.
- Introduce activity audit controls (required) – The audit controls required under the technical safeguards are there to register attempted access to ePHI and record what is done with that data once it has been accessed.
- Facilitate automatic logoff (addressable) – This function – although only addressable – logs authorized personnel off of the device they are using to access or communicate ePHI after a pre-defined period of time. This prevents unauthorized access of ePHI should the device be left unattended.
The Physical Safeguards focus on physical access to ePHI irrespective of its location. ePHI could be stored in a remote data center, in the cloud, or on servers which are located within the premises of the HIPAA covered entity. They also stipulate how workstations and mobile devices should be secured against unauthorized access:
- Facility access controls must be implemented (addressable) – Procedures have to be introduced to record any person who has physical access to the location where ePHI is stored. This includes software engineers, cleaners and even a handyman coming to change a light bulb. The procedures must also include safeguards to prevent unauthorized physical access, tampering, and theft.
- Policies relating to workstation use (required) – Policies must be devised and implemented to restrict the use of workstations that have access to ePHI, to specify the protective surrounding of a workstation (so that the screen of a workstation cannot be overlooked from an unrestricted area) and govern how functions are to be performed on the workstations.
- Policies and procedures for mobile devices (required) – If mobile devices are to be allowed access to ePHI, policies must be devised and implemented to govern how ePHI is removed from the device before it is re-used.
- Inventory of hardware (addressable) – An inventory of all hardware must be maintained, together with a record of the movements of each item. A retrievable exact copy of ePHI must be made before any equipment is moved.
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.
The OCR pilot audits identified risk assessments as the major area of Security Rule non-compliance. Risk assessments are going to be checked thoroughly in the second phase of the audits; not just to make sure that the organization in question has conducted one, but to ensure to ensure they are comprehensive and ongoing. A risk assessment is not a one-time requirement, but a regular task necessary to ensure continued compliance.
The administrative safeguards include:
- Conducting risk assessments (required) – Among the Security Officer´s main tasks is the compilation of a risk assessment to identify every area in which ePHI is being used, and to determine all of the ways in which breaches of ePHI could occur.
- Introducing a risk management policy (required) – The risk assessment must be repeated at regular intervals with measures introduced to reduce the risks to an appropriate level. A sanctions policy for employees who fail to comply with HIPAA regulations must also be introduced.
- Training employees to be secure (addressable) – Training schedules must be introduced to raise awareness of the policies and procedures governing access to ePHI and how to identify malicious software attacks and malware. All training must be documented.
- Restricting third-party access (required) – It is the role of the Security Officer to ensure that ePHI is not accessed by unauthorized parent organizations and subcontractors, and that Business Associate Agreements are signed with business partners who will have access to ePHI.
- Reporting security incidents (addressable) – The reporting of security incidents is different from the Breach Notification Rule (below) inasmuch as incidents can be contained and data retrieved before the incident develops into a breach. Nonetheless, all employees should be aware of how and when to report an incident in order that action can be taken to prevent a breach whenever possible.
The difference between the “required” safeguards and the “addressable” safeguards on the HIPAA compliance checklist is that “required” safeguards must be implemented whereas there is a certain amount of flexibility with “addressable” safeguards. If it is not reasonable to implement an “addressable” safeguard as it appears on the HIPAA compliance checklist, covered entities have the option of introducing an appropriate alternative, or not introducing the safeguard at all.
That decision will depend on factors such as the entity’s risk analysis, risk mitigation strategy and what other security measures are already in place. 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.