HIPAA Compliance Refresh: A Thorough & Accurate Risk Assessment

Submitted by Justin Kelm, President, JK Technology Solutions

Complying with HIPAA data privacy and protection regulations would be easy if installing a predefined list of security solutions is all that is required. HIPAA Compliance goes way beyond this and for good reason. In principle, regulators, local or international, want practices to:

  • assess the type of data they store and manage
  • gauge the potential risks the data is exposed to
  • list down the remediation efforts needed to mitigate the risks
  • undertake necessary remediation efforts regularly
  • and most importantly, document every single step of this seemingly arduous process as evidence

Each of the above steps are mandatory and non-negotiable. A closer look will tell you that installing a list of extensive security solutions comes only after the first three steps in the process have been followed. Skipping past these initial steps and acting merely on presumptuous knowledge is tantamount to leaving your practices’ future to sheer chance.

A summary of the HIPAA Security Rule specifically covers the importance of Risk Assessments in maintaining HIPAA Compliance.

https://www.hhs.gov/hipaa/for-professionals/security/laws-regulations/index.html

“Risk Analysis and Management”

“The Administrative Safeguards provisions in the Security Rule require covered entities to perform risk analysis as part of their security management processes.”

“Risk analysis should be an ongoing process, in which a covered entity regularly reviews its records to track access to e-PHI and detect security incidents, periodically evaluates the effectiveness of security measures put in place, and regularly reevaluates potential risks to e-PHI.”

Security Risk Assessments Unearth Crucial Insights

A risk assessment is truly the best place to start in your journey to achieve and maintain compliance. How can you possibly know what your most critical security risks and vulnerabilities are without a thorough and accurate examination of where you stand right now?

A thorough and accurate risk assessment is the first step towards achieving compliance. It can unearth a host of crucial insights from even the deepest and darkest alleys of your IT environment to ultimately empower your decision making. Having actionable insights at your disposal can help you build strategies to reduce risk levels in practical ways instead of shooting in the dark by testing various tools.

When repeated regularly, it can help you demonstrate continuous HIPAA compliance while keeping cyberthreats at bay.

Here are some of the most important details that become more apparent and unambiguous with every risk assessment.

Baseline of the System

A risk assessment helps you chart out the lifecycle of all data that is collected, stored, and managed in your entire network.

Identification of Threats

A meticulous risk assessment identifies all the possible threats, such as intentional, unintentional, technical, non-technical and structural, that your business data is exposed to.

Identification of Vulnerabilities

With each assessment, you get the latest list of vulnerabilities prevalent in your network with respect to patches, policies, procedures, software, equipment and more.

Current Status of Existing Controls

From the assessment report, you can also understand the existing security and privacy controls protecting your business against vulnerabilities.

Probability of Impact

An accurate assessment report is fully capable of anticipating the probability of a threat that might exploit one of your network’s existing vulnerabilities.

Strength of Impact

Risk assessment also helps you gauge the possible impact of any threat hitting your business.

Why Risk Assessment Is Needed for Compliance

While assessing whether you did everything in your capacity to ensure full compliance with the regulations, you also need to keep in mind that a regulator seeks evidence of compliance – documented reports. Besides helping you chart a successful path to compliance a thorough risk assessment adds great weight to demonstrating evidence of compliance. When you present the risk assessment reports along with other documentation, you demonstrate how your business carried out due diligence in upholding principles of data privacy and protection.

Please remember that no regulator expects you to have a fail-safe strategy. What matters is uncompromising intent, informed action, and undeterred consistency. If you can demonstrate all this, you will most likely avoid any punitive action as well as a long list of problems that could surface afterwards.

Help Is Just a Conversation Away

 

Contrary to what is often claimed, there are no shortcuts to compliance or to any of the steps that lead to it. At the outset, achieving compliance might seem grueling. However, it isn’t as bad as it seems when due process and expert guidance is followed.

Browse a summary of the HIPAA Security Rule here.