HIPAA regulations ensure that healthcare organizations are protecting electronic health records. It improves the efficiency and quality of the healthcare systems. However, it is also a burden for healthcare companies. They need to follow the HIPAA requirements for avoiding monetary penalties. A risk assessment will help you in ensuring compliance. However, incomplete or erroneous risk analysis can leave loopholes in your security systems. This can lead to a security breach. Risk assessments are challenging for companies that don’t have access to in-house IT experts. Most healthcare organizations don’t have access to the necessary resources for conducting a risk assessment. In this article, we are going to share a guide that will help you in conducting a HIPAA Risk assessment in 2022. This will help you in ensuring that you can protect your Electronic health records.
What is a HIPAA Risk assessment?
If your organization is creating or maintaining public health information, then you need to take measures for protecting this data. You need to identify security risks. This will help you in implementing safeguards for maintaining compliance with the HIPAA. It will help you in ensuring that you are following the HIPAA standards.
HIPAA risk assessment will help you in evaluating the security threats to your organization’s electronic health records. If you are not addressing these security threats, then it will lead to a violation of HIPAA.
The risk assessment will contain instructions that you can follow for satisfying a certain standard. Some of these instructions will be required for your organization. The risk assessment will help you in finding security loopholes in your IT plan. This will help you improve your IT security. It will help you in implementing new security controls and tools.
How to Conduct a HIPAA Risk assessment?
There are various methods that you can use for performing HIPAA risk assessment. Every method has its own importance. There is no best practice or single method that you can follow for ensuring compliance. You have to ensure that the method that you are following is aligning with HIPAA security compliance. A good example of this is NIST SP 800-30. You can follow this process for ensuring that you are following NIST compliance. Some of the main steps that you can follow for conducting a HIPAA risk assessment are:
Define key concepts
The starting steps will help you in setting the tone of the entire assessment. This step will identify the types of assets that your organization is using for creating and storing ePHI. Examples will include devices like smartphones and storage devices. It will also include email as you will use email for transmitting electronic health records.
The first step is to find all the devices that you are using for storing or transmitting these records. After that, you need to find out who has access to these records. The data collected in this step will help you in establishing areas of impact. It will help you in documenting the flow of these records in your organization.
HIPAA security rule simply means that you need to protect your ePHI. Thus, you need to implement security controls for protecting this data. You can’t implement these security controls until you determine the weakness in your security network. If you want to check the strength of your security controls, then you first need to define vulnerabilities and threats.
You need to understand the technical, physical, and administrative safeguards required by HIPAA compliance. The assessor might need to talk with IT teams for checking the deployment of security controls and safeguards. This step is very important as it will help you in understanding your current IT security level.
You need to protect your organization from technical threats like phishing, Trojan, computer theft, insider threat, and ransomware. Your employees might be using weak passwords which can lead to a data breach. Lack of encryption is another common problem. Malware protection is important as it will help you in protecting your systems from ransomware. Unpatched systems can be a big problem for your business. Thus, you should ensure that all your systems are updated. These are some common technical threats that you should assess.
You also need to check the physical security of your organization. This will include things like checking security cameras, building access controls, alarms, bollards, security guards, and access badges. Make sure that your physical facility is secure.
It is important to protect your employees from social engineering attacks like phishing and vishing. You can conduct security training programs for training your employees. This will ensure that your employees can identify phishing emails.
Your organization should be ready for disasters also. Disaster events like cyberattacks, earthquakes, tornados, floods, and hurricanes can affect your compliance. You have to ensure that you can maintain continuity during these disasters.
Customize the risk assessment plan according to your organization
Every organization will have its own needs. Two organizations operating in the same industry can have completely different needs. The needs will differ according to the business model, infrastructure, and size of your organization. HIPAA risk assessment can be customized according to your organization’s needs. You can customize the plan according to the capabilities, complexity, and size of your facility. The plan will also depend on your IT security capabilities and infrastructure. You need to consider the criticality and probability of security risks. Also, you need to measure the cost of current security measures.
Conduct an initial HIPAA risk assessment
This step is very important for your organization. It will help you in identifying all threats that can affect the availability, integrity, and confidentiality of your health records. In this step, you need to identify the vulnerable areas in your organization. These vulnerable areas can be exploited by insider threats, cyber actors, natural events, and user error.
You need to first identify all the threats. This will help you in creating a risk management strategy for your organization. You can use this strategy for addressing the vulnerable areas in your organization.
Check current security controls and measures
You need to check your current security controls also. Make sure that you have documented all your current security measures. You can do this by checking all the security measures that you are using. It should include both physical controls like security desk, physical locks, policies, and technical controls like encryption and access controls.
This will help you in gaining a complete picture of your current security controls. You have already identified the vulnerable areas in your organization. The next step is to check if your current security controls can help you in dealing with these threats. If your current security measures are sufficient, then you don’t need to implement new security controls. However, you will mostly find that your current security controls are not good enough. Thus, you will need to upgrade your current IT security infrastructure.
Determine all the risks
According to IT security experts, the risk is considered to be a combination of the impact of a threat and the possibility of that threat. If some threat is very harmful but its probability is very low, then you can’t consider it is very risky as it is very hard to execute it. For example, it is impossible to protect your business from zero-day attacks. However, the possibility of a zero-day attack is also very low. Thus, most organizations don’t focus too much on protecting their organization from these attacks. The impact of phishing attacks is considered to be moderate but its probability is very high. Thus, every organization will try to deal with this attack.
You should start by assigning the probability of every threat occurring. This can be done by using the environmental factors and checking historical data. You can also check other security reports for finding this data.
It is important to give a risk score to every risk. This can be done by attaching a numeric value to every risk. It can range from 0 to 5 where 0 simply means that it is very rare and 5 means it is very common. You also need to determine the impact of every vulnerability and threat. Make sure that you are attaching numerical values to impact also.
You can calculate the risk score by multiplying the impact score with the probability score. This risk score will help you in assigning risk levels to every threat. You can create a risk matrix by using this data. Most organizations are using this risk matrix for creating their IT security plan.
Develop control recommendations
You should understand the threat scenario. A threat scenario is going to be the foundation of every risk assessment. The concept of a threat scenario comes when a threat agent is trying to exploit a vulnerability in your system. An example of this will be organizations that are allowing their employees to use weak passwords for accessing PHI.
An attacker can steal passwords from your employees. They can use simple brute force attacks for opening their accounts. Attackers will get access to all your patient data. This will lead to a huge data breach.
You can decrease the impact of these threat scenarios by implementing proper security controls. Sometimes your ex-employees can have access to your important records. It is important to ensure that you are terminating access to these systems. This can help you in decreasing the impact of these attacks.
You should focus on decreasing the privacy and time available to threat sources. Attackers can send phishing emails to your employees. Your employees might click on this link. However, the link won’t work if you have already installed the anti-virus software in your employee’s system. It will automatically alert the IT team. This will help you in reducing the impact of your attacks. Implementing good security controls will help you in improving the effectiveness of your business continuity plan.
Document your findings
The documentation is going to be the final step of your HIPAA risk assessment. Make sure that you have clearly mentioned where you are storing PHI data and who has access to them. You should also mention the vulnerabilities and threats that are present in your network. It is important to ensure that you are mitigating the identified vulnerabilities and threats. Documentation is critical for your organization. It will help you in ensuring that you are ready for HIPAA compliance audits. Regular security audits will help you in improving your data security. It will ensure that your healthcare data is protected from cyber-attacks.
A risk assessment will help you in safeguarding your physical health information. It will ensure that you are complying with the HIPAA security rule. The main aim of HIPAA is to ensure that organizations are protecting physical health records. A good risk assessment will help you in identifying risks. It will also help you in documenting the mitigation efforts. If you are not following the HIPAA guidelines, then it can lead to huge penalties. HIPAA is a very strict organization. Thus, you should ensure that you are trying your best to follow the HIPAA guidelines.
Regular risk assessments will help you in addressing vulnerabilities and threats. It will help you in protecting your organization from penalties and fines. Sometimes it can even lead to jail time. You should also know that risk assessment is not a one-time process. If you want to protect your organization, then you need to regularly conduct risk assessments. You should perform it twice every year. If you are doing some major change in your organization, then you should conduct it again.
Risk assessments are not a small task for organizations. This is very tough if you don’t have proper control over your IT and technical infrastructure. Experienced MSPs like Bleuwire can help you in solving this problem. They will help you in ensuring compliance and security. Bleuwire has worked with hundreds of organizations. You don’t need to worry about conducting any security assessment. Bleuwire will help you in conducting risk assessments and updating your security plan. They will create a good IT security plan for your organization. If you need more information regarding IT security risks, then you can contact Bleuwire.