Carol Amick

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According to HHS, approximately 70% of organizations are not HIPAA compliant. HIPAA mandates industry-wide standards for healthcare information and electronic billing and requires protection as well as confidential handling of protected health information.

According to HIPAA rules, any company that deals with 

 must have a physical network and process security measures that are followed to ensure compliance. It may be safe to say that many organizations are still perplexed about HIPAA audits, enforcements, and compliance. As a result, the number of organizations that fail to meet compliance each year remain the majority.

To begin understanding compliance, healthcare organizations would be wise to consider three key recommendations.

1. Analyze the past to avoid making the same mistake twice

It is important for hospitals and healthcare facilities to look at some of the common mistakes that are repeatedly noted in 

 security reviews. HIPAA states that out of all the reviews completed, there are a number of frequent compliance violations and issues that are found each year. This includes impermissible uses and disclosures of protected health information, lack of safeguards to protect health information, lack of patient access to their personal health information, lack of administrative safeguards on electronic protected health information, and use or disclosure of more than the minimum protected health information. Protecting valuable data by analyzing past mistakes is an important step in the compliance process.

2. Perform a risk assessment and gap analysis

One preventative measure in assessing an organization’s compliance with HIPAA is a risk analysis and a gap analysis. The confusion and lack of understanding around the two examinations has been common among healthcare professionals in the marketplace for some time. Not understanding the differences can be detrimental to an organization, and puts them at a significantly higher risk. According to HHS and Office for Civil Rights (OCR) guidelines, all healthcare organizations must specifically conduct a risk analysis to be considered within HIPAA compliance.

A HIPAA gap analysis can be used to measure the organizations information security standing against HIPAA, which is part of HHS audit protocol. Comparing the organization’s current practices to the HHS OCR audit protocol will identify the strengths and weakness of the security program. From there, the organization can determine whether they have reasonable and appropriate administrative, physical, and technical 

 in place to protect patient health.  Performance of the gap analysis also allows the organization to develop an audit response toolkit which includes the data and documentation that would be able to support compliance with the HIPAA regulations to regulatory agencies.

The risk analysis is a required control as defined in audit protocol. Without conducting a thorough and comprehensive risk analysis, a healthcare organization cannot identify applicable threats and vulnerabilities that allow for them to take corrective action. Completing a thorough risk analysis provides insight into the organizations’ security position, and allows for change before an audit takes place. Risk analysis should also be updated at least annually to ensure they reflect current operational practices.

To begin, an organization should document any ePHI (electronic personal health information) transmitting or processing services. This includes any business associates or employees that receive and use the ePHI. It’s important to evaluate all aspects of the organization’s operation to verify all uses and disclosures of ePHI are identified. Don’t assume that your IT shop is aware of all of your uses and disclosures, inquire of all of the operational areas of your organization. 

The risk assessment should evaluate the security, use, and disclosure of PHI against HIPAA’s privacy, security, and breach notification implementation specifications.

3. Develop an action plan and a response toolkit

For many healthcare organizations, the question is not if they will receive a HIPAA audit or an OCR investigation, but when. The OCR, which is responsible for completing HIPAA audits, will contact the organization. The OCR will further ask for a variety of documents and data. Once these documents and data are reviewed, the OCR will send the organization a preliminary copy of its findings. This preliminary report gives healthcare organizations the opportunity to respond to the OCR, and have its responses included in the final report.

From the final report, the OCR will determine if an organization was in compliance of HIPAA and, if not, where an organization was lacking. If an organization was not in total compliance, the OCR will provide corrective action and technical assistance the organization can use to work toward compliance.

Developing an action plan and evaluating the organization’s information security against the OCR audit protocol to develop an audit response toolkit will leave organizations with practical actions that serve their best interest, eliminate mistakes, and mitigate risk.

Carol Amick is manager of healthcare services at 

, a leading provider of information security and risk management services. She is an experienced healthcare compliance professional with over 20 years of experience in healthcare. After starting her career at HCA she moved on to become a compliance consultant for a “Big 4” accounting firm and has since served as the internal audit director, compliance director and privacy officer for several healthcare companies. 

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Most organizations aren’t HIPAA compliant and don’t understand rules and don’t understand protected health information requirements. Here are three ways to change that.

Carol Amick

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