Understanding and Managing the HIPAA Security Rule

Protecting the privacy of patients is of paramount concern to healthcare organizations today. Data breaches and/or hacking attempts are happening more frequently. Regulatory requirements are constantly changing. And the pace of technology innovations keeps increasing. The penalties, both financial and reputational, can be disastrous for any organization — and its compliance team — that is not prepared and in the know at all times

For example, recently a healthcare institution mailed hundreds of patient statements, containing names, account numbers and payments due, to wrong addresses. The organization believed that, for most of these statements, this was not a reportable breach, because there was no patient diagnosis, treatment information, or other medical information listed.

This was not correct. And the failure to understand the rule and its nuances resulted in a $2 million settlement.

The HIPAA Security Rule is the hedge against that kind of disaster  —  so grasping its complexity is crucial.

The regulations that comprise the Security Rule are often the most difficult to understand and implement, as every security compliance measure must be carefully monitored and reported. Not only are all healthcare organizations required to meet the standards and legal requirements in the Security Rule, there can also be implementation specifications which include provide detailed instructions and steps needed for compliance.

From an administrative perspective, HIPAA requires a documented framework of policies and procedures. These policies and procedures detail exactly what your organization does to protect key information. For example, policies can outline the requirements for training for all employees, including those who do and do not have direct access to vital patient information.

The documents that outline the policy and procedure framework must be retained for at least six years (although state requirements may mandate longer retention periods). As policies change, so must your accompanying documentation. And to further ensure your compliance, periodic reviews of policies and responses to changes in the electronic patient health information environment are also recommended.

From a security perspective, HIPAA requires a comprehensive evaluation of the security risks your organization faces, as well as the electronic health record technologies your organization uses.  This includes a combination of physical safeguards — such as IT infrastructure, computer systems and security monitoring systems — and technical safeguards — such as risk management software, healthcare management software or regulatory software. These safeguards are designed to both protect patient information and control access to it.

Fortunately, the Security Rule allows for scalability, flexibility and generalization. This means that smaller organizations are given greater latitude in comparison to larger organizations that have significantly more resources. HIPAA’s security requirements are also not linked to specific technologies or products, since both can change rapidly. Instead, requirements focus more on what needs to be done and when, and less on how it should be accomplished.

Managing the complexity of the HIPAA Security Rule can be easier. At youCompli, we help you identify, document and monitor your critical HIPAA information. We understand the time and resource constraints that compliance officers operate under — the need for quickly collecting and accessing quality data and reporting it. Our solutions enable you to remain up-to-date with healthcare regulations — what they mean and how to implement them with precision accuracy in cost-efficient and effective ways. Contact us for more information on how to approach and implement the Security Rule and remain in compliance.

Legal Challenges and the Benefit of a Comprehensive Compliance Program

The list of compliance and legal challenges facing providers, hospitals and healthcare systems over the next year is long:

  • Physician arrangements and fair market value;
  • Mergers and acquisitions;
  • Quality metrics and risk sharing;
  • Fraud, waste, and abuse;
  • Coding and billing transactions;
  • Reimbursement;
  • Medical staff issues and burnout;
  • Labor and employment issues;
  • HIPAA and HITECH; and
  • Technology and integrated medical devices.

A list like this can seem daunting. However, a comprehensive compliance program with appropriate resources can help avoid disastrous results related to healthcare compliance and legal challenges.

Labor and Employment Law

The Atlantic reported in January 2018, “Health Care Just Became the U.S.’s Largest Employer In the American labor market.”  The growth of the healthcare sector brings increased labor and employment challenges.  Although the terms are often used synonymously, labor law focuses on groups of workers (think unions and collective bargaining) while employment law focuses on individual workers, (think discrimination of an individual in a protected class).

A comprehensive compliance program will decrease labor and employment law challenges, by ensuring human resource policies and procedures comply with federal and state laws.  Moreover, personnel file audits will demonstrate compliance with those laws.

Transactional Law

Mergers, acquisitions, partnerships, joint ventures and U.S. antitrust law

The Agency for Healthcare Research and Quality (AHRQ) reported in its 2018 National Healthcare Quality & Disparities Report that almost 70% of U.S. hospitals and 43% of primary care physicians are part of consolidated health care systems. Consolidations require an astute compliance and legal team to ensure compliance with antitrust law. These transactions continue to draw scrutiny from the Federal Trade Commission due to monopoly concerns.

The challenge for healthcare organizations is even greater when business crosses state lines. The organization must then comply with multiple state laws simultaneously.  As part of a comprehensive compliance program, a compliance professional should work closely with in-house or outside counsel to ensure the business transactions and consolidations include a compliance due diligence perspective, for example reports to the board of directors.

Security Law

HIPAA

Compliance is mandatory; failure to comply is an opportunity to ruin an organization both financially and reputationally.  Ransomware attacks on healthcare providers through their computers and medical devices are on the rise. While most IT departments focus on HIPAA security for computers, few address security issues with interconnected medical devices.

A comprehensive compliance program will include recommendations to address the management of cybersecurity for medical devices like those outlined by the U.S. Food and Drug Administration (FDA).

Practice Tips

  1. Use of reports to support legal defense of employment or labor law violations, if needed.
  2. Use of notification and management system to prevent legal challenges by providing up-to-date guidance to support compliance activities.
  3. Conduct an evaluation of medical devices in accordance with the FDA FAQ. Disable the voice recognition feature of smart devices while conducting confidential discussions in a room with a smart TV or speaker.

A system such as youCompli is a strong addition to a comprehensive compliance program, providing up to date notifications of regulatory change, as well as full insight and audit of the compliance process.

Denise Atwood, RN, JD, CPHRM
District Medical Group (DMG), Inc., Chief Risk Officer and owner of Denise Atwood, PLLC
Disclaimer: The opinions expressed in this article or blog are the author’s and do not represent the opinions of DMG.

Denise Atwood, RN, JD, CPHRM has over 30 years of healthcare experience in compliance, risk management, quality, and clinical areas. She is also a published author and educator on risk, compliance, medical-legal and ethics issues. She is currently the Chief Risk Officer and Associate General Counsel at a nonprofit, multispecialty provider group in Phoenix, Arizona and Vice President of the company’s self-insurance captive.  

Privacy vs. Transparency: You’re in the Middle

Since 1996, HIPAA has required hospitals and other providers to strictly maintain the privacy and security of patient and clinical records.

In 2010, the Affordable Care Act (Obamacare) required them to digitize those records for greater transparency.

Today, some 96% of hospitals and 78% of doctors’ offices use electronic health records.

As a result, patients can instantly access the notes from their doctor visits, review their prescriptions, see their lab results, and email questions to the doctor(s) they’ve been seeing. And doctors, whether primary care providers or specialists, can have a patient’s personal information and medical history right at their fingertips.

Unfortunately, so can others.

In 2018, a total of 18 million patient records were hacked and phished. In just the first half of 2019, almost twice as many – 32 million – were.

Clearly, there’s a tug of war between privacy and transparency, and hospitals are the rope.

In 2018, the last year for which complete figures are available, hospitals paid out an average of more than $2.5 million in settlements and civil monetary penalties. That year, the HHS Office of Civil Rights conducted a total of 25,520 complaint and compliance review investigations. And even if the vast majority don’t lead to cash penalties, even the mildest OCR action – resolution after intake and review – can still cost you staff hours and money.

That’s one reason it pays to keep on top of all the latest HIPAA and ePHI changes.

Another is on the horizon for this year. Throughout 2019, OCR has been considering HIPAA regulation changes, and at least some of those should become final this year. Some of those could include easing “aspects of HIPAA Rules that are proving unnecessarily burdensome for HIPAA covered entities and provide little benefit to patients and health plan members.”

Others involve making it easier for hospitals and doctors to coordinate, and requiring instead of just allowing hospitals to share ePHI data with other providers.

That’s why alerts to changes practically as they occur, determining how they apply to you, then implementing and documenting compliance with no wasted time or money makes for good self-defense.

In the battle between privacy and transparency, see how we can keep you out of the crossfire.

Cybersecurity: The Nightmare That Keeps Me Up At Night

You are preparing for board meeting, but you can’t get into your reporting application.  You log off the computer and then log back in – no good.  You call the helpdesk and hear what you never want to: “The application is offline due to a potential cyber attack.”

Keeping organization data safe from hackers is a real concern for compliance professionals.  When asked what keeps them up at night, most would say it is the fear of finding one of the IT systems or applications was hacked. The nightmare may be recurring for compliance professionals who work in health care where personal, protected health information (PHI) data is stored in electronic health record applications.

To optimize cyber protection and minimize cyber events, it is recommended that compliance departments partner with their organization’s information technology (IT) and risk management departments.  A good place to start collaborating is to write and implement an organization-wide cybersecurity plan (CSP) based on each discipline’s input, this way input is included from each discipline leading to a more robust plan

As required under HIPAA and HITECH, Compliance and IT professionals generally focus on how to prevent both privacy and security breaches respectively, so the CSP should include prevention steps from both of those aspects.  While risk management includes prevention, risk also focuses on loss mitigation and minimizing impact to the organization’s reputation after a cyber event has occurred.

And the CSP must include ongoing staff education.  While there are many commercially available tools or applications which provide cyber protection against email hackers, phishers, malware, spyware, and viruses, these tools are only as good as the end users working on the organization’s computers.  Of course, the CSP should include appropriate fire walls and penetration testing by an outside vendor to assess the organizations privacy and security vulnerabilities; however, the best prevention is education for staff so they can identify emails which may contain malware, spyware or viruses.

Ongoing education should occur with staff at all levels of the organization.  Education should include internal IT generated phishing emails with remediation for those who “take the bait” and click on the bad links.  It should also include cross-departmental table-top exercises where cybersecurity related scenarios are presented and discussed to ensure familiarity with the CSP and to identify and improve upon weaknesses in the plan, staff education, or the applications used.

PRACTICE TIPS:

  1. Schedule a one-hour call with your insurance broker to review your cyber liability insurance policy and reporting requirements in the event of a privacy or security breach.
  2. Ensure you are current with not only federal, but state security and privacy laws.

Denise Atwood, RN, JD, CPHRM
District Medical Group (DMG), Inc., Chief Risk Officer and owner of Denise Atwood, PLLC
Disclaimer: The opinions expressed in this article or blog are the author’s and do not represent the opinions of DMG.

Denise Atwood, RN, JD, CPHRM has over 30 years of healthcare experience in compliance, risk management, quality, and clinical areas. She is also a published author and educator on risk, compliance, medical-legal and ethics issues. She is currently the Chief Risk Officer and Associate General Counsel at a nonprofit, multispecialty provider group in Phoenix, Arizona and Vice President of the company’s self-insurance captive.