Patient privacy and the confidentiality of patient data are paramount to healthcare providers. However, with the increase of electronic health records, unauthorized access and breaches of patient data are becoming more common. That's where the Health Insurance Portability and Accountability Act (HIPAA) comes in.
HIPAA is a federal law enacted in 1996 that sets standards for the privacy and security of protected health information (PHI). HIPAA aims to provide a framework for protecting patient privacy and ensuring the confidentiality, integrity, and availability of PHI. The law has two main rules: the Privacy Rule and the Security Rule. In this article, we will focus on the Privacy Rule and explore what it entails and why it is important.
What are the HIPAA Violations?
Security and HIPAA Risk Assessments
Helping Healthcare Organizations Comply with HIPAA
Meaning of HIPAA
HIPAA is an acronym for the Health Insurance Portability and Accountability Act, a federal law enacted in 1996. The law contains provisions related to health insurance coverage, medical savings accounts, and the privacy and security of PHI. The Privacy Rule is a subset of HIPAA that sets standards for the use and disclosure of PHI by covered entities.
Why HIPAA Was Created
HIPAA was created to address several concerns, including the portability of health insurance coverage, administrative simplification, and the privacy and security of PHI. Prior to HIPAA, there were no federal regulations governing the privacy and security of PHI. HIPAA aimed to provide a framework for protecting patient privacy and ensuring the confidentiality, integrity, and availability of PHI.
HIPAA's provisions are divided into five titles, with Title II specifically focusing on the privacy and security of PHI. Under Title II, HIPAA has two main rules: the Privacy Rule and the Security Rule. The Privacy Rule establishes national standards for the protection of PHI and applies to healthcare providers, health plans, and healthcare clearinghouses. The Security Rule sets standards for protecting electronic PHI (ePHI) and applies only to covered entities that create, receive, maintain, or transmit ePHI.
HIPAA versus FERPA
HIPAA and FERPA are two federal laws that regulate the privacy and security of different types of information. While HIPAA is focused on protected health information (PHI) and applies to healthcare providers, health plans, and healthcare clearinghouses, FERPA applies to educational records and educational institutions that receive federal funding. While there are some similarities between the two laws, such as the requirements for risk assessment and risk management, there are also important differences in the types of information covered, the types of organizations that must comply, and the specific requirements for compliance. Healthcare organizations should be aware of these differences when developing their compliance strategies and implementing security measures to protect sensitive patient data.
HIPAA Standards for Privacy
HIPAA sets strict standards for the privacy of PHI. Covered entities must only use and disclose PHI for treatment, payment, and healthcare operations or with the patient's consent or as otherwise permitted by law. Covered entities must also implement safeguards to protect PHI, including administrative, physical, and technical safeguards. These safeguards must be reviewed and updated regularly to ensure ongoing compliance.
The rule requires healthcare organizations to obtain written consent from patients before using or disclosing their PHI, except in certain situations such as treatment, payment, and healthcare operations.
Under HIPAA, patients have the right to:
- access their medical records and request corrections
- receive a notice of privacy practices from their healthcare provider
- file a complaint with the OCR if they believe their rights have been violated.
- designate a privacy officer to oversee HIPAA compliance
- provide regular training to employees on HIPAA regulations
- obtain written business associate agreements from vendors who handle ePHI
- develop policies and procedures to ensure compliance with the Privacy Rule.
What Are the HIPAA Security Rules?
The HIPAA Security Rule establishes standards for protecting ePHI. The rule requires healthcare organizations to implement specific administrative, physical, and technical safeguards to ensure the confidentiality, integrity, and availability of ePHI.
The HIPAA Security Rule requires healthcare organizations to:
- implement policies and procedures to prevent, detect, contain, and correct security violations
- conduct regular risk assessments to identify potential vulnerabilities
- implement workforce security awareness and training programs
- establish access controls to limit access to ePHI to only authorized personnel
- encrypt and decrypt ePHI when it is stored or transmitted
- implement audit controls to record and examine activity in information systems containing ePHI
- implement integrity controls to ensure that ePHI has not been altered or destroyed
- develop contingency plans for responding to emergencies or other incidents that damage systems containing ePHI.
Security and HIPAA Risk Assessments
HIPAA requires healthcare organizations to conduct risk assessments to identify potential vulnerabilities and implement appropriate safeguards to protect ePHI. Risk assessments are an important component of a healthcare organization's security strategy because they help identify potential threats and vulnerabilities and prioritize security measures.
Risk assessment for HIPAA compliance involves evaluating the administrative, physical, and technical safeguards in place to protect ePHI. Organizations must evaluate the likelihood and impact of potential threats to ePHI, and identify appropriate measures to address those threats.
The HIPAA Security Rule also requires healthcare organizations to implement reasonable and appropriate security measures based on the results of their risk assessments. This includes implementing security policies and procedures, workforce security training, access controls, encryption, audit controls, and contingency planning.
What Are the HIPAA Violations?
HIPAA violations can result in significant consequences for covered entities and business associates. The types of penalties and fines that can be imposed depend on the severity of the violation, the number of people affected, and the level of intent.
One common HIPAA violation is the failure to obtain patient consent before disclosing PHI. This occurs when healthcare providers disclose patients' protected health information to individuals or entities without obtaining written consent from the patient. The failure to implement safeguards to protect PHI is another common violation, which can occur when healthcare organizations fail to properly secure patient data.
Unauthorized access to or disclosure of PHI is also a significant HIPAA violation. This can occur when employees or other individuals gain access to PHI that they are not authorized to view, or when PHI is disclosed to unauthorized parties. Failure to provide patients with access to their own PHI is another violation that can occur when healthcare providers do not give patients the ability to review or obtain copies of their medical records.
Lastly, failure to train employees on HIPAA policies and procedures can result in HIPAA violations. This can happen when healthcare organizations do not adequately train their employees on the importance of protecting patient data or the specific policies and procedures related to HIPAA compliance.
Penalties of HIPAA Violations
HIPAA violations carry significant penalties, ranging from $100 to $50,000 per violation, with a maximum of $1.5 million per year for each violation of an identical provision. In addition to the monetary penalties, there are other negative consequences that come with violating HIPAA regulations. Violations can result in a loss of trust from patients and customers, negative media attention, and damage to an organization's reputation. In some cases, HIPAA violations can even lead to criminal charges and imprisonment.
To illustrate the severity of HIPAA violations, it is worth mentioning some cases where healthcare organizations were fined for their non-compliance. For example, in 2020, Premera Blue Cross was required to pay $6.85 million to settle potential HIPAA violations. The OCR found that Premera had not conducted a proper risk analysis, implemented risk management plans, or consistently encrypted ePHI, which led to a data breach that impacted more than 10 million individuals.
Similarly, in 2019, the OCR fined the University of Rochester Medical Center (URMC) $3 million for HIPAA violations. The OCR discovered that URMC had not encrypted ePHI on its mobile devices, resulting in a data breach that impacted over 3,000 individuals. URMC also failed to conduct a risk analysis, implement risk management plans, and train its workforce on HIPAA regulations.
To avoid such penalties, healthcare organizations must prioritize HIPAA compliance and take proactive steps to protect PHI. This includes conducting regular risk analyses, implementing risk management plans, encrypting ePHI, and providing workforce training on HIPAA regulations. By doing so, healthcare organizations can ensure they avoid costly HIPAA violations and safeguard their patients' privacy and security.
Hideez Authentication Service: Helping Healthcare Organizations Comply with HIPAA
The Hideez Authentication Service is a passwordless identity and access management solution that can help healthcare organizations comply with HIPAA and its security rules. The solution provides passwordless SSO and multi-factor authentication, role-based access control tools, and centralized identity management to improve security and protect ePHI.
Hideez Service eliminates the need for passwords, which are a common source of security vulnerabilities. The solution uses a mobile app that enables secure desktop authentication with biometric verification, and hardware security keys, to authenticate users and grant access to protected systems and data.
In addition, the Hideez Authentication Service helps healthcare organizations comply with HIPAA's security rules by providing comprehensive security policies and procedures, access controls, and audit trails. To further support healthcare organizations, Hideez offers a 30-day free trial of the Authentication Service and encourages readers to book a demo of the solution. By implementing the Hideez Authentication Service, healthcare organizations can improve security, protect ePHI, and comply with HIPAA and its security rules.