On Your Mark, Get Set, Assess! An Action Plan For Conducting A Hipaa Privacy Risk Assessment

Even better, the HIPAA functionality of the Netwrix solution goes far beyond risk assessments. It enables you to detect active threats in a timely manner to prevent security incidents and business disruptions. In addition, unlike many other auditing tools, the Netwrix solution includes predefined compliance reports that meet HIPAA requirements and other common regulations, saving a lot of time and effort in preparing for compliance. Conducting a thorough risk assessment is critical to HIPAA compliance and will be the first thing audited in the event of a breach. On the surface, the “risk analysis” required by the HIPAA Security Rule is what many IT and security professionals refer to as a “risk assessment.” A risk analysis is one of the required implementation specifications. Avertium has a team of HIPAA compliance experts who specialize in conducting HIPAA risk assessments and then developing and implementing strategies to address identified vulnerabilities.

The Department of Health and Human Services does not endorse or recommend any particular risk analysis or risk management model. The documents referenced below do not constitute legally binding guidance for covered entities, and compliance with any or all of the standards contained in these materials is not evidence of compliance with the risk analysis requirements of the Safety Rule. Rather, the materials are presented as examples of frameworks and methodologies that some organizations use to guide their risk analysis.

Regardless of what changes the Bush administration or others hope to make to the regulations, covered entities should not delay their HIPAA preparations. An important first step on the road to implementation is to conduct a comprehensive HIPAA privacy risk assessment. Each central bank must overcome organization-specific challenges in attempting to maintain a consistent program for conducting HIPAA security risk assessments. All ECs and third-party payers or BAs that have access to PHI are required HIPAA compliance to conduct HIPAA security risk assessments on a regular basis, regardless of the size, structure, or complexity of the organization. While small hospitals and individual providers may not be as complex as large health systems, they are still considered centralized entities and therefore are equally responsible for protecting personally identifiable information. Physical protections include access to both the physical structures of a covered entity and its electronic equipment (45 CFR ยง164.310).

However, these audits often do not adequately review the rigor of the risk analysis process. The CISO should be an impartial resource that provides appropriate checks and balances within the EC. This applies to any potential conflict of interest or political pressure to whitewash the results of HIPAA security risk assessments.

These security measures can be both technical (such as encryption, two-factor authentication, and other technology-based measures) and non-technical. Organizations should assign risk levels for all combinations of threats and vulnerabilities identified during risk analysis. For example, the risk level could be determined by analyzing the values assigned to the probability of the threat occurring and the resulting impact of the threat. The risk level could be determined by assigning a risk level based on the average of the assigned probability and impact levels.

A HIPAA risk assessment should identify all areas of an organization’s security that require attention. Organizations should then develop a risk management plan to address the vulnerabilities revealed by the assessment and, if necessary, implement new procedures and policies to close the vulnerabilities most likely to result in a personal data breach. The final stage of a HIPAA risk assessment should be the development and implementation of a HIPAA privacy compliance program. The program should include measures to address the risks to personal information identified in the HIPAA Privacy Risk Assessment and be revised as suggested by HHS as new work practices are implemented or new technologies are introduced. Many organizations undergo some level of third-party reporting on HIPAA security compliance. Typically, these types of HIPAA audits evaluate the structure and effectiveness of the current process for meeting the requirements of the HIPAA Security Rule.

Suppliers often do not have sufficient resources to manage security risks internally. Conducting internal and external security risk assessments annually is time-consuming and multi-faceted, and requires adequate resources if it is to be done well. This basic guide to HIPAA security risk assessments walks you through the essential components of conducting assessments and what to do after they are completed.