How to Be HIPAA Compliant: Is Training Enough?

In the ever-evolving world of healthcare, protecting sensitive patient information isn’t just a good practice—it’s the law.  

HIPAA has long been the North Star guiding healthcare organizations toward data security and patient privacy, while employee HIPAA training is often the first step taken to ensure compliance. 

But while HIPAA compliance training is essential, it’s just one piece of the complex compliance puzzle.  

Why HIPAA Training for Employees Isn’t Enough  

HIPAA training for your employees is non-negotiable. It’s the foundation upon which your organization’s commitment to patient data security rests. However, as the end of the year approaches, marked by a looming HIPAA Security Risk Assessment deadline, it’s time to confront a harsh reality: training is not enough to ensure compliance. 

Approximately half of insider-caused breaches are due to human error, making frequent and proper training imperative. But training is not the endpoint of your compliance journey. Although training equips your team with knowledge, it cannot analyze your organization’s current compliance gaps, uncover lurking vulnerabilities, or help you navigate the ever-shifting regulatory landscape. 

As the December 31st HIPAA Security Risk Assessment (SRA) deadline approaches, waiting to begin the complex, deep dive into your organization’s data security isn’t wise. Luckily, it’s not too late to get ahead of the assessment and complete four essential steps, in addition to training, that will give you everything you need to complete your SRA and remain compliant. 

How to Be HIPAA Compliant: 4 Essential Steps  

Here are four essential steps that go beyond HIPAA training for small medical practices:

1. Complete the HIPAA Security Risk Assessment (SRA)

HIPAA compliance starts with conducting a Security Risk Assessment. This in-depth analysis uncovers vulnerabilities, risks, and threats within your organization.  

The SRA should be completed by the end of each year, or if your organization has had significant changes in its internal system that warrant reevaluation of security measures. Starting the SRA well in advance is the best way to ensure that it will be accurate, timely, and fully fleshed out. 

While submitting the SRA keeps you compliant, the real work begins through remediation, the process of addressing identified vulnerabilities. Remediation is about actively improving your security posture throughout the year by completing yearly, monthly, weekly, and ongoing tasks to fill compliance gaps. 

2. Conduct Penetrating Testing

Penetration testing is your offense in the world of data security. It involves ethical hackers attempting to breach your security defenses to uncover vulnerabilities before malicious actors do.  

Regular penetration testing goes beyond training by identifying weaknesses and potential entry points. Most organizations use external penetration testing, where the ethical hacker breaches your system like a cyber attacker from the outside. Internal penetration testing mimics an attack from within, so the data analyst already has some degree of access. 

Penetration testing is a proactive measure to strengthen your defenses, providing peace of mind that you’re one step ahead of potential threats. While the HIPAA Security Rule mandates a risk analysis, it doesn’t require penetration testing. This form of testing is essential for analyzing risks that may otherwise go unnoticed and nipping them in the bud before they lead to a costly breach. 

3. Create Policies & Procedures

While training imparts knowledge, policies and procedures turn that knowledge into actionable guidelines. You must have comprehensive policies and procedures covering data access, encryption, incident response, and more.  

These dynamic documents should be living guidelines that adapt to evolving regulations and technology. They serve as your organization’s compass, ensuring that every employee understands their role in maintaining HIPAA compliance. 

Organizations should regularly review and update written policies to stay aligned with evolving regulations and internal system changes.  

 4. Build a Book of Evidence

Creating and maintaining a Book of Evidence is like chronicling your journey toward HIPAA compliance. It’s a well-organized collection of documentation and records that prove your commitment to data security.  

The Book of Evidence serves as your historical record of compliance efforts, from policies and procedures to training records, incident reports, and security risk assessments. In the event of an audit or investigation from the Office for Civil Rights (OCR) or another regulatory body, it becomes your armor against potential non-compliance fines and penalties. 

Getting Started with the HIPAA SRA 

HIPAA compliance is a multifaceted effort that requires a holistic approach. To establish a culture of compliance and responsibility, covered entities must go beyond training to complete every part of the puzzle. 

If you’re ready to tackle all compliance aspects, HIPAA One is the automated solution supported by expert assessors that will guide you through every element of the year-round compliance process. You’ll be confident in your compliance and ready for whatever comes.