There is a 75.6% chance of a breach of at least five million healthcare patient records in the next year.
This is especially problematic for small healthcare organizations; 20% of small practices have experienced a breach, and 75% of breaches reported to the HHS were hacking or IT incidents.
Mitigating the chances of a security breach is more important than ever, and successfully completing a periodic HIPAA Security Risk Assessment (SRA) is therefore a crucial component of effective compliance and risk management.
In fact, the Department of Health and Human Services (HHS) Office for Civil Rights (OCR) requires covered entities to conduct a risk assessment each year to identify security risks, vulnerabilities, and threats to PHI.
But where exactly should you start with your assessments – and what is even involved in them?
The Basics of a HIPAA Security Risk Assessments
Your annual HIPAA SRA is designed to:
- Identify cybersecurity vulnerabilities that threaten to cause a data breach and impact the privacy of PHI.
- Prepare for effective remediation so that your organization addresses the most immediate risks.
- Demonstrate efforts to ensure compliance and drive urgency around cybersecurity.
Why Do You Need a HIPAA SRA Checklist?
HIPAA compliance is complex, with administrative, physical, and technical safeguards required to keep data secure. But this makes your security risk assessment (SRA) difficult to manage:
- For small and medium-size entities, the challenge is often a lack of resources or knowledge. Individuals may be solely responsible for the SRA – despite not being a trained cybersecurity professional.
- For enterprise entities, the sheer scale of SRAs is the most common challenge. You need to complete assessments for each individual entity, which requires a huge lift from your team – and often creates visibility issues.
A checklist helps ensure you hit all the essential factors that are required to complete an SRA. If you don’t know where to start, following a HIPAA security risk assessment checklist is a great way to tackle compliance and systematically plan, organize, and prioritize your efforts, identify security gaps, and abide by OCR requirements.
Read on for a HIPAA security risk assessment checklist with 4 actionable steps to make your SRA process smooth and effective.
Step 1: Inventory Your Data and Security Measures
The first step in conducting a HIPAA security risk assessment is to inventory your data. This includes assessing the amount of protected health information (PHI) you have, such as patient names, addresses, birthdates, medical history, and social security numbers.
You’ll also want to determine where sensitive data is stored, who has access to it, and how it has been used in the past. The goal of this is to understand what exactly your organization possesses to determine its value and its potential risks. Once you identify all your data, make sure to document your findings properly.
Step 2: Identify Threats and Vulnerabilities
The next step in completing your HIPAA security risk assessment is to identify threats and vulnerabilities that might be facing your data. A threat is an event that could occur, such as a security breach, while a vulnerability is a weakness in the system that a threat could exploit. For example, data breaches, ransomware attacks, phishing attacks, and others are all considered threats. Identifying both will help you paint a complete security picture.
Identifying potential risks goes hand in hand with assessing current security measures used to protect data and determining whether these measures are effective. Always document your findings so there’s a clear list of all the processes and policies in place.
Step 3: Determine the Potential Impact of Threats
An essential step in the risk assessment process is determining the potential impact of a threat. The effect can often be financial and harmful to patients, employees, or the public. Information security threats are often linked with other risks, such as privacy and confidentiality; therefore, you should consider these when determining your organization’s risk profile.
When conducting your risk assessment, think about all aspects of your company, including its:
- Structure, mission statement, and culture
- Personnel roles and annual training for employees
- Physical location and facilities
- Technology used by staff members
- Systems that store data electronically
- Relationships with vendors who provide services such as email hosting
After collecting this information, use it to determine how each factor contributes toward improving information security practices within the organization overall.
It’s also imperative to determine the likelihood of potential threats and vulnerabilities impacting your organization and their risk levels (often done by assigning a numeric value). The higher the risk level, the higher its impact and the chance it will occur.
Using information such as the frequency of the risk occurring in the past, the scope of the risk’s potential impact, and how likely, based on historical data in the industry and your organization, you can formulate an idea of what a threat might mean. As always, these findings should be documented and discussed.
Step 4: Discuss Findings & Prepare to Repeat
Once your findings are documented, your team should discuss the results and develop clear, actionable next steps to mitigate threats. These processes and procedures for mitigation likely won’t be a magic bullet, but having measures in place to maintain effective HIPAA compliance is a necessity.
Although that’s the last step of the HIPAA Security Risk Assessment checklist, the risk assessment process is ongoing. It’s important to note that the checklist alone is not enough to achieve compliance. The HIPAA Security Risk Assessment is a dynamic document that must be updated regularly, and it ensures that compliance regulations are met. It will change as your organization changes, so it’s essential to review the risk assessment results periodically and make any necessary updates.
As the data landscape continues to shift, it’s necessary to keep up with these changes to avoid any new threats and vulnerabilities within your systems and identify newly introduced security measures to incorporate into your strategy. By regularly updating your assessment process, you can make sure that you’re aware of these potential issues and can prioritize them accordingly.
Conclusion
Risk assessments are essential for ensuring compliance with the HIPAA Security Rule because they help identify potential security risks in your organization and point you toward ways to mitigate them. By following this HIPAA Security Risk Assessment checklist, you’re one step closer to achieving full compliance.
Consider enlisting the help of a HIPAA expert when conducting your risk assessment, as they can provide their expertise in conducting a comprehensive assessment, interpreting the results, and creating an action plan.
If you want to learn more about effectively conducting a HIPAA security risk assessment, get in touch with the experts at HIPAA One by Intraprise Health.
