Checklist for HIPAA Compliance

HIPAA Compliance: A 9-Point Checklist

How to achieve HIPAA compliance

When Congress passed the Healthcare Insurance Portability and Accountability Act in 1996, they certainly opened a big can of worms!

Achieving HIPAA compliance presents many challenges. These include the complexity of the regulation and the ever-evolving cybersecurity threat landscape. Organizations also need to keep up with regular HIPAA changes, ensure employees interact with data properly, and manage the risks of their vast third-party ecosystems.

More specifically, the HIPAA Privacy Rule requires protecting the privacy of patient health information. Providers, health plans, and third-party service providers who handle patient information must prove they secure electronic records containing confidential health information as they transfer, receive, process, and share patient records, billing, and claims.

The Risks of Non-Compliance with HIPAA

For organizations subject to the HIPAA Privacy Rule, failure to comply can result in significant financial penalties and mitigation costs. In September 2023, the U.S. Department of Health and Human Services reached a settlement with LA Care, the nation’s largest publicly-operated health plan. Following a large breach of patient records, LA Care agreed to pay $1.3 million and to invest in implementing a comprehensive corrective action plan.

Weak security postures can also lead to attacks that seriously hamper operations. For example, Change Healthcare, a United Health Group subsidiary, had to disable 100 systems following a ransomware attack. This left the company unable to process claims and prompted some of its provider organizations to struggle with keeping their clinics open due to the lack of cash flow.

Perhaps the biggest risk healthcare entities face by not complying with HIPAA is the loss of patient trust. Patients suffer the most from HIPAA non-compliance and turn away from providers and health plans that don’t protect their sensitive information. That’s because cybercriminals use stolen records to commit identity theft, fraud, and other scams. These consequences can affect an individual’s access to healthcare.

The Path to Achieving HIPAA Compliance

Despite the challenges, with proper planning, your organization can create a path to achieving and maintaining HIPAA compliance. To help you with your journey, here’s a 9-step checklist to guide you.

Step #1 – Appoint a compliance officer

First designate an individual to oversee your HIPAA compliance program. Without a single person at the helm, your efforts will bog down or spring holes that leave you open to violations. For this person to succeed, give them executive support with the authority and the resources to enforce the compliance policies.

Step #2 – Conduct risk assessments

This includes identifying the potential risks to personal health information within your organization. Evaluate the effectiveness of your security controls periodically and document the findings. As you identify security gaps, develop corrective action plans.

Step #3 – Develop policies and procedures

These include establishing policies for handling health information along with procedures for access control and data encryption. After initially going through this exercise, review the policies and procedures every few months to account for changes to HIPAA and within your technology environment.

Step #4 – Implement access controls

As you conduct risk assessments (Step 2) that identify compliance gaps, implement the necessary controls to restrict patient information access to authorized personnel only. By applying role-based access controls, you can ensure employees access only the information necessary for their roles. As part of this step, regularly review and update your access permissions.

Step #5 – Deploy data encryption

This step includes encrypting patient information in transit among your internal systems and in data exchanges with your data-processing partners. Also encrypt data at rest to protect it from unauthorized access. In addition, utilize strong encryption methods and update them regularly to address emerging threats.

Step #6 – Establish a breach notification protocol

Should a breach of systems with patient information occur, you must have a clear plan for how you will respond. This includes notifying affected individuals and the Department of Health and Human Services. In some cases, HIPAA requires you to issue a press release. As with the other steps on this checklist, test and update your breach response plan on a scheduled basis.

Step #7 – Maintain physical security

Also consider the physical security of your facilities and any devices that store or access patient information. Implement measures such as badge access to your data centers as well as surveillance cameras. For any patient information in physical form, establish secure disposal methods.

Step #8 – Train your employees

Compliance requires awareness of proper conduct when interacting with data by everyone across your organization. Provide training sessions at least once a year and when you first hire employees on HIPAA requirements and data protection best-practices. Also educate your staff on recognizing phishing attempts and other security threats. In addition to the training, HIPAA requires you to maintain records of your training activities and participant acknowledgments.

Step #9 – Conduct Regular Audits and Monitoring

Regularly audit compliance with HIPAA policies and procedures. Use monitoring tools to detect unauthorized access or anomalies in the handling of PHI. Document your audit findings and take corrective actions as needed.

Partner with HIPAA-Compliant Service Providers

In addition to your internal HIPAA compliance measures, consider your ecosystem of third-party service providers that handle patient information. Given that many cyberattacks start by finding a weak link in third-party supply chains, make sure your partners comply with HIPAA regulations as well. You can do this through a Business Associate Agreement as defined by HIPAA where your providers outline their responsibilities for protecting patient information.

A particularly important partner to focus on is your data center provider. For DataBank colocation customers, we serve as a trusted Business Associate to healthcare Covered Entities who manage protected health information or provide services to other companies that manage e-patient information.

Because we perform an annual audit every year in each of our data centers, customers subject to the HIPAA Privacy Rule can trust their IT equipment is housed within a top-tier facility that adheres to the most stringent audit requirements in the industry. Our shared risk model and Business Associate Agreement also allow you to transfer as much as 80% of the HIPAA controls to DataBank to unburden your IT team and make compliance easier.

The Advantages of Partnering with a HIPAA-Compliant Data Center Provider

Partnering with a HIPAA-compliant multi-tenant data center provider like DataBank offers numerous advantages: enhanced data security, a reliable power and cooling infrastructure, and expert support in maintaining compliance. We provide state-of-the-art security measures, giving you peace of mind knowing your data is housed in an environment that meets the stringent HIPAA requirements.

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