HIPAA and IT Audits
Imagine you are the Information Security Officer at a medium-sized hospital chain. The CEO and the other senior leadership of the company want to ensure that all of their hospitals are and remain HIPAA compliant. They are concerned about the HIPAA Security and Privacy Rules and its impact on the organization. You begin looking at the information provided by the Department of Health and Human Services, located at http://www.hhs.gov/ocr/privacy/hipaa/enforcement/index.html. Specifically, you are asked to provide an analysis of two (2) of the cases found here with emphasis on what was done to resolve the compliance issues.
https://www.hhs.gov/hipaa/for-professionals/compliance-enforcement/examples/all-cases/index.html
Section 1. Written Paper
Non-compliance with HIPAA regulations can result in significant fines and negative publicity. To help ensure that your organization remains in compliance with HIPAA regulations you have been asked to write a three to five (3-5) page paper in which you:
1a. Create an overview of the HIPAA Security Rule and Privacy Rule.
1b. Analyze the major types of incidents and breaches that occur based on the cases reported.
1c. Analyze the technical controls and the non-technical controls that are needed to mitigate the identified risks and vulnerabilities.
1d. Analyze and describe the network architecture that is needed within an
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organization, including a medium-sized hospital, in order to be compliant with HIPAA regulations.
1e. Analyze how a hospital is similar to and different from other organizations in regards to HIPAA compliance.
1f. List the IT audit steps that need to be included in the organization’s overall IT audit plan to ensure compliance with HIPAA rules and regulations.
1g. Use at least five (5) quality resources in this assignment. Note: Wikipedia and similar Websites do not qualify as quality resources.HIPAA and IT Audits
Student:
Institution:
HIPAA and IT Audits
With the high increase of information security in health industries, the Health Insurance Portability and Accountability Act (HIPAA) has provided national standards to protect medical information from computer hacking, data breaching. HIPAA works with set of rules and principles that maintains data integrity, confidentiality, and protection of medical electronics. HIPAA undertakes IT audits programs that review whether the organization complies with policies and procedures of security as well as breach notifications (Vanderpool, 2019). The paper is an analysis HIPAA compliance issues in health sectors together HIPAA IT audits.
1a). The HIPAA privacy rule and HIPAA security rules are two different kinds of norms enforced to enhance privacy. Privacy rules protect an individual’s identifiable health information while security rules are standards that protect health information contained and transferred in electronic form(Jia, et, al.,2019). Privacy rule is adopted for all safeguarded patient’s information in oral, written, or electronic form while security rule only applies to protected medical data in electronic form. For instance, data stored in disks, the internet, or computers. Both HIPAA privacy and security rules apply to covered entities such as health care providers, prescription drug card sponsors, healthcare clearinghouses, as well as health plans such as health insurance.
Privacy rules ensure that covered entities have technical safeguards, administrative, and physical protection (Jia, et, al.,2019). Some of the privacy rules state that a covered entity is expected to protect health information from disclosure, which is contrary to requirements. A covered health organization must protect electronic safeguarded information to reduce cases of a data breach unless the organization is permitted to disclose the information. Security rule contains detailed rules, for instance, enhancement of security compliance to electronic information systems, carrying out policy and data assessment regularly, as well as adoption and upgrade of information systems to enhance efficiency. The HIPAA privacy rule gives patients the freedom and right over their medical information, for instance, the right to make a copy.
1b). According to the case reports, a private practice had issues about disclosure, safeguards, and impermissible uses of patient’s health information (PHI). The staff member involved in HIV testing disclosed several PHI to another patient leaving patients information displayed on computer screens. Patient’s HIV information is very private and requires high standards of privacy and safeguards according to HIPAA security and privacy rule unless permitted to disclose by the patient. Another case in a general hospital involves inappropriate, confidential communication between a hospital employee and the patient. The hospital employee went contrary to the patient’s privacy requirements of using the patient’s work contact instead of home contact. The hospital employee, therefore, sent a message containing a confidential note of medical conditions and treatment plans via home contact, which was viewed by the daughter. The hospital employee did not know how to handle medical data according to HIPAA privacy rules.
1c). HIPAA technical and non-technical safeguards are needed to mitigate risks and vulnerabilities experienced in the case reports. In the case of private practice information disclosure, lack of protection, and impermissible use of patient’s health information can be mitigated by installing minor or minimizing screens containing patient’s health information to avoid disclosure. Additionally, the staff member can reposition the computer from the patient’s view to prevent the disclosure of sensitive information. Non-technical safeguards would include ensuring that viewers of any health information are authorized, train staff members on privacy policies and procedures that restrict sharing confidential information with other patients without permission.
The case on confidential communication in general hospital, non-technical safeguards includes training of hospital employees on transfer of minimum and necessary information to patients, especially in message form. Sending medical records on messages can be unconfidently, primarily through home contact or address. Additionally, the kind of information left in message form should be less sensitive compared to the one sent through mails or via phone calls. Viewing registration contacts to use on a patient’s file is vital before sending any information. The hospital employees were trained on how to be careful and professional when dealing with the transfer of patient’s data through electronic devices. The facility can come up with a mechanism to monitor activities carried out by employees through information systems or where the electronic patient’s health information is considered.
1d). HIPAA compliance involves many aspects, including network architecture. Network administrator’s large and medium-sized hospitals use security protocols to guide the in developing network architecture (Thissen and Mason, 2019). Developing a suitable and accepted network architecture saves the organization from the lawsuit. The network architecture is designed to configure health care security controls through building an internet infrastructure to the best of HIPAA security rule and data management. The security devices are vital for the organization to support technical safeguards, operational, administrative, and physical. Infrastructure layout handles aspects such as firewalls, routers, and switches for compliant network architecture.
Medium-sized clinics require twenty-five to one hundred electronic devices connecting to the network where switches are integrated around the facility for a telephone. LAN and WAN are installed for effective operation and control (Thissen, and Mason, 2019). The system runs through all rooms, including executive offices, treatment rooms, and laboratories. For wireless connectivity, devices connected to support user’s mobility, especially physicians between different treatment rooms and enable access to patient’s data from anywhere. Medium clinic architecture provides internet services to necessary clinical operations as well as the accessibility of ports compared to small-sized clinics.
1e). Hospitals have similarities and differences from other organizations according to HIPAA compliance (Sokol, 2017). Hospitals and other organizations are subjected to penalties in case of violation of rules and policies, although the way offenses are assessed differently. For instance, in other organizations, non-compliance is handled through prosecution. At the same time, hospitals following HIPPA regulations are waived in exceptional circumstances as well as a lawyer is relatable to significant harm.
Both organizations adhere to a secure socket layer (SSL) and protection of data transmitted through the organization’s servers (Sokol, 2017). Both organizations comply and follow the set of rules and regulations when dealing with sensitive information. Other organizations are protected by various agencies that deal with data protection in any organization, for instance, the general data protection regulations. On coverage, HIPAA is, however, different because it only restricted to health organizations such as clinics, hospitals, and all other covered entities care.
HIPAA only handles security issues in hospitals inside the united states but not outside, which makes it an organization-centric regulation while other organizations can be protected from data insecurity, for instance, through GDPR. HIPAA being an organization-centric regulation agency protects any patient medical information but does not pay attention to data consent compared to other organizations. Other organizations are required to provide data consent, which is active. Therefore in HIPAA, once undercover, there are no restrictions towards data as long as the information is medically based.
Hospitals are allowed to transfer or disclose limited data to the third party for the business purpose, although exclusive of name, address, image, and all identifications (Sokol, 2017). Unlike other organizations, sharing information without consent is prohibited. Handling data in different organizations have more restrictions compared to hospitals. Other organizations have the right to be forgotten where the client’s information can be erased from the database, although when requested. HIPAA does not allow the rule to be overlooked because hospitals under HIPAA requirement the information is used as part of the patient’s history.
1f). HIPAA IT auditing has several steps included in an audit plan that meets the demand of HIPAA compliance regulations. HIPAA audits are, however, vital and conducted to track and monitor compliance and identify weaknesses. There are six audit steps prepared to begin with HIPAA employee training. Training employees is essential to enhance an understanding of HIPAA regulations and compliance (Brogaard, and Uldbjerg, 2019). Policies are used in the training process and documentation of the training to present before the office of civil rights. Generate a risk management plan and analysis to identify security risks within the facility. In the process, every activity is recorded or written down, also known as a security document according to compliance rules.
Appoint a security assessment and privacy officer who is responsible and understands the impact of a patient’s health information security information. The officer includes third party vendor and their role in ensuring health electronics are protected. The officer is also expected to be honest about data breaches identified during the audit process and make a regular analysis of IT systems. Review policy implementation is another step and analyzes how the policies are implemented and utilized by the facility (Brogaard and Uldbjerg, 2019). An implementation schedule is also included in the audit for the OCR. Conduct an internal audit program that reviews the privacy and security compliance plan as well as challenges identified in internal risk assessment. Lastly, create a domestic remediation plan for risk correction purposes. The remediation plan is essential to all covered entities in maintaining compliance through the internal processes.
To sum up, HIPAA and IT audits has Helped most health organizations in managing data and securing sensitive information. HIPAA privacy rule and security rule work together to enhance compliance in the covered entities. According to security incidents and data breach in both private practice and general hospital cases, technical and non-technical methods can be applied to mitigate risks and vulnerabilities. Training of workers and adopting a secure means of communication by maintaining HIPAA security rule on saved electronic data. A capable network architecture deployed according to HIPAA regulations is vital in enhancing a steady and secure means of information flow throughout the facility. Lastly, an IT audit plan consists of critical steps that ensure a professional and effective IT audit compliant to HIPAA regulations.
1e).
References
Brogaard, L., & Uldbjerg, N. (2019). Filming for auditing of real-life emergency teams: a systematic review. BMJ Open Quality, 8(4).
Jia, Y., Lawton, T., White, S. P., & Habli, I. (2019). Developing a Safety Case for Electronic Prescribing. In Studies in Health Technology and Informatics: MEDINFO2019 (pp. 629-633). York.
Sokol, A. J. (2017). Clinical Research and Data: HIPAA, the Common Rule, the General Data Protection Regulation, and Data Repositories. Merrill Series on The Research Mission of Public Universities, 47-62.
Thissen, M. R., & Mason, K. M. (2019). Planning security architecture for health survey data storage and access. Health Systems, 1-7.
Vanderpool, D. (2019). HIPAA COMPLIANCE: A Common Sense Approach. Innovations in Clinical Neuroscience, 16(1-2), 38.
