Steps to Conducting a HIPAA Risk Assessment for Healthcare Providers

The Health Insurance Portability and Accountability Act (HIPAA) provides guidelines for conducting risk assessments to help minimize the chances of data breaches. These breaches can be expensive and can damage your organization’s reputation, among other serious impacts. Not following these guidelines or doing incomplete assessments can leave your organization, staff, and patients vulnerable. The following offers steps for carrying out these assessments throughout the year.

HIPAA risk assessment requirements

Risk assessment guidelines can differ, but most organizations can follow a similar path to complete them. Broadly, steps to conduct a risk assessment include:

  • Define assessment scope: The scope of your assessment should cover any potential risks your facility or practice could experience regarding the confidentiality, availability, and integrity of protected health information (PHI). You must ensure this information’s creation, maintenance, transmission, and retrieval is safe and secure.
  • Documenting data: Typically, you will need to collect data through logs and paperwork and document the storage locations, how you acquire information, and your strategies for maintaining and transmitting this information. Your documentation should include the security measures you’ve implemented.
  • Identifying potential risks: A crucial part of conducting a risk assessment is identifying potential risks. Document any unique risk to your organization or facility. For example, if you use cloud solutions for data storage, you should consider cloud-specific risks.
  • Assess security measures: To ensure the utmost security, you should evaluate your current security measures and how you can improve them. Assessments should detail any effort you make to enhance security and whether your facility properly uses these measures.
  • Evaluating potential impacts of vulnerabilities: Another element of a risk assessment is identifying the potential impacts of data breaches. Consider unique threats to protect health information availability, integrity, and confidentiality. Determine possible adverse outcomes if a breach occurs.
  • Determining risk levels: After considering potential risks, you should consider the risk level. Analyze the chance that a person or entity may exploit your vulnerabilities and determine what impacts this could have on your facility or information. Determining the risk severity can allow you to create a more refined process for preventing the most severe breaches and mitigating risks in general.
  • Reviewing and updating the assessment: As a final step in your risk assessment, you should document any changes you’ve made and all results you acquired. Refer to this information any time you revisit security measures and share this information with your security team so they can enhance their practices.

Common HIPAA violations in healthcare

Avoiding HIPAA violations is crucial for running a successful and reputable healthcare practice. Even minor violations can occur, underscoring the need to stay informed and maintain compliance. Sometimes, you might not realize there’s a violation until it’s too late. Conducting regular risk assessments is the best way to identify and minimize these potential risks, ensuring your practice remains secure.

Common violations include:

  • Sharing identifiers like names, birth dates, or email addresses of people under 18.
  • Speaking about protected information in public spaces.
  • Posting patient information on social media without that patient’s permission.
  • Technology problems like leaving computers logged in or allowing unauthorized employee access.
  • Failing to train employees and document completion.
  • Disposing of protected information in appropriate ways, such as throwing information into a publicly accessible trash can.

A comprehensive guide to risk assessments

To ensure quality risk assessment, steps can be taken routinely to maintain security. Below, you’ll find checklists for monthly, quarterly, and annual timelines along with ongoing practices for continuous monitoring and improvement.

Monthly HIPAA risk assessment checklist

Creating a HIPAA breach risk assessment and implementing the appropriate security measures involves continuous improvement actions and reevaluating existing security measures. Each month, you can complete several actions to reduce security risks. Follow this monthly checklist:

  • Update network device firmware.
  • Generate reports for system security.
  • Address any concerns with servers, mobile devices, and workstations.
  • Evaluate reports regarding failed logins.
  • Identify any threats or security events on antivirus logs.
  • Communicate remediation updates with staff.
  • Make changes to notes and documents depicting any adjustments you made.

Quarterly HIPAA risk assessment template

At peak times during the year, you should take several larger steps to evaluate your security levels, including:

  • Evaluating and tracking system inventory controls for accuracy.
  • Monitoring accounts for proper permissions and terminated users.
  • Auditing elevated user activities.
  • Reviewing employee badge access.
  • Testing backup procedures.

Annual HIPAA risk assessment tool

Annual risk assessments allow you to create an intensive view of your security measures. Your annual assessment should include steps such as:

  • Performing a network vulnerability scan.
  • Reviewing procedures, plans, and policies.
  • Updating changes to procedures, plans, and policies.
  • Conducting security training.
  • Reviewing perimeter controls.
  • Conducting disaster recovery testing.
  • Evaluating security incidents.
  • Performing risk assessments for third-party vendors.
  • Updating risk management plans.

Ongoing practices for enhanced security

In the healthcare industry, risks are always present, and breaches can happen at any time. Ongoing threats mean it’s crucial to consistently practice safety measures. There are several actions you can take that can make a significant impact, including:

  • Sending security reminders to your staff.
  • Monitoring security controls after operational or environmental changes.
  • Maintaining Business Associate Agreements.
  • Performing system monitoring.
  • Training and testing employees against email threats such as phishing.
  • Implementing content filtering for email and spam.
  • Reviewing security audit log reports.
  • Investigating any security alerts.
  • Evaluating maintenance records regarding facility changes.
  • Updating and applying malware updates on systems.

Find your HIPAA risk assessment solution at Rectangle Health

Preventing HIPAA violations and maintaining compliance can be manageable with the right support. At Rectangle Health, you can find the help you need to complete risk assessments and resources to work efficiently while retaining high security levels.

We take the stress out of compliance management. With Bridge™ Compliance, you can maintain compliance programs with ease. Access online employee training, free annual risk assessments, and a user-friendly interface to develop and store policies and procedures. Our solution frees up your team and manages documentation and training so you can focus on what really matters — delivering quality care to your patients.

Rectangle Health is a leader in innovative healthcare technology. Over 36,000 healthcare providers trust us to deliver high-quality solutions that save time and enhance processes. With more than 30 years of innovation and a healthcare-driven focus, we have the solution you need. Request a demo today to see how we can help your organization.

Reference List:

HIPAA PHI: Definition of PHI and list of 18 identifiers. (n.d.). Human Research Protection Program.

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