Key Takeaways
- Protecting PHI: HIPAA compliance is a federal mandate designed to protect all forms of Protected Health Information (PHI) and Electronic PHI (ePHI) related to health status, care, or payments.
- Dual Security Framework: Compliance is governed by the Privacy Rule (defining patient rights and authorized access) and the Security Rule (outlining necessary technical, administrative, and physical safeguards).
- Broad Applicability: Adherence is required not only by Covered Entities (like healthcare providers) but also by Business Associates (such as IT suppliers or consultants) and their subcontractors who interact with PHI.
The Keys of HIPAA Compliance
HIPAA is a regulatory framework put in place by the United States federal government to protect the use, transmission, and storage of protected health information. Let’s break down the keys of HIPAA compliance and what that might mean for your organization.
What is HIPAA
The U.S. federal government has strict standards for the use and transmission of protected health information (PHI). Any personal data related to a person’s health status, healthcare needs, or healthcare payments would fall under PHI. There is also ePHI, or electronic protected health information.
Medical data is extremely sensitive, that is why the government enforces its protection by creating security guidelines and institutes penalties for failing to comply with necessary regulations. HIPAA is the framework used to protect health information.
Speak to a Compliance Specialist.
Who needs HIPAA compliance?
There are 3 main types of organizations that need to be aware of, and adhere to, HIPAA compliance best practices:
- Entities that create or transmit PHI or ePHI need to abide by HIPAA regulations. Typically this would be organizations that perform procedures and accept payments for health services.
- Businesses that interact with PHI but are not involved in creating it such as IT suppliers or consultants.
- Subcontractors hired by the other types of organizations to perform specific roles.
4 HIPAA Compliance Rules
HIPAA Privacy Rule – The first rule outlines patient rights in regards to their health information and who can access it. This identifies what information is considered PHI or ePHI and how it should be maintained and transmitted. This rule also outlines the necessary paperwork and consent forms relating to PHI.
HIPAA Security Rule – This rule outlines the technical measures needed to properly protect the privacy of PHI. This typically includes 3 main areas:
- Administrative – the organization’s policies and procedures related to handling PHI.
- Physical – the way you manage locations that store PHI and where they are.
- Technical – the technology used to keep ePHI secure.
HIPAA Breach Notification Rule – This rule outlines what your organization needs to do in the event of a security breach. No matter how well you prepare, no system is completely foolproof. That is why it is good to be prepared in the event of an emergency. The affected organization have a plan to notify individuals, disclose the issue in a public statement, and ensure these actions are taken in the proper timeframe.
HIPAA Omnibus Rule – This rule is a fairly recent addition. It states that entities will be held responsible for violations by business associates or contractors. This is why it is important to align risk assessment processes and the procedures utilized to meet compliance standards internally and externally.
Your HIPAA Compliance Partner
When it comes to HIPAA compliance, it’s important to select the right partner. Auditwerx has extensive industry experience in completing HIPAA compliance assessments, SOC assessments, PCI assessments, and more. If you’re ready to learn more about compliance, contact us today.
FAQs
What specific types of information does the HIPAA framework require organizations to protect?
HIPAA mandates the protection of Protected Health Information (PHI), which includes any personal data related to an individual’s past, present, or future health status, healthcare provisioning, or payment for healthcare services. When this information is in an electronic format, it is called ePHI.
What is the key distinction between the HIPAA Privacy Rule and the Security Rule?
The Privacy Rule establishes the patient’s rights regarding their health information, specifying who can access it and how it can be maintained. The Security Rule outlines the necessary technical, administrative, and physical measures—such as encryption and access controls—needed to protect ePHI.
Does HIPAA compliance extend to third-party vendors and contractors?
Yes, absolutely. The HIPAA Omnibus Rule extends responsibility. Not only are the original healthcare providers responsible, but Business Associates (vendors who interact with PHI) and their subcontractors are also held accountable for adherence and are subject to penalties for violations.
What is the purpose of the HIPAA Breach Notification Rule?
The Breach Notification Rule mandates a pre-defined plan for when a security incident occurs. It requires the affected organization to swiftly notify the affected individuals and, when required, issue a public statement within a specified timeframe.
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