Managing HIPAA Technical Safeguards for Small Practices

Summary: Compliance with HIPAA regulations is essential to protect compliance and profitability in every medical practice. This article will guide you through HIPAA technical safeguards and considerations for managing access to a HIPAA-protected network using best practices and proactive protections.

HIPAA IT Security Protects More Than Patients

Healthcare organizations must adhere to strict regulations when managing access to sensitive patient information. The Health Insurance Portability and Accountability Act (HIPAA) requires all covered entities along with their business associates to implement comprehensive measures to safeguard protected health information (PHI), WITH a HIPAA compliance checklist, HIPAA compliance VPN solutions, and conducting HIPAA security risk assessments. As more health records are accessed, stored and shared digitally, regulations have been updated to help ensure continued data privacy. Practices owners should know that their and employees’ protected health, financial and employment information is also at risk in a poorly protected network.

Understanding HIPAA IT Protections

HIPAA technical safeguards refer to the technology and procedures required to protect electronic protected health information (ePHI) and control who has access to it. These safeguards are outlined in the HIPAA Security Rule and are divided into several categories:

• Access Controls – Ensure that only authorized personnel can access ePHI. Implement unique user IDs, emergency access procedures, and automatic logoff mechanisms.
• Audit Controls – Maintain hardware, software, and procedural mechanisms to record and monitor access to ePHI
• Integrity Controls – Implement measures to ensure ePHI is not altered or destroyed in an unauthorized manner
• Transmission Security – Protect ePHI transmitted electronically using end-to-end encryption and established secure communication protocols
• Install Authentication Mechanisms – Verify that the person accessing ePHI is who they claim to be

HIPAA Compliance Checklist for Network Access

A comprehensive HIPAA compliance checklist can help your organization meet the requirements for managing access to HIPAA-protected networks effectively:

• Conduct HIPAA Security Risk Assessments
  • Identify potential vulnerabilities in your network and systems
    • Conduct a network penetration test to help identify vulnerabilities within your network. Network cyber security is always a top priority.
  • Evaluate the chances of a cyberattack – By knowing the likelihood of an attack and the impact of potential threats, you will be better prepared to eliminate or mitigate the possible threats
  • Implement strategies to eliminate or mitigate any identified risks
• Develop and Implement Access Control Policies
  • Define your practice’s user roles and permissions
  • Limit access to ePHI based on job responsibilities – For example, an office scheduling assistant does not need to access imaging files. Access assignations must be job-specific.
  • Regularly review and update all access controls
  • Have controls in place to immediately shut down access for off-boarded employees or business associates
• Use HIPAA-Compliant VPN Solutions for Secure Remote Work – The use of virtual private networks (VPNs) must be mandatory for remote work. VPNs can ensure that remote access to your network is secure. When selecting a VPN:
  • Choose a VPN that offers end-to-end encryption and strong authentication protocols
  • Monitor and log all VPN activity to detect unauthorized access or usage
• Implement Secure Authentication Mechanisms
  • Use multi-factor authentication (MFA) to enhance security – MFA requires users to supply two or more verification factors to gain access to a platform (the code is sent to a phone or another device). MFA is a vital component of secure identity and access management. In addition to asking for a username and password, MFA requires one or more additional verification factors, which decreases the likelihood of a successful cyberattack
  • Enforce Strong Password Policies – Complex multi-character passwords are mandatory components of a secure network. The days of using birthdays, repeated numbers or reusing the same passwords are over
  • Require Regular Credential and Permissions Updates – Regularly updating and managing user credentials and access permissions decreases the chances of stolen ePHI
  • Monitor and Audit Network Access – Few things in cyber security are “set and forget.” Continuously monitoring and auditing network access can alert you to suspicious, unauthorized access and ensure compliance with your practice’s protocols. Examples of suspicious network activity are unusual amounts of data being off-loaded, unusual activity during off hours or logins from unusual locations or IP addresses.
• Train Workforce on HIPAA Compliance
  • Provide Training for All Practice Staff (including clinicians) on the importance of protecting patient privacy. Humans are typically the weak links in cybersecurity. Most malware and ransomware attacks begin when an employee clicks on a phishing link. Therefore, repeated and updated employee security awareness training for all new and existing staff is key to strengthening compliance.
  • Educate Employees about passwords, MFA, secure access practices and potential security threats. Provide updated examples and case studies of cyberattacks affecting medical practices.
  • Use Secure Communication Protocols such as SSL/TLS (Secure Sockets Layer and Transport Layer Security). Train remote workers on when and how to use VPNs if using non-office WiFi to access the practice network and data.
  • Encrypt All Data Transmissions on all platforms containing ePHI. Even if a cybercriminal gains access during the transmission process, the data will appear as gibberish without a decryption key that translates it back into readable text.

Q: Can I use public WiFi when working remotely?

A: Public WiFi is not secure, and hackers frequently attempt to breach it. Before using public WiFi, install and activate HIPAA compliant VPN solutions on mobile devices such as phones, tablets and laptops.

The Role of HIPAA Compliant VPN Solutions

A HIPAA compliant VPN is crucial for securing remote access to HIPAA-protected networks. Using a VPN can help document compliance efforts for your practice and provide several additional layers of security for patient and practice data. Here are factors to consider when implementing a VPN for HIPAA compliance:

• Encryption – Ensure the VPN uses AES-256 encryption to protect data while in transit
• Authentication – Implement Multi-Factor Authentication (MFA) to verify user identity
• Logging and Monitoring – Maintain logs of VPN connections and regularly review them for suspicious activity
• Access Control – Restrict VPN access based on user roles and responsibilities to provide an additional layer of control
• Device Security – Ensure that devices connecting to the VPN meet security requirements, such as up-to-date software and antivirus protection

Conducting a HIPAA Security Risk Assessment

Managing healthcare cyber threats in medical practices is becoming increasingly complex and regulated. A security risk assessment is critical to managing access to HIPAA-protected networks. This assessment helps identify vulnerabilities and implement measures to safeguard ePHI. Here is a step-by-step guide to conducting an effective risk assessment:

• Identify ePHI (Electronic Protected Health Information)
  • Determine where ePHI is stored, transmitted, and accessed
  • Include cloud storage, mobile devices, and remote access points
• Analyze Potential Threats and Vulnerabilities
  • Identify internal and external threats to ePHI
  • Assess vulnerabilities in your network, applications, and devices
• Evaluate Security Measures
  • Review existing technical, physical, and administrative safeguards
  • Determine whether current measures are sufficient to mitigate risks
• Determine the Likelihood and Impact of Risks
  • Assess the probability of potential threats exploiting vulnerabilities
  • Evaluate the potential impact on the confidentiality, integrity, and availability of ePHI
• Develop a Mitigation Plan
  • Prioritize risks based on their likelihood and impact
  • Implement additional security measures to address high-priority risks
• Document Findings
  • Maintain detailed documentation of the assessment process and findings
  • Include evidence of mitigation strategies and security improvements
• Review and Update Regularly
  • Conduct risk assessments periodically and after significant changes to your network or operations

Q: Is conducting a HIPAA security risk assessment a DIY function?

A: No. Patient privacy and data breach liability risk are too important for incomplete or amateur attempts at data protection. Medical IT support experts can help you achieve full HIPAA compliance and address all vulnerabilities.

Best Practices for Managing Access to HIPAA-Protected Networks

Protecting ePHI is not limited to technical safeguards performed by a network IT expert. There are more related steps involved. To ensure secure and compliant access to and protection for HIPAA-protected networks, follow these best practices:

• Segmentation
  • Segment the network to isolate systems containing ePHI from other parts of the network
  • Limit lateral movement within the network to limit the exposure potential of sensitive data
• Endpoint Security
  • Use endpoint protection solutions to secure all devices accessing the network
  • Keep all devices updated with the latest security patches
• Data Minimization
  • Limit the collection, storage, and transmission of ePHI to only what is necessary
• Incident Response
  • Develop and implement a detailed incident response plan (during a cyberattack is not the time to figure this out)
  • Include step-by-step procedures for detecting, reporting, and responding to security incidents
• Third-Party Risk Management
  • Assess the security posture of third-party vendors/suppliers/associates with access to your network
  • Ensure all vendors sign business associate agreements (BAAs) and comply with all HIPAA requirements. Everyone with access to your network must be on the same cyber security page

Q: How can I implement sufficient HIPAA technical safeguards?

A: Enlist managed support services from medical IT experts familiar with HIPAA regulations.

Cyber risk management and compliance are complex and ever-evolving. Managing access to HIPAA-protected networks requires a comprehensive approach that includes implementing the technical safeguards, following a HIPAA compliance checklist, training employees for security awareness, utilizing HIPAA compliance VPN solutions, and conducting regular security risk assessments. With the assistance of outsourced and managed IT professionals, your medical practice can adopt these practices, maintain a strong security posture, protect sensitive patient information and ensure compliance with HIPAA regulations.

Your Practice and Profitability Depend Heavily on Your Ability to Protect Data

Failing to protect sensitive patient data adequately exposes your practice to liability for each record exposed in a data breach. Liability exposure can include fines, legal fees, notification costs, network recovery fees, regulatory scrutiny, consumer and employee lawsuits, lost partnerships and harm to reputation.