Safeguards to protect patient data

July 12, 2021//Alli Schuh

Protecting patient data is a herculean task for healthcare organizations, as protections must be in place for internal and external threats. On top of that, HIPAA regulations add in a layer of required parameters that healthcare organizations must have in place to be compliant and not face penalties. 

HIPAA has 2 types of rules to protect patient information that must be followed: the Privacy Rule, and the Security Rule. The Privacy Rule protects what is known as personally identifiable information, or PII, and who may have access to it, while the Security rule protects all personal health information (PHI) a covered entity creates, receives, maintains, or transmits in electronic form, known as ePHI, and ensures that only authorized users have access to that information. The biggest difference is the Privacy Rule also protects written or oral communication of PII, while the Security Rule does not. The electronic systems within your healthcare organization hold the most valuable information, so compliance with the Security Rule is key to making sure your patient data is protected. So how do you start putting processes in place to protect ePHI? We have compiled a list of where to start:

  1. Conduct a risk analysis
  2. Implement EMR Access Auditing 
  3. Ensure appropriate access for third parties/business associates
  4. Educate staff on protecting patient information 

Risk analysis

The first thing to start the process of protecting your patient’s data is conducting a full risk analysis to determine what systems your organization has and which ones need to be the most protected. Not all systems contain sensitive information, and they might not need the same safeguards as something like your EMR system. With a risk analysis laid out, you can start looking into what processes should be implemented and system safeguards that need to be put in place for each system. For example, patient data is one of the most sought after types of information, so ensuring appropriate access to your organization’s EMR system is a necessary safeguard. 

 

EMR Access Monitoring Checklist

Are you properly tracking internal access to Electronic Medical Records? Download the interactive EMR access monitoring checklist for the steps necessary to build out a successful EMR access review process.

Implement EMR access auditing

Audit controls are required under the Technical Safeguards within the HIPAA Security Rule. As it states, “a covered entity must implement hardware, software, and/or procedural mechanisms to record and examine access and other activity in information systems that contain or use ePHI”. The biggest system that uses this information is the Electronic Medical Record system (EMR) that your facility is utilizing. While the rule does not state that software must be the method used, going the route of manually auditing is pretty much impossible for compliance teams to handle. Over a million accesses are made into the EMR each day, making it impossible to audit all accesses in a reasonable amount of time and prone to error. Utilizing a patient privacy monitoring system that does the work for you can help streamline this process and ensure any suspicious accesses to patient information are flagged and reviewed in a timely manner. 

Ensure appropriate access for third parties/business associates

The HIPAA Security Rule was established not just for healthcare organizations, but also for any party that touches or interacts with PHI. This includes business associates – external third parties such as claims processors, bill collectors, medical transcriptionists, consultants, or accounting firms. Healthcare providers are required to demonstrate a high level of visibility and control around business associate activities to remain in compliance with mandatory standards. This includes ensuring that business associates only access the patient data they need and nothing more. Here are some ways you can maintain visibility and control over the access your business associates have to EMR and PHI:

  • Make sure to have a Business Associate Agreement (BAA) in place. In compliance with HIPAA, all third parties or business associates are required to provide in writing that they will safeguard the information. 
  • Use least privileged access for business associate access rights so they are only accessing information that’s absolutely critical to their business.
  • Implement multi-factor authentication to quickly and efficiently authenticate user access.
  • Conduct due diligence required by HIPAA such as documentation and monitoring of business associate activity and risk assessments.

Thankfully, there are solutions that can help streamline these processes. Remote access tools that are built for healthcare can standardize and restrict access while also auditing business associate activity so IT teams aren’t bogged down by access requests and gathering documentation. These systems also give healthcare organizations more peace of mind about the “who, what, when, why, and how” of business associates accessing EMR and patient files. 

Educate staff

The best way to ensure compliance from staff is through continuous education. HIPAA education is required, but continuing education on best practices for being vigilant in other areas, such as email, can further ensure compliance and protection of patient data. Processes should be put in place for new hires, as well as a continuing education plan for current employees. Helping staff be aware of what external threats look like and educating them on why inappropriate access to medical records is a serious violation of HIPAA that can result in extreme consequences can help keep employees on their toes about staying compliant and making sure their coworkers stay compliant as well. 

Protecting your patient’s data is a requirement and a necessity. Not only can healthcare data breaches result in HIPAA penalties, but it can cost your organization more money after the breach to cover the cost of rebuilding the trust from patients. Conducting a risk analysis of the systems within your organization to get an understanding of what safeguards need to be in place is step one. From there, start implementing technology to protect data from insider and outsider threats through auditing employee access to patient records, and ensure visibility and control over business associates by only permitting access to the information they need. Employee education can ensure everyone on staff understands the rules of HIPAA compliance and are vigilant when it comes to outsider threats. Compliance officers have a heavy responsibility, but with a plan and technology, protecting patient data can be a little bit easier.

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