Staying Compliant with HIPAA Regulations

Meeting the Challenges of HIPAA Compliance

As communication with patients becomes more electronic and nearly instantly available on mobile devices, the nuances of keeping protected health information (PHI) safe and secure continue to evolve. As a result, consistently managing compliance with HIPAA (Health Insurance Portability and Accountability Act) regulations becomes more taxing. Despite these challenges, organizations must stay on top of data privacy and security procedures to help mitigate the risk of threats and safeguard sensitive patient information.

High on the list for healthcare workers when being trained on HIPAA compliance is simplicity. Resources that explain HIPAA policies in a straightforward and easy-to-understand way are very useful in helping staff learn how to be compliant. While training and policy updates can pull frontline workers away from active patient care, they’re an important part of compliance. To minimize negative impact to daily workflow and schedules, updated resources and trainings should be as efficient as possible.

Although there are several ways to bolster your HIPAA compliance program, organizations should at least try to leverage the following strategies.

1. Regularly Assess How HIPAA-Protected Information Is Shared in Your Network and Beyond

Before you can address any privacy and security shortfalls, it’s important to first understand how your organization shares PHI and when the process has last been updated. Given rapidly advancing digital technologies, you may find that your organization’s PHI protection processes are out of date.

Consider developing a HIPAA compliance assessment strategy that includes the following elements:

- Determining which internal departments, vendors, or business associates may have received protected health information from your organization

- Evaluating current policies and practices for opportunities to better protect PHI

- Examining what security measures are in place

Developing these practices can give your organization the baseline assessment needed to make it easier to keep track of process changes and developments. Organizations should review their HIPAA compliance assessment strategy regularly—ideally at least once a year—to ensure any new vendors, communication methods, or other risk points are documented and addressed.

2. Implement Mitigation Strategies Based on Security Hazards

During your assessment, you might discover potential gaps in your organization’s HIPAA compliance efforts. It’s important for organizations to try to reduce existing weaknesses and high-probability threats. Some options include installing new or stronger encryption software, updating internal policies on social media use, and additional staff training and practice exercises to address risks such as email phishing.

Training should include recognizing the ongoing threats from malware and hackers, including but not limited to phishing. Not only should staff be trained specifically on prevention of these threats, but they should also be given practice exercises, such as e-mail based awareness campaigns.

Improving your HIPAA compliance efforts requires participation from your entire organization. It’s critical to connect with providers, administrators, IT professionals, and other members of your staff to help ensure they are aware of any HIPAA-related issues and to gather input on potential solutions.

It also might be helpful to seek counsel from HIPAA experts outside of your organization during and after your annual compliance assessment. These professionals can help you understand the latest HIPAA guidance, identify potential issues in your organization’s compliance efforts, and help develop policies to address them.

3. Have a Plan for Breach Notifications

Despite your organization’s commitment to HIPAA compliance, it is still possible to experience a data breach. In 2020, there was a 73% increase in the number of confirmed data breaches in the healthcare industry, potentially exposing 12 billion pieces of PHI. These incidents could simply involve an unintentional lapse in protocol by a staff member or a more nefarious situation, such as a cyberattack.

To help prevent further compliance issues and to ensure a breach response that is within legally required timeframes, it is mission critical to have detailed policies that outline every layer of notification protocols. According to Shred-It's 2021 Data Protection Report, nearly 1 in 3 (29%) healthcare organizations experienced a data breach in 2021; however, only 58% of healthcare organizations have a data breach incident response plan in place.

4. Provide Training to Help Employees Safeguard PHI

Healthcare providers and administrators are responsible for ensuring PHI is not used or disclosed improperly. HIPAA compliance requires regular staff training to help keep the latest guidance and policy changes front of mind for those with access to PHI.

When organizing new HIPAA training programs, it’s important to understand providers’ and administrators’ perspectives in your organization. Your staff may have busy schedules that limit time for training, and some might need more resources to understand HIPAA guidance. To address these concerns and better support unique training needs, it’s appropriate to provide reasonable time and access for individuals to complete trainings at their own time and pace. You can also make your HIPAA trainings more effective by customizing them to fit your organization’s specific security needs and procedures.

5. Ensure You Are Prepared for Upcoming HIPAA Updates

In December 2020, the Office for Civil Rights (OCR) issued a Notice of Proposed Rule Making (NPRM) to update HIPAA regulations to be more aligned with the 21st Century Cures Act, the Office of the National Coordinator of Healthcare IT (ONC) Information Blocking policies, and the Centers for Medicare & Medicaid Services (CMS) Interoperability and Patient Access rules.

The proposed changes to the HIPAA Privacy Rule, which established national standards for PHI, include strengthening individuals’ rights to access their own health information, improving information sharing for care coordination and case management, and facilitating greater family involvement in the care of individuals experiencing emergencies or health crises.

The new HIPAA policies are expected to be released as “Final Rules,” in 2022. Compliance with HIPAA changes could require extensive changes to your privacy rule procedures and security forms, thus it’s important to pay close attention to the Department of Health and Human Services’ (HHS) online newsroom, which will provide regular updates on the timing and content of the Final Rules. These updates will help you begin considering how your organization will comply with the new HIPAA rules before they take effect and are enforced.

You Don’t Have to Tackle HIPAA Compliance Alone

Ongoing HIPAA compliance requires constant vigilance and should be a top priority in today’s complex healthcare landscape. To help with these efforts, organizations can turn to an external HIPAA expert that has the knowledge and experience to help support a robust and reliable program. Stericycle’s HIPAA privacy and security manuals and online trainings help save time so you can focus on patient care. Our customizable HIPAA resources also help you create policies to meet your compliance needs.

At Stericycle, we offer a comprehensive program that includes assessment assistance, training, and more, serving as a valuable resource when you are creating, modifying, and sustaining your HIPAA compliance program.