The HIPAA E-Tool® — What is the Key to Success for HIPAA Compliance
The Health Insurance Portability and Accountability Act (HIPAA) requires covered entities and their business associates in health care to protect patient health information. Health care organizations that fail to comply with HIPAA requirements face civil monetary penalties (CMPs), as well as possible criminal charges.
In addition, a breach of protected health information (PHI) can be expensive and result in serious reputational harm.
Many organizations never realize their practices are in violation of HIPAA until it’s too late. They’re hit with a debilitating fine — and their reputation is tarnished.
Fortunately, our HIPAA E-Tool can help you protect patient data, avoid expensive investigations and prevent breaches with our innovative Software as a Service (SaaS), designed with cutting-edge functionalities that help keep health data secure.
If you’re asking yourself, “What is the Key to Success for HIPAA Compliance?” then The HIPAA E-Tool® might be the right solution for your practice.
The HIPAA E-Tool® is an easy-to-use, web-based compliance program designed to simplify and walk you step-by-step through the mandated administrative, technical, and physical safeguards required by HIPAA. Every policy you need is included, covering HIPAA’s Privacy, Security and Breach Notification rules. When the law changes, we update everything on our end, keeping you up-to-date.
The HIPAA E-Tool includes pre-written policies, a Risk Analysis module for covered entities and business associates, interactive training for employees, and forms and templates that are editable to suit the needs of your office.
- Review your HIPAA policies to make sure they are up-to-date and complete
- Provide staff training to familiarize them with the policies they need to know about depending on their job responsibilities.
- Do an inventory of all the locations of protected health information (PHI), both electronic and non-electronic, and
- Review the vulnerabilities and threats to PHI security
HIPAA is like middle school math. You need to show your work.
If you are ever investigated or sued, you need to be able to prove to the investigators at the Office for Civil Rights (OCR) who enforce HIPAA (or a judge or State Attorney General) what you did and when, to demonstrate you take HIPAA seriously and doing everything you can to maintain the integrity, privacy and security of PHI.
The HIPAA E-Tool® makes documentation easy. Your program saves everything in one place, keeps it secure in the cloud, and lets you access it anytime from anywhere with an internet connection. If you are asked to prove your work, you can zip it in a file and send it, with time stamps showing your careful compliance.
Administrative SafeguardsThe administrative safeguards focus on how the organization is managed. HIPAA requires policies, procedures, and internal controls that follow HIPAA. Examples include appointing privacy and security officials, having an up-to-date notice of privacy practices, training the workforce, and supervision to ensure the policies are being followed. Another key administrative safeguard is managing communications with patients. Patients have the right to access their own medical records, and they may authorize others to receive their protected health information. Policies, procedures and training are needed to ensure patients’ rights are protected and that staff know how to protect those rights. The HIPAA E-Tool® has an Administrative Safeguard Checklist to help you verify you have every Administrative safeguard required.
Technical safeguards focus on risks that threaten electronic protected health information or EPHI. EPHI is defined as any protected health information (PHI) that is maintained in or transmitted by electronic media. All EPHI is also PHI.
For example, access controls and audit logs help to limit and monitor who on the staff can access files containing EPHI.
Another example is the use of encryption for PHI transmitted electronically, whether by email or text where it may be accessed by unauthorized individuals; however, organizations are permitted to choose any encryption method that meets HIPAA’s required specifications and standards.
Also, patients may choose to communicate with their providers by unencrypted means; this is permitted, as long as the provider complies with the HIPAA “duty to warn”. Before communicating using an unencrypted method, the provider must warn the patient that there is some level of risk, and obtain the patient’s written agreement. The warning and the agreement both need to be documented.
Ensuring Success with HIPAA Compliance: Physical Safeguards
The physical aspects of HIPAA require that any patient data is protected from unauthorized access and maintained securely. These include hard copy documents, electronic files, faxes, and even voicemail recordings. All PHI must be stored in a locked drawer or room where only authorized personnel have access. Printers should be in a secure area and workstations should be shielded.
You should also ensure that your organization takes all reasonable steps to prevent unauthorized access to records outside of your control, such as medical records being sent to third party vendors who are HIPAA business associates.
HIPAA compliance is an ongoing process that requires everyone in your organization to be aware of and accountable for their role, working as a team member in support of every other staff member responsible for HIPAA. What is the key to success for HIPAA compliance? A HIPAA compliance plan should include:
- HIPAA policies to protect patient health information
- Risk Analysis and Risk Management policies, with Risk Analysis conducted every year and Risk Management all year round
- Breach Notification policies for responding to data breaches
- Workforce training for everyone who has access to PHI, both electronic and non-electronic; repeat the training as needed, at least once a year
- A contingency plan for emergencies caused by natural disasters, power outages or cybersecurity incidents
- Step-by-step guidance, with every question you need to ask
- Interactive easy-to-use fillable forms will meet every requirement of HIPAA
- Once completed, Risk Analysis shows the action steps needed which become your Risk Management Plan
- Everything is documented in one secure place
Risk Analysis and Risk Management are required by HIPAA but also make good business sense for any practice. p
Risk Management helps you:
- Reduce risks to your practice and patients
- Prevent or reduce the chance of data breaches
- Minimize potential penalties and fines, which can run into hundreds of thousands of dollars
- Minimize the risk of privacy breach lawsuits which can cost millions, or cause you to close your practice
- Protect your reputation and brand
HIPAA Provides Flexibility
The HIPAA Security Rule does not require that you use a specific method or vendor to safeguard PHI, nor does it say that you must eliminate every risk to PHI in your practice.
But HIPAA does require that you implement security measures “reasonable and appropriate” for your office. Apply the best safeguards for your needs, taking into consideration factors such as costs, size and complexity of your practice, types of activities involved, technical capabilities, and probability or impact of potential risks.
Once you’ve completed your Risk Analysis, you’re in a better position to make these choices for your Risk Management plan.
The HIPAA Security Rule is a Blueprint to Prevent Cybersecurity Incidents
Cybersecurity is growing concern for all types of businesses around the world, but healthcare is in the crosshairs. Cyber criminals want to steal PHI because it’s so valuable – they can sell it on the black market or the dark web at a much higher price than credit card data or social security numbers alone. Illegal hackers use phishing, attack unpatched software, and attack with malware to gain access and steal data. Nightmare scenarios include EHR downtime, service cutbacks or suspension. Patient care suffers. Ransomware demands are common once the hacker obtains and locks your data.
By following the HIPAA Security Rule, you’ll learn all the latest best practices recommended by the FBI, the NSA and Cybersecurity and Infrastructure Security Agency (CISA), the top cybersecurity experts in the world. The HIPAA E-Tool® also contains all the requirements and standards recommended by NIST (the National Institute of Standards and Technology).
A key to successful HIPAA compliance is properly training staff to understand HIPAA, and what their particular obligations are depending on their job function. Train new staff members on their first day and make sure they sign a confidentiality agreement documenting that they understand their responsibilities under HIPAA. Include cybersecurity awareness training to help staff avoid becoming a victim of phishing.
Re-train staff members annually, and provide refresher training for employees as needed. Make sure that all staff members know who the designated HIPAA Privacy Official is and how to reach them.
Your staff needs to know exactly what is and isn’t allowed by HIPAA. They need to understand how to respond when a patient asks for their medical records or when a third party requests information.
The HIPAA E-Tool® includes staff training (study materials, quizzes and answer keys) and answers to all these questions.
Many healthcare organizations outsource some aspect of their operations — billing, IT services, or records management — which means PHI will be handled by a third party at some point.
A key to successful HIPAA compliance is to manage your third-party business associates. Or, if you are a business associate, you must manage any subcontractor business associates you use.
Business associates are vendors (to a covered entity) that “create, receive, maintain or transmit” protected health information (PHI), while performing a service involving the PHI. They are separately and independently liable for compliance with HIPAA.
To comply, you must conduct due diligence. Three simple steps are required:
- identify your business associates (or subcontractor business associates)
- ask whether the business associates comply with HIPAA and have they completed a Risk Analysis
- enter into a HIPAA-compliant business associate agreement with each business associate
Many people see HIPAA as time-consuming, expensive and complicated. But it doesn’t have to be. At The HIPAA E-Tool® we believe HIPAA compliance is easy step-by-step, once you know the steps.
The HIPAA E-Tool® has organized all the rules and requirements in logical order, making it manageable by a busy office manager or compliance official. The key compliance person can enlist other team members to help. By creating a culture of compliance and using recommendations from the Risk Management plan year round, you can achieve HIPAA compliance success without large expense or excessive time. Our HIPAA E-Tool® delivers the policies, technology, training, and guidance necessary to support a strong HIPAA Compliance Program.
The HIPAA E-Tool® is the key to success for covered entities and business associates of all sizes and types – hospitals, health plans, physicians, clinics, dentists, specialty care providers and pharmacies, and business associates can implement efficient, low cost, and effective HIPAA compliance Security and Privacy Policies and Procedures.
HIPAA regulations are complex and difficult to navigate. The HIPAA E-Tool® makes the process of becoming HIPAA compliant simple and easy. Give us a call today to learn how our program can help you become HIPAA compliant, avoiding many of the pitfalls that make navigating all the HIPAA Rules challenging.
Copyright © 2023 ET&C Group LLC.The HIPAA E-Tool® and Protecting Patient Privacy is Our Job® are registered trademarks of ET&C Group LLC
The HIPAA E-Tool
PO Box 179104
St. Louis, MO 63117-9104
8820 Ladue Road Suite 200
St. Louis, MO 63124