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InarecentinterviewwithBeckersHospitalReview,OurCCOBobGranthighlightedwhatisneces-
saryforhealthcareproviderstoachieve,illustrateandmaintainHIPAAcompliancein5easytoun-
derstandsteps.
1.Perform a"true"riskanalysis.Tounderstandsystem vulnerabilities,healthcareprovidershavetodo
aninternalriskanalysisorhireanoutsideauditortoperform ariskanalysisforthem.Toperform a
"true"riskanalysis,theproviderhastobeabletosay"no,wedon'tcomplywithacertainpartofthe
regulation,"saysMr.Grant.Althoughmanyhealthcareprovidersarehesitanttoadmittheyarenot
HIPAAcompliant,honestlyansweringriskanalysisquestionsisnecessarytoascertainwhatasystem's
weaknessesare,addsMr.Grant.
2.2.Havearemediationplan.Healthcareprovidersneedtousetheinformationfrom theriskanalysis
todevelopaplantoresolveitsvulnerabilities,saysMr.Grant.Alongwiththeremediationplan,pro-
vidersalsoneedtotrackthedocumentationthatshowsthenon-complianceissuewasfixed.There
aretoolsavailablethathelpproviderstrackthedocumentation,andhealthcaresystemswithmulti-
plefacilitiesshouldutilizethetoolstosimplifytheprocess,addsMr.Grant.
3.Havevendormanagementprotocols.Healthcareprovidersneedtohaveavalidbusinessassoci-
ateagreementinplacewithallvendorstheyaresharingpatientinformationwith,saysMr.Grant.
ProvidersshouldsendvendorsaHIPAAsecurityaudittoensurethevendorisincompliancewiththe
HIPAAsecurityrule.Itisimportantforhealthcareproviderstoaddressallvendornon-compliance
issuesbecause"ifyouactlikeanostrichandputyourheadinthesand,HHSwillcomedownonyou
hard,"addsMr.Grant.
4.Updatedocuments.TheHIPAAomnibusrulerequireshealthcareproviderstohaveamanualcon-
tainingcurrentpoliciesandproceduresaddressingeachpartoftheomnibusrule— suchasbusiness
associateagreementmonitoringandsanctionstrategy.Providers'policiesandproceduresmustbe
updated"periodically,"anditisgoodpracticetoupdatewithfederalgovernmentrulechangesor
everytwoyears,saysMr.Grant."Youmaynothavetochangethemanualwhenit'sreviewed,but
youatleasthavetoreviewthepoliciesandtrackthatyoudidbyatleastchangingtherevised
date,"addsMr.Grant.
5.Haveanincidentmanagementplan."Everyonehasasecurityincident,it'sthenatureofhealth-
care,andsecurityincidentscanhappenatanyorganization,"saysMr.Grant.Thehealthcareindus-
tryreliesonphones,faxmachinesandotherelectronicdevicesthatareoftencompromisedand
leadtodatabreaches.Asanincidentresponsemeasure,healthcareprovidersneedtokeepaccu-
raterecords— suchasemployeeHIPAAtrainingdocumentsandauditlogs— todeterminewhatin-
formationwascompromisedduringabreachandtobeabletotracktheincidenttotheresponsible
party,addsMr.Grant.
-BobGrant,CCOatCompliancyGroupandformerHIPAAauditor
5KeyStepsofHIPAACompliance

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5 key steps of HIPAA compliance

  • 1. InarecentinterviewwithBeckersHospitalReview,OurCCOBobGranthighlightedwhatisneces- saryforhealthcareproviderstoachieve,illustrateandmaintainHIPAAcompliancein5easytoun- derstandsteps. 1.Perform a"true"riskanalysis.Tounderstandsystem vulnerabilities,healthcareprovidershavetodo aninternalriskanalysisorhireanoutsideauditortoperform ariskanalysisforthem.Toperform a "true"riskanalysis,theproviderhastobeabletosay"no,wedon'tcomplywithacertainpartofthe regulation,"saysMr.Grant.Althoughmanyhealthcareprovidersarehesitanttoadmittheyarenot HIPAAcompliant,honestlyansweringriskanalysisquestionsisnecessarytoascertainwhatasystem's weaknessesare,addsMr.Grant. 2.2.Havearemediationplan.Healthcareprovidersneedtousetheinformationfrom theriskanalysis todevelopaplantoresolveitsvulnerabilities,saysMr.Grant.Alongwiththeremediationplan,pro- vidersalsoneedtotrackthedocumentationthatshowsthenon-complianceissuewasfixed.There aretoolsavailablethathelpproviderstrackthedocumentation,andhealthcaresystemswithmulti- plefacilitiesshouldutilizethetoolstosimplifytheprocess,addsMr.Grant. 3.Havevendormanagementprotocols.Healthcareprovidersneedtohaveavalidbusinessassoci- ateagreementinplacewithallvendorstheyaresharingpatientinformationwith,saysMr.Grant. ProvidersshouldsendvendorsaHIPAAsecurityaudittoensurethevendorisincompliancewiththe HIPAAsecurityrule.Itisimportantforhealthcareproviderstoaddressallvendornon-compliance issuesbecause"ifyouactlikeanostrichandputyourheadinthesand,HHSwillcomedownonyou hard,"addsMr.Grant. 4.Updatedocuments.TheHIPAAomnibusrulerequireshealthcareproviderstohaveamanualcon- tainingcurrentpoliciesandproceduresaddressingeachpartoftheomnibusrule— suchasbusiness associateagreementmonitoringandsanctionstrategy.Providers'policiesandproceduresmustbe updated"periodically,"anditisgoodpracticetoupdatewithfederalgovernmentrulechangesor everytwoyears,saysMr.Grant."Youmaynothavetochangethemanualwhenit'sreviewed,but youatleasthavetoreviewthepoliciesandtrackthatyoudidbyatleastchangingtherevised date,"addsMr.Grant. 5.Haveanincidentmanagementplan."Everyonehasasecurityincident,it'sthenatureofhealth- care,andsecurityincidentscanhappenatanyorganization,"saysMr.Grant.Thehealthcareindus- tryreliesonphones,faxmachinesandotherelectronicdevicesthatareoftencompromisedand leadtodatabreaches.Asanincidentresponsemeasure,healthcareprovidersneedtokeepaccu- raterecords— suchasemployeeHIPAAtrainingdocumentsandauditlogs— todeterminewhatin- formationwascompromisedduringabreachandtobeabletotracktheincidenttotheresponsible party,addsMr.Grant. -BobGrant,CCOatCompliancyGroupandformerHIPAAauditor 5KeyStepsofHIPAACompliance