HIPAA Risk & Gap Assessment
While risk assessments are beneficial for organizations of all sizes and across all industries, they are uniquely important for healthcare organizations. Providers are responsible for meeting high standards required by our government to protect private patient information.
HIPAA Risk & Gap Assessment
Healthcare organizations are currently facing an avalanche of electronic data, from electronic health records (EHR) to diagnostic images to multitudes of different document and file types. Due to the recent COVID-19 pandemic, changes in healthcare delivery are critical to reduce staff exposure, preserve personal protective equipment (PPE) and minimize the impact of patient surges on facilities. Healthcare systems have had to adjust the way they triage, evaluate and care for patients using methods that do not rely on in-person services.
During this time of global digital transformation, ensuring security and regulatory compliance of these large datasets is vital to the success of healthcare organizations.
While risk assessments are beneficial for organizations of all sizes and across all industries, they are uniquely important for healthcare organizations. Providers are responsible for meeting high standards required by our government to protect private patient information. However, according to the United States Department of Health and Human Services, approximately 70% of healthcare organizations are not HIPAA compliant.
The Health Insurance Portability and Accountability Act (HIPAA) mandates industry-wide standards for healthcare information and electronic billing and requires protection as well as confidential handling of protected health information. With the modernization of patient care, it is safe to say that many organizations remain perplexed regarding evolving HIPAA enforcement and compliance.
What is always understood is that non-compliance can damage reputations and impose deep fines to the organization. It can also require a tenure of third-party oversight to ensure future regulatory compliance. The Code of Federal Regulations, Title 45 Public Welfare demands strict adherence from healthcare providers across several areas including:
- Privacy Rule
- Security Rule
- Breach Notification Rule
- Enforcement and Sanctions
- Omnibus Rule of 2013
InfoSystems has an extensive understanding of the complexity of HIPAA compliance and can conduct a comprehensive HIPAA gap analysis unique to your organizational challenges. During the analysis, our team examines administrative, physical and technical safeguards, as well as policy, procedural and privacy requirements. Our team provides a high-level view of areas to improve ahead of an audit and steps on how to do so, helping ensure that organizations remain compliant. With each assessment, our clients:
- Gain an understanding of your organization’s compliance to the HIPAA Security and Privacy Rules
- Identify and document a remediation plan that defines clear steps to attain HIPAA compliance
- Achieve credibility with customers, investors, partners and creditors
- Demonstrate due care in your organization’s efforts to manage risk and compliance
The Security Management Process standard in the Security Rule requires organizations to implement policies and procedures to prevent, detect, contain, and correct security violations. Risk analysis is one of four required implementation specifications that provide instructions to implement the Security Management Process standard. Section 164.308(a)(1)(ii)(A) states:
RISK ANALYSIS (Required). Conduct an accurate and thorough assessment of the potential risks and vulnerabilities to the confidentiality, integrity, and availability of electronic protected health information held by the organization.
The HIPAA Security Rule requires that covered entities and its business associates conduct a risk assessment of their healthcare organization. Additionally, to aid in audit preparation, InfoSystems offers HIPAA risk assessments, which help in identifying threats and risks to your organization and sensitive data. The results of your Risk Assessment guide your remediation and risk management efforts moving forward. Our experts help organizations understand your specific vulnerabilities, so that you can move forward confidently with day-to-day operations being aware of what to monitor. Our risk assessment process includes the following steps:
- Prepare for the risk assessment by identifying scope
- Identify threat sources
- Identify vulnerabilities
- Determine likelihood of future threat events
- Determine magnitude of threat impact
- Determine overall risk
- Communicate results & opportunities for risk remediation
InfoSystems can help.
InfoSystems brings a deep understanding of multiple frameworks including HIPAA, NIST, CSC20 and PCI DSS, allowing our experts to take an unbiased and holistic approach to security and compliance while ensuring you maximize the return on your investment in services. At the conclusion of our engagement, organizations will have gained an understanding of the risks and vulnerabilities to the confidentiality, integrity and availability of protected health information (PHI) in your environment.
When an incident occurs, it is imperative to be ready to handle the situation as quickly and efficiently as possible. Identification, containment and eradication are key to re-establishing normal operational levels. InfoSystems’ Incident Response Program (IRP) services provide your organization with cyber experts that can assist your IT team when dealing with the unexpected.
While current circumstances demand IT teams and security providers develop nuanced and far-reaching protocols to monitor these devices, mobile usage itself is not new, and there are capable means already in place through Mobile Device Management (MDM) that work to monitor, control, and combat network breaches.
The NIST (National Institute of Standards and Technology) Security Controls were instituted to support information systems’ ability to stay secure and resilient amid evolving threats and work to maintain the confidentiality, integrity and overall security of federal and industry information systems.
As cybercriminals become more sophisticated, it is imperative that enterprises and their security teams rise to the challenge and employ strong and comprehensive measures to protect network data. Penetration testing is one of the most effective ways to be proactive and aware of vulnerabilities and protocol.
SOC 2 is a technical audit that requires organizations to adhere to information security policies and procedures. Most specifically, SOC 2 focuses on technology-based service organizations whose business stores customer data in the cloud or service organizations that have technology-based access to customer data through managed service agreements.