HIPAA Assessment

In any organization that works with personal health information (PHI), the regulations established by HIPAA set the standard to ensure the protection and privacy of individuals’ health information as companies adopt new technologies and processes to improve the quality and efficiency of patient care.

The HIPAA Security Rule is one of the regulations established under the Health Insurance Portability and Accountability Act (HIPAA) of 1996. The Security Rule outlines the standards and safeguards that covered entities and their business associates must implement to protect electronic protected health information (ePHI). Its primary focus is on ensuring the confidentiality, integrity, and availability of electronic health information.

The Security Rule applies to covered entities, which include healthcare providers, health plans, and healthcare clearinghouses that transmit any health information in electronic form, as well as their business associates—entities that handle or process ePHI on behalf of covered entities.

The Security Rule is designed to complement the HIPAA Privacy Rule, which addresses the protection of all forms of protected health information, not just electronic. Together, these regulations play a critical role in safeguarding patients’ sensitive health information and ensuring the privacy and security of health data in the healthcare industry. Non-compliance with the Security Rule can result in significant penalties and enforcement actions.

As part of Pondurance’s cyber risk and regulatory compliance assessment services, we offer a focused review of your IT systems environment to identify areas of risk and maturity as they relate to the HIPAA Security Rule. At the conclusion of the assessment, Pondurance delivers an executive summary along with detailed findings, risk ratings, and recommendations, using the National Institute of Standards and Technology (NIST) maturity levels rating system for each control requirement. This ensures you have a comprehensive foundation to develop a plan of action milestones.

The Pondurance HIPAA Security Rule Compliance Assessment is conducted by our team of security experts, partnering directly with you to guide you through the process. A team of Pondurance experts embeds with your multidisciplinary teams, analyzes your current HIPAA compliance posture, and outlines a set of desired outcomes for proper handling of electronic PHI with categorized references to how they can be achieved.

What is HIPAA Assessment and Compliance?

HIPAA (Health Insurance Portability and Accountability Act) assessments and compliance refer to the processes and measures put in place to ensure that organizations handling protected health information (PHI) are adhering to the requirements set forth by the HIPAA regulations. These assessments aim to identify potential risks, vulnerabilities, and areas of non-compliance related to the security and privacy of sensitive patient data.

HIPAA is a crucial law in the United States that governs the privacy and security of individually identifiable health information held by covered entities (e.g., healthcare providers, health plans, and healthcare clearinghouses) and their business associates (e.g., vendors and contractors handling PHI on behalf of covered entities).

What are the Basic Elements Needed for HIPAA Compliance?

Risk Assessment: Organizations must identify and assess potential risks and vulnerabilities to the confidentiality, integrity, and availability of PHI they handle. Pondurance can assess your organization’s current security controls and practices to identify gaps and areas that need improvement to meet HIPAA requirements while identifying cybersecurity vulnerabilities.

Policies and Procedures Review: Organizations must have appropriate policies and procedures in place to safeguard PHI. These are reviewed to ensure they meet HIPAA standards. Pondurance can help in developing security policies and procedures aligned with HIPAA requirements. As well as help with incident response planning, testing the plan through tabletop exercises and working to remediate vulnerabilities.

Technical Security Evaluation: The assessment includes the evaluation of technical safeguards such as access controls, encryption, and audit logs to protect PHI. A HIPAA compliance assessment, conducted by Pondurance as your cybersecurity partner, not only offers a focused review of your IT systems environment to identify areas of risk and maturity as they relate to HIPPA compliance but also provides a thorough review of your organization’s security controls, policies, and procedures.

Incident Response Plan: A well-defined incident response plan is essential to address any security breaches or unauthorized disclosures of PHI effectively.

As experts in cybersecurity and incident response, Pondurance offers a broader look at your cybersecurity through customized cybersecurity risk assessments that also align with your HIPAA Assessments. We have decades of experience in helping organizations create, update, or enhance their incident response plan and test those plans with custom tabletop exercises.

Pondurance will also assess your compliance with the following areas:

Physical Security Evaluation: The physical security of areas where PHI is stored or processed is assessed to prevent unauthorized access.

Employee Training: Organizations must provide HIPAA training to their employees to ensure they understand their responsibilities in protecting PHI.

Reporting and Documentation: Pondurance delivers an executive summary and detailed summary with maturity ranking, risk level, compliance risks as well as recommendations for remediation. Our reports include valuable and practical insight into existing cyber risk levels and HIPAA compliance.

At the conclusion of the assessment, and delivery of reports, if your organization is out of compliance, we offer a tailored, prioritized approach to helping you get in compliance quickly.

Remediation Guidance: Pondurance can provide guidance and recommendations on how to address the identified issues and can also implement the necessary security measures to become compliant. Beyond HIPAA compliance assessments, Pondurance can identify and prioritize cybersecurity risks, recommend risk mitigation strategies, and implement the strategies to address your specific, unique business needs.

Security Monitoring and Incident Response: Maintaining HIPAA compliance often requires continuous monitoring of security systems and a robust incident response plan to detect and respond to security breaches promptly. Pondurance has a long history of helping organizations maintain compliance and mature their cybersecurity posture, through protecting their networks and data from cyber criminals.

Like other cybersecurity and compliance practices and the use of assessments, HIPAA compliance is an ongoing process, and organizations need to regularly assess their security measures, maintain documentation, and address any identified issues to stay compliant.

Who Conducts a HIPAA Assessment?

There may be several parties involved in conducting a HIPAA assessment including internal compliance officers and external compliance firms that specialize in healthcare.

Engaging with Pondurance as your HIPAA risk assessment partner, provides you with confidence that the assessment is conducted by a qualified and impartial professional who possesses the necessary knowledge and expertise to evaluate your security measures effectively.

As your cybersecurity partner, Pondurance ensures that the assessment and compliance process is conducted thoroughly and accurately. With our HIPAA Security Rule Compliance Assessment, you can achieve the standards of a comprehensive cybersecurity program outlined by the HIPAA Security Rule and reduce your overall risk.

The scope and depth of the HIPAA assessment can vary depending on factors such as the size of the organization, the nature of its operations, and the type of PHI it handles. All parties involved with conducting the assessment should be knowledgeable about the specific requirements of HIPAA and be able to apply them effectively to the organization being assessed. In many cases, it is a team of internal and external resources partnering for assessments and ongoing compliance.

During the assessment, the conducting party will review the organization’s policies, procedures, security measures, employee training programs, incident response plans, and other relevant aspects to ensure compliance with HIPAA regulations. They will identify areas of non-compliance or potential risks and provide recommendations for remediation and improvement.

HIPAA compliance is not a one-time event; it’s an ongoing effort to safeguard patient data and maintain a secure environment for patient information.

HIPAA compliance may be the first step in your healthcare organizations journey, with a cybersecurity partner like Pondurance, you have the ability to ensure compliance and improve your cybersecurity. As technology continues to evolve, so do the methods of cyber threats and attacks. Healthcare organizations of all sizes are increasingly finding themselves vulnerable to sophisticated cybercriminals seeking to exploit weaknesses in their security defenses. In response to these growing challenges, many healthcare organizations are moving beyond compliance to cybersecurity maturity and realize they need support and guidance on where and how to get started beyond compliance needs on their cybersecurity journey.

Pondurance takes a consultative approach with each healthcare organization and maps out a customized, flexible roadmap designed to provide the steps needed to get organizations protected quickly and to help each to maintain compliance, reduce their risk, and protect their organization and the patients they serve.

For more information on how Pondurance can assist you in your HIPAA compliance assessment, reach out for a no-obligation conversation here.