Guide to HIPAA Technical Safeguards

Introduction

Health Insurance Portability and Accountability Act, or HIPAA, violations and the unauthorized access or use of PHI are a continued concern for entities covered by HIPAA and their business associates. While HIPAA may seem complex, its goal is to help organizations minimize the risks associated with storing or transmitting sensitive information. Therefore, a key element of HIPAA’s security measures is the implementation of technical safeguards, as outlined in the HIPAA Security Rule.

Technical safeguards are the security measures that companies must implement to secure electronic protected health information (ePHI). Therefore, it is crucial for healthcare organizations to review the HIPAA technical safeguards for PHI in order to comply with regulations and protect PHI. 

Let’s take a look at the technical safeguards of HIPAA’s Security Rule in detail.

HIPAA’s Security Rule 

The HIPAA Security Rule is a federal regulation that sets standards for protecting the confidentiality, availability, and integrity of electronic protected health information. Covered entities, including healthcare clearinghouses, health plans, and healthcare providers, as well as their business associates, must implement appropriate technical, administrative, and physical safeguards to protect ePHI. This includes conducting risk assessments to identify and mitigate potential risks to the security of ePHI. 

In addition, covered entities must provide training to employees on HIPAA software development compliance and establish procedures and policies to ensure compliance with the rule. Even entities that use certified electronic health record technology must assess their security risks and put in place safeguards to ensure they comply with the Security Rule. Covered entities need to document all security compliance measures. 

What Are Technical Safeguards?

The HIPAA Security Rule defines technical safeguards as a combination of procedures/policies and technology that protect ePHI and control access to it. They are designed to ensure the integrity, confidentiality, and availability of electronic protected health information and to prevent unauthorized access or use of the information. Technical safeguards are an important part of any healthcare organization’s overall security strategy and are essential for ensuring compliance with HIPAA regulations.

A covered entity must have security measures in place that allow it to meet protection standards adequately. It must also determine which security measures and technologies suit its organization.

For example, a healthcare organization with a smaller system may not require the same endpoint security tool as a large health information exchange. The Health and Human Services (HHS) states in its HIPAA Security Series that a covered entity should consider the vulnerabilities and risks to electronic protected health information (EPHI), the capabilities of the entity, its complexity and the cost of protective measures, and the size when determining the appropriate balance of security measures.

Required vs. Addressable Definition

In the HIPAA Security Rule, implementation specifications are divided into two categories: “addressable” and “required.” These categories describe the level of obligation for covered entities to follow the specified standards. 

HIPAA “Required” Security Measures

The term “required” in the context of HIPAA refers to a specific standard or implementation specification that must be followed in order to be compliant with the law. These standards are outlined in the HIPAA regulations and are considered mandatory. These required requirements include: 

• Policies and procedures: Covered entities must have in place written policies/procedures that describe how they will comply with HIPAA’s requirements. And the policies/procedures must be reviewed and updated as required.

• Risk analysis and risk management plan: Covered entities must conduct a risk analysis to identify and assess the risks to the integrity, availability, and confidentiality of ePHI. Based on the results of the risk analysis, covered entities must develop a risk management plan to address identified risks.

• Training: Covered entities must provide HIPAA training to all members of their workforce. This training must be provided to new employees upon hire and must be updated periodically to reflect changes to HIPAA regulations.

• Business associate agreements: If a covered entity works with a business associate (i.e., a vendor or contractor that handles ePHI on the covered entity’s behalf), the covered entity must have a written business associate agreement in place that sets forth the business associate’s obligations with respect to the handling of ePHI.

HIPAA “Addressable” Security Measures

In addition to these “required” requirements, HIPAA also has “addressable” requirements. The term “addressable” refers to implementation specifications that covered entities and business associates must address but may be implemented in a way that is different from the prescribed standard. In other words, covered entities and business associates have the option to adopt the addressable implementation or to use an alternative approach that achieves the same result as the addressable specification.

Some examples of addressable requirements include:

• Disaster recovery plan: Covered entities must have a disaster recovery plan in place to ensure the availability of ePHI in the event of a natural disaster, power outage, or other emergencies.

• Contingency plan: Covered entities must have a contingency plan in place to ensure the availability of ePHI in the event of system failure or other unexpected disruption.

• Physical safeguards: Covered entities must implement appropriate physical safeguards to protect electronic protected health information from unauthorized access, use, or disclosure. These safeguards may include locked doors, security cameras, and access controls.

• Technical safeguards: Covered entities must implement appropriate technical safeguards to protect electronic protected health information from unauthorized access, disclosure, or use. These safeguards may include firewalls, encryption, and access controls.

An entity has three options when dealing with an “addressable” security measure: implementing the specification, implementing an alternative that meets the same objective, or implementing nothing.

It’s always a good idea to go above and beyond when it comes to HIPAA compliance. If you’re unsure, implementing a solution that meets the requirements of the Security Rule is a safe choice.

List of HIPAA Technical Safeguards

Here are the four main areas to consider when implementing HIPAA technical safeguards: 

Access Controls

Access controls are a type of technical safeguard that is used to protect electronic protected health information (ePHI) in accordance with HIPAA. These controls are designed to ensure that only authorized users are able to access ePHI and that the access they have is limited to the minimum necessary to perform their job duties.

Organizations can implement access control in a number of ways, including through the use of user authentication, passwords, and permissions. They can also be used to enforce the separation of duties so that no single user has complete control over all aspects of ePHI.

Here are the implementation specifications associated with the Access Controls standard:

Unique User Identification (Required)

Unique user identification is a type of HIPAA technical safeguard for access controls that requires each user to have a unique login or identifier to access ePHI. This helps to prevent unauthorized access and ensures that user activity can be tracked and logged accurately. Other types of HIPAA technical safeguards for access controls include user authentication, access authorization, audit controls, encryption, physical safeguards, and data backup and disaster recovery.

Emergency Access Procedure (Required) 

The emergency access procedure is a critical component of HIPAA technical safeguards and is designed to ensure that individuals have timely and appropriate access to protected health information (PHI) during an emergency situation. This procedure outlines the steps that must be taken to ensure that authorized individuals can access PHI in a timely manner, while also protecting the confidentiality, integrity, and availability of the information. 

The emergency access procedure should specify the types of emergency situations that would trigger the need for emergency access to PHI, such as natural disasters, medical emergencies, or cyber-attacks. It should also specify the roles and responsibilities of different individuals or teams in the organization, such as the emergency response team, the information security team, and the HIPAA privacy officer. The emergency access procedure should also outline the specific steps that must be taken to provide emergency access to PHI.

Automatic Logoff (Addressable)

Automatic logoff is a type of HIPAA technical safeguard for access controls that automatically logs a user off after a certain period of inactivity. This helps to prevent unauthorized access to ePHI by ensuring that users cannot leave their computer or device logged in and unattended.

Automatic logoff is an addressable safeguard, meaning that it is not required by HIPAA but may be implemented if it is reasonable and appropriate for the organization. Other types of HIPAA technical safeguards for access controls include user authentication, access authorization, audit controls, encryption, physical safeguards, and data backup and disaster recovery.

Encryption and Decryption (Addressable)

Encryption is the process of converting sensitive data into a coded form that those with the proper decryption key can only access. This helps to protect the data from tampering or unauthorized access. Decryption is the process of converting encrypted data back into its original form. This can only be done with the proper decryption key.

Encryption and decryption are types of HIPAA technical safeguards for access controls that are addressable. Both encryption and decryption are important for protecting ePHI from unauthorized access and ensuring compliance with HIPAA regulations. If an organization determines that encryption is reasonable and appropriate for their operations, they must implement it to protect ePHI.

Audit Controls

Audit controls are a type of security measure that is implemented in HIPAA to protect the privacy and security of ePHI. These controls are designed to help organizations monitor and detect unauthorized access to ePHI, as well as to track and document access to ePHI for audit and compliance purposes.

Audit controls are an important component of an organization’s HIPAA compliance program and are required to be in place for all covered entities and business associates. Some examples of audit controls include audit trails, system logs, and access controls.

Here is the implementation specification associated with the Audit Controls standard:

Mechanism To Authenticate ePHI (Addressable) 

Several mechanisms can be used to authenticate electronic protected health information (ePHI). One common approach is to use a username and password combination, where the user is required to enter their unique login credentials in order to access the ePHI. Another approach is to use two-factor authentication, which requires the user to provide not only their login credentials but also a second form of authentication, such as a one-time code sent to their phone/email or a biometric factor such as a fingerprint or facial recognition.

Other mechanisms that can be used to authenticate ePHI include digital certificates, smart cards, and token-based authentication. It is important to choose an authentication method that is secure and appropriate for the specific needs of the organization. The use of strong and unique passwords, regularly updating passwords, and enabling two-factor authentication can help to enhance the security of ePHI.

Person or Entity Authentication 

Person or entity authentication is a technical safeguard required by HIPAA to ensure that only authorized individuals or entities are able to access ePHI. This safeguard involves verifying the identity of a person or entity attempting to access ePHI using methods such as login credentials or biometric authentication.

The purpose of person or entity authentication is to protect against unauthorized access to ePHI, which could compromise the privacy and security of patients. HIPAA requires that covered entities implement appropriate person or entity authentication controls to ensure that only authorized users are able to access ePHI. This may include the use of strong and unique passwords, two-factor authentication, or other types of identity verification methods.

Transmission Security

Transmission security, also known as data transmission security, is a technical safeguard that is used to protect the transmission of electronic protected health information (ePHI). It is one of the technical safeguards required by the Health Insurance Portability and Accountability Act (HIPAA) to ensure the confidentiality, integrity, and availability of ePHI.

There are several ways to secure the transmission of ePHI, including the use of encryption, secure sockets layer (SSL), and virtual private networks (VPNs). Encryption is the process of converting data into a code that someone with the correct decryption key can only access. SSL is a security protocol that is used to establish an encrypted link between a web server and a user, such as a web browser. VPNs allow clients to connect to a remote network over the internet securely.

Here is the implementation specification associated with the Integrity Controls standard:

Integrity Controls (Addressable)

Integrity controls refer to measures that are put in place to ensure that electronic protected health information (ePHI) is not altered or corrupted during transmission. These controls are designed to ensure that the ePHI being transmitted is complete and accurate and that it has not been tampered with in any way.

Several types of integrity controls can be used to protect ePHI during transmission. One common approach is to use checksums or hash values, which are calculated for the ePHI before it is transmitted and then compared to the ePHI after it is received to ensure that it has not been altered. Another approach is to use encryption, which can help to protect the ePHI from being read or modified by unauthorized parties.

It is important to choose appropriate integrity controls based on the specific needs of the organization and the sensitivity of the ePHI being transmitted. The use of strong encryption, regular checksum calculations, and other appropriate controls can help to ensure the integrity of ePHI during transmission.

Encryption (Addressable)

Encryption is a technique that is used to protect information from being accessed by unauthorized parties. In the context of transmission security, encryption provides protection as data is transmitted over a network. When encrypted data is converted into a form that is only readable to the individual who has the proper decryption key, it helps to ensure that the data remains secure and confidential as it travels over the network.

Several different types of encryption algorithms can be used, each with its strengths and weaknesses. Some common encryption algorithms include symmetric key algorithms, such as AES and Blowfish, and public key algorithms, such as RSA and ECC. Choosing an encryption algorithm that is strong and appropriate for the specific needs of the organization.

Summary

In conclusion, HIPAA technical safeguards are necessary to secure electronic protected health information (EPHI) in today’s technological landscape. It is essential for covered entities and business associates handling electronic PHI to review their use of technical safeguards to ensure compliance.

At Flatirons, we are HIPAA-compliant and provide custom healthcare software services. If you have any further questions or would like to discuss how we can help your organization with HIPAA Compliance, please contact us. Our team, comprising experts from various disciplines, is eager to develop the mobile app of your dreams.